a quality improvement project: enhancing care of patients...

Running head: ENHANCING CARE OF PATIENTS WITH TYPE 2 DIABETES 1

A Quality Improvement Project: Enhancing Care of Patients with Type 2 Diabetes at an Inner-City Clinic

A scholarly project Presented toThe Faculty of Maryville University

Catherine McAuley School of NursingIn Fulfilment of the Requirements

For the Degree of Doctor of Nursing PracticeFOLASHADE OYEKUNLE, MSN, AGNP-C

JULY 16, 2018

ENHANCING CARE OF PATIENTS WITH TYPE 2 DIABETES 2

TABLE OF CONTENTS

Title Page 1

Table of Contents 2

Abstract 3

Chapter 1: Introduction 4

Chapter II: Review of Related Literature 7

Chapter III: Methods 14

Chapter IV: Findings 18

Chapter V: Discussion 23

References 30

Appendix 34


A Quality Improvement Project: Enhancing Care of Patients with Type 2 Diabetes at an Inner-

City Clinic

Background: Type 2 diabetes (T2DM) has become a global problem. Clinicians are working fervently to find better ways of managing diabetes to reduce complications that arise from uncontrolled diabetes. Effective education of patients can go a long way in ensuring patients understand the pathophysiology of diabetes and how it can be managed to reduce incidents of morbidity and mortality that arise from uncontrolled diabetes. Lack of adequate knowledge about diabetes pathophysiology, complications, and self-management is one of the major factors that lead to increase in mortality and morbidity rates of T2DM. Adequate and effective patient education can help reduce incidents of micro vascular and macro vascular complications from T2DM (Dias, Rodriguez, Sales, Oliveira, & Nery, 2016). After being diagnosed with T2DM, patients were provided with a two-day diabetic education class that encompasses the pathophysiology and self-care management of diabetes. The purpose of this project was to determine if this educational intervention promoted positive changes in hemoglobin A1c (HgA1c), weight, and adherence to follow-up visits.

Objective: The purpose of this project was to examine if a two-day diabetes educational intervention could promote positive changes in baseline HgA1c, weight, and adherence to follow-up visits at three to six months and nine to 12 months post-educational intervention.

Design: The study utilized a retrospective chart review using a quantitative exploratory method that did not engage participants. Participants’ electronic medical records (EMRs) were reviewed determine if there were changes in HgA1c, weights, and follow-up visits post-educational intervention. Participants that attended diabetes education from January 1, 2016 to December 31, 2016 were selected for the project. Changes in baseline HgA1c, weight, and follow up visits were measured to determine if the educational intervention had been effective.

Results: The findings of this project determined that there was a non-significant interaction between the baseline HgA1c groups and observations at three to six months and nine to 12 months, F(1,73) = 0.42, p = 0.52, η2 = 0.01, power = 0.10. A non-significant interaction effect between baseline weight groups was also observed at three to six months and nine to 12 months, F(2,72) = 0.18, p = 0.83, η2 = 0.01, power = 0.08. The conclusion is that despite attending the two-day diabetic education classes, these patients do not have the required knowledge needed to remain compliant and manage T2DM; this translates to ineffective patient education.

Conclusions: Culturally-sensitive patient education is very important. Assessing the target population and determining their education needs can make a difference in disease perception and compliance. Patients’ culture, race, socioeconomic status, religious beliefs have to be considered when providing education about disease process and management. This capstone project proved that ineffective education can lead to wrong disease perception and non-compliance thereby increasing morbidity and mortality rates among the target population.

Key Word: Type 2 Diabetes, hemoglobin A1C, weight.


Chapter 1: Introduction

Introduction to the Problem

Diabetes mellitus has become a global problem. It is one of the major source of mortality

and morbidity worldwide, and the multi-organ system damage that results from uncontrolled

diabetes is a major source of concern for clinicians. The American Diabetes Association (ADA)

estimates that diabetes affects about 9.4% of the population in the United States (US) (American

Diabetes Association, 2015). The ADA also estimates approximately 25%-40% of the population

have not been diagnosed. Also, 90% of diabetes diagnoses are Type 2 Diabetes (T2DM) which

lead to increase in mortality and morbidity rates due to its associated cardiac and vascular

complications.

The United States is not the only country affected by the increased incidence of diabetes.

The prevalence of diabetes diagnoses has also seen an upward trend among developing nations in

Africa (Adisa, Alutundun, & Fakeye, 2009; Gill, Price, Shandu, Dedicoat, & Wilkinson, 2008).

This upward trend has also been noted especially among African Americans and approximately;

3.7 million or 14.7% of African Americans aged 20 years or older have been diagnosed with

T2DM (Centers for Disease Control and Prevention, 2017). This trend can be attributed to non-

compliance due to lack of effective education about T2DM (Adisa et al., 2009). Provision of

effective diabetes education can make a difference in the prevention of macro- and micro-

vascular complications that lead to high mortality and morbidity rates among this African

American population.

Purpose and Aims

The purpose of this quality improvement project was to determine if a two-day

educational workshop improved African American patients’ baseline glycated hemoglobin


(HgA1c) level, blood glucose, and weight loss at three to six months and nine to 12 months post

educational intervention. The researcher aimed to explore if the two-day educational intervention

improved HgA1c, blood glucose, and weight loss of patients completing the educational

intervention compared to patients who did not participate.

The research was carried out at an inner-city primary care clinic that provides healthcare

services to low-income African Americans patients who receive Medicaid. Increased incidents of

T2DM with complications have been noted and associated with low income status (Maniarasu &

Muthunarayanan, 2017; Ross, Gilmour, & Dasgupta, 2010; Zhao et al., 2013). Compared with

other ethnic groups, African Americans have been noted to have increased incidents of T2DM.;

Risk factors such as poor diet, behavioral lifestyles, physical inactivity, obesity are contributing

factors that put this population at increased risk (Davis, Xu, Gebreab, Riestra, Gaye, Khan,

Wilson, Bidulescu, 2015). Thus, the target population is at an increased risk of developing

complications from T2DM and suffering from cardiac and vascular complications making this

project an opportunity to evaluate the effectiveness of the educational intervention.

The educational intervention consisted of patient education on self-care practices, how to

check and monitor blood glucose levels, diet and lifestyle modifications, weight loss/exercise,

signs of hypo/hyperglycemia, foot care, annual eye exams, and importance of medication

compliance. The question for this quality improvement project was: Does a two-day educational

workshop for African American patients at an inner-city clinic improve baseline HgA1c, blood

glucose levels, and weight loss at three to six months and nine to 12 months post intervention.

Background of Problem of Interest

The background of this project stemmed from the need to decrease the incident of

complications from uncontrolled diabetes. T2DM is a major threat to health in the United States.


Diabetes diagnoses among people aged 20 years and older in the African Americans is about 3.7

million or 14.7% (Centers for Disease Control and Prevention, 2017). The Center for Disease

Control and Prevention (CDC) estimates that approximately 8.1 million people remain

undiagnosed, this includes African Americans and all other ethnic groups, thus the need for

effective diabetes education remains one of the most important factors of managing the disease

in order to lower the risks of complications (Centers for Disease Control and Prevention, 2017).

The above statistics validated the need for better solutions to improve care and patient

compliance to prevent complications of this devastating disease. Complications from diabetes

include eye, nerve, and kidney damage. With adequate blood glucose control, these

complications can be minimized or avoided. Thus, the recent rate of increase in diabetic

diagnoses in the United States places all clinicians at a high alert; it also puts providing adequate

education about diabetes prevention and management as top priority. Hence, making this

educational intervention significant to determine if there was an improvement in baseline HgA1c

levels, and weight loss among patients that attended the program. Lack of adequate knowledge

about diabetes pathophysiology, complications, and self-management is one of the major factors

that lead to increase in mortality and morbidity rates of T2DM. Adequate and effective patient

education can help reduce incidents of micro vascular and macro vascular complications from

T2DM (Dias, Rodriguez, Sales, Oliveira, & Nery, 2016).

Conclusion

Providing effective culturally sensitive education is key to improving the quality of life of

people that have been diagnosed with diabetes and people with pre-diabetes. Presenting

education in ways that is easy to understand complications and disease management can go a

long way in reducing the morbidity and mortality rates from diabetes and other cardiovascular


diseases. Progression of T2DM to multi-organ failure can be avoided with effective diabetes

education; it can help improve or increase compliance and ensure positive outcomes for patients.

It is of utmost importance for healthcare providers to be able to accurately assess a population or

patients’ needs to provide care and education to improve compliance and decrease mortality and

morbidity from T2DM.

Chapter II: Review of Related Literature

Critical Analysis of Conceptual and Theoretical Literature

A thematic analysis detects patterns, regularities and inconsistencies in a research study

(Polit & Beck, 2012). During the review of the available literature chosen for this project, the

themes identified are sociocultural beliefs, inadequate family/community support system, limited

knowledge due to lack of culturally sensitive education about type 2 diabetes. All the

aforementioned themes could serve as hindrances to compliance with diabetes care plan provided

for the patients (Adisa et al., 2009; Distiller, Brown, Joffe, & Kramer, 2010; Gill et al., 2008;

Nwaokoro et al., 2014; Purcell & Cutchen, 2013; Shilubane, Cur, Potgieter, & Litt el Phil, 2007;

Vissenberg, Nierkens, Uiteewal, Geraci, Middelkoop, Nijpels, & Stronks, 2012).

Sociocultural Beliefs

Sociocultural beliefs can either help or hinder patients from being compliant with plan of

care. Patients’ sociocultural and religious beliefs play an important role in the way they percept

disease and health promotion (Purcell & Cutchen, 2013). Among African Americans, spirituality

or religiosity (attending church, prayer and fasting) and different time orientation are closely

related to beliefs about health and disease management (Rovner, Casten, & Harris, 2013). Time

orientation deals with the present and the future. The present focuses on immediate consequences

of individual action while the future focuses on long term planning and cumulative consequences


of individual action. It is believed among African Americans that people that are future oriented

are more likely to engage in health promoting behaviors such as being compliant with plan of

care, eating right and exercising. People that are oriented to the present find it difficult to connect

their present behaviors with future consequences (Rovner et al., 2013). For example, they do not

see the connection that exists between obesity, unhealthy eating habit, sedentary lifestyle and

type 2 diabetes; and, therefore, they may find it difficult to remain compliant with the plan of

care and be more inclined to suffer from complications from type 2 diabetes.

Inadequate Family/Community Support System

Involving family members, church, and the community in diabetes education and

management can have positive impacts (Vissenberg et al., 2012). Support from family members

can encourage patients to strive to remain compliant with diabetes plan of care. It is also noted

that religion and family support act as enablers that can help keep patients compliant to diabetic

care plan (Purcell & Cutchen, 2013). Furthermore, the African American religious organizations

or churches are known for their pivotal support and development of the African American

communities with regards to economic, educational, and social welfare (Chatters, Taylor, &

Jackson, 2009). Therefore, involving the family and the church can provide the much- needed

support for the people in the community that are diagnosed with diabetes. The support from

family members and community can help with compliance with plan of care. Providing diabetes

education by organizing community information sessions in churches and town halls will give

patients the kind of community and family support system that is needed to foster compliance.

Limited Knowledge Due to Lack of Culturally Sensitive Education

Lack of knowledge about diabetes pathophysiology, management, self-care practices, and

damaging implication to health and quality of living can lead to non-compliance. Limited


knowledge has been linked to inaccurate risk perception by patients (Migliore, Barroso, &

Vorderstrasse, 2016). Without this knowledge, patients do not know the consequences of

uncontrolled diabetes and its resultant target- organ damage. Providing culturally sensitive

education targeted towards the community can help improve awareness about diabetes and

management (Gill et al., 2008).

Furthermore, lack of knowledge about diabetes can also lead to non-compliance with

medication regimen which eventually leads to increased risks of complications from diabetes

(Saleh, Mumu, Ara, Abdul Hafez, & Ali, 2014). In addition, diabetes education should be

provided by clinicians who have been trained in cultural relations, are conversant with the

sociocultural belief of the target population and can provide education in simple terms devoid of

medical jargons. Involving family members and community in diabetic self-care management is

productive. Providing education about checking blood glucose, participating in weight loss

program, diet modification, diabetes foot care, compliance with medication and appointments,

signs and symptoms of hypo/hyperglycemia are ways to improve patients’ outcome and decrease

risks of complications from T2DM (Shilubane et al., 2007).

Overall Strengths and Weaknesses

Many research studies have been conducted about the upward trend in the type 2 diabetes

diagnoses especially in the African American communities. The available literature discusses

several factors that affect disease perception and compliance such as; sociocultural beliefs, lack

of family support, and lack of adequate knowledge about diabetes and its complications. All of

the studies examined used the quantitative research method which allowed data to be collected

objectively without the researcher becoming emotionally involved (Terry, 2015). Furthermore,

structured interviews and questionnaires were the preferred methods of data collection in all the


research studies. Structured interviews and questionnaires are easy to understand and this allows

researchers using these methods to get participants’ response quickly. (Terry, 2015). The

common variable identified across all research studies are non-compliance to diabetic care plan

and self-care practices due to lack of knowledge, non-adherence to diabetic care plan can lead to

low quality of life, sociocultural and religious beliefs can lead to non-compliance, effective

culturally sensitive education can improve compliance among patients, family and community

support can help improve compliance among patients (Adisa et al., 2009; Distiller et al., 2010;

Gill et al., 2008; Purcell et al., 2013; Saleh et al., 2014; Shilubane et al., 2007; Vissenberg et al.,

2012). The research studies were applicable and were also relevant to the purpose of this

scholarly project.

Sampling method seemed to be a major problem in most of the literature reviewed. Only

one of the studies stated the sampling method used in getting participants for their studies.

Sampling bias can often lead to research results being made unsuitable for use as evidence-based

practice. Furthermore, the number of participants used in one of the studies was too small for the

results of the research to be generalized. Additionally, it was also noted that all the research

studies examined failed to state the hypotheses guiding their studies, although they were implied.

Hypotheses need to be clearly stated as the validity of a research theory is evaluated and tested

through the hypothesis (Polit & Beck, 2012). Also, one of the studies made use of self-reports.

Although self-reports can be helpful in research, the validity and accuracy of these results have

to be questioned as they can be biased (Polit & Beck, 2012).

Gaps and Limitations

Culturally sensitive education about diabetes in the African American community is

lacking. Many papers have been written with regards to lack of knowledge as being one of the


major reasons why this population continues to suffer complications and have low quality of life

(Adisa et al., 2009, Gill et al., 2008). Having identified this need, there was no conclusion as to

how to keep this population compliant after providing culturally sensitive education about

diabetes.

One of the limitations noted was the use of self-reports of results by participants which

might not be a true representation of the truth. Also, the sampling method were not clearly stated;

thus, there was no way to ascertain if the participants used were right for the study. The

possibility of bias when recruiting participants was a concern and this could have negative

impacts on the results of the research studies. Another limitation identified was the lack of follow

up with the participants to ascertain compliance with plan of care. The lack of resources and

adequate staffing to ensure continuity was another limitation observed during the literature

review. Additionally, small sample size in some of the studies made them unsuitable for

generalization and the participants were not true representations of the target demographic.

Another limitation noted in the studies was the use of quantitative research design, while this

design is known to establish the correlational and causal relationships among variables of the

research, some subjective details that relate to the social aspects of interaction and human motion

and perceptions may be lost and this can lead to negative impressions of the project leading to

inaccurate results (Terry, 2015).

Concepts and Definitions

Sociocultural: This is a combination of two words; social and culture. Social means “living in

communities; relating to society” (Webster’s New Basic Dictionary & Thesaurus, 2010, p. 156).

Linguistically, social is defined as “of relation to variety of language that is used by a group of

people sharing some characteristics, such as ethnicity or income level and differs in


pronunciation, grammar, or vocabulary from the standard variety” (Webster’s New Basic

Dictionary & Thesaurus, 2010, p. 156). It is the relationship between human society as portrayed

by behavior and interaction that is unique to the specific group. Cultural is an adjective derived

from Culture (Noun), it means anything or phenomenon that pertains to culture. Culture itself is

defined as “the norms and patterns of behavior that are consecrated by tradition and obligatory

for representatives of an ethnos” (Drach, 2014, p. 109-111). Culture is also seen as an illusion

and subjective when compared to reality, culture is man-made and not a true representative of

nature, it is created through human wills and desires (Harrison, 2014). Furthermore, culture

consists of a group of people who share the same background and beliefs; it follows a shared

pattern of behaviors learned through socialization within the same group of people. (Marzilli,

2014).

Type 2 Diabetes Mellitus: “Type 2 diabetes mellitus consists of an array of dysfunctions

characterized by hyperglycemia and resulting from the combination of resistance to insulin

action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion”.

(Khardori, 2017, p. 1). It is characterized by three cardinal signs of polyphagia, polydipsia, and

polyuria. Most people do not know they have diabetes. Thus, patient education about risk factors

and screening is very crucial. Guideline for diagnosis according to the American Diabetes

Association (ADA) are: A fasting plasma glucose level of 126 or more, a hemoglobin A1c level

above 6.5, or a random plasma glucose higher than 200. Risk factors for type 2 diabetes are:

family history, obesity, hypertension, hyperlipidemia, African American, and age 45 years or

older (American Diabetes Association, 2015).

Noncompliance: This means doing the opposite of what an individual is directed to do by a

person in a position of authority within a specific time frame (Lipshultz & Wilder, 2017).


Glycated Hemoglobin (HgA1c): This is the average measurement of blood glucose control over

the past two to three months (American Diabetes Association, 2015).

Culturally sensitive education: This kind of education takes into consideration the patients’

social, cultural, and religious beliefs. These beliefs can have negative impact on adherence to

care plan and also impact the patient’ trust in the healthcare provider (Gross, Anderson, Busby,

Frith, & Panco, 2013).

Theoretical or Conceptual Framework

The Betty Neuman system model is relevant to the student’s scholarly project. This

model encourages healthcare providers to see each patient or population as unique. It encourages

them to treat the total person as opposed to the disease, taking into consideration the patient’s

sociocultural, psychological, religious, and economical background (Neuman & Fawcett, 2010).

Using this model can guide the clinician to assess patients accurately and providing culturally

sensitive healthcare in a way that makes it easy for the patient to comply with the plan of care.

She believes that the goal of nursing is to prevent instability to patients or population, because

they are exposed to instability that might be caused by variables like environmental,

psychological and emotional stressors, it is the healthcare provider’s duty to help the clients fight

these stressors (Neuman & Fawcett, 2010). The model identifies two lines of defense; the

flexible and normal lines of defense. The flexible line is always attacked first by stressors and

tends to act as buffer for the normal line of defense, failure of the flexible line of defense will

lead to an attack on the normal line which causes instability to clients. She also identifies three

ways that the healthcare provider can use to combat these stressors: primary, secondary, and

tertiary preventions. Primary prevention is when the nurse carries out an assessment on the client

to identify potential stressors (Neuman & Fawcett, 2010). The nurse takes actions to help the


client cope and withstand pressures from stressors. Immunization, diabetes education, weight

loss program, diet modification, and exercise are all part of primary prevention. The secondary

prevention occurs when the client is already unstable due to illness. Quality nursing care is

provided as an intervention during the secondary stage. The tertiary prevention is geared towards

nursing actions that will help the client maintain stability. For example, the nurse provides

education and support to help clients maintain health and wellness (Neuman & Fawcett, 2010).

Chapter III: Methods

Methodology and Design

The project was a retrospective chart review using a quantitative exploratory method that

did not engage participants. A quantitative research design is beneficial for researching or

investigating the effectiveness of a given intervention as it pertains to a particular patient

population (Terry, 2015). Medical records were obtained by the researcher on-site from the clinic

for data collection. For this study, the author utilized seventy-five medical record. These records

were studied and analyzed to see if there was any improvement in HgA1c level, weight loss and

adherence to follow-up visits post educational intervention. The researcher recorded the

minimum necessary data to accomplish the goal of the project on the data collection sheet.

Furthermore, all potential patient identifiers were removed to decrease the risk of exposure and

protect patients’ privacy. This research method was suitable for this project as the researcher

aimed to do a program evaluation through a retrospective chart review to explore if a two-day

diabetic educational workshop for patients with T2DM improved baseline HgA1c levels and

weight loss at three to six months and at nine to 12 months post educational intervention.

The setting of the project was an inner-city clinic in the Midwest region of the United

States. The clinic cares for adult patients that are mainly low-income African Americans with


diseases such as diabetes, hypertension, minor infections, congestive heart failure, chronic

kidney disease, and lung diseases. The data for the project were extracted from the medical

records of patients that had diagnosis of T2DM in the targeted inner-city clinic. The abstracted

retrospective data from the electronic patient medical records used for the study were recorded in

a word document data collection sheet with all the potential patient identifiers removed, it was

password protected, locked in the researcher’s office, and only accessed by the author of the

study. All patients that received treatment in the clinic from January 1, 2016 to December 31,

2016 were reviewed for potential inclusion.

The data abstracted from the electronic medical record (EMR) were from an adult

population that comprised 90% African Americans and 10% African immigrants. Participants

were 18 years or older; both genders were included. The inclusion criteria for participants’ charts

were the following: (a) attended program from January 1, 2016 – December 31, 2016; (b)

baseline HgA1c; (c) baseline weight; (d) HgA1c three to six months post educational

intervention; (e) HgA1c nine to 12 months post intervention; (f) weight three to six months post

educational intervention; (g) weight nine to 12 months post educational intervention; and (h)

compliance with follow-up visits. The exclusion criteria for the project were as follows: (a) less

than 18 years; (b) absence of T2DM diagnosis; (c) seen at the clinic before January 1, 2016 or

after December 31, 2016; (d) absence of initial HgA1c level; and (e) no HgA1c levels at three to

six months and nine 12 months after first visit. A subsequent inclusion and exclusion process

was done until the determined number of EMRs was achieved.

Needs Assessment

Efficient management of T2DM requires maintenance of healthy HgA1c levels which

should be lower than 6.5g/dl as noted by the American Diabetes Association (ADA, 2016).


Patients can achieve effective control of T2DM through compliance with medications and self-

care practices. Diabetes education cannot be overemphasized because it increases the patients’

awareness to T2DM prevention and control of complications (Dias, Rodriguez, Sales, Oliveira,

& Nery, 2016). The need for effective management of T2DM has become a huge task for

patients, T2DM was reported in 2013 to be the seventh leading cause of death in the United

States by Centers for Disease Control and Prevention (CDC, 2017).

This researcher saw the need for a program evaluation in the clinic when she noted high

incidence of T2DM complications among the population of the target clinic. The clinic provides

services for low income population that are on Medicaid and Medicare. Samples for the research

study were taken from the clinic’s EMRs and 75 EMRs were used for data collection.

Research Question

The research question for this project was: Does a two-day educational workshop for

African American patients at an inner-city clinic improve baseline HgA1c, weight loss, and

follow-up visits at three to six months and nine to 12 months post educational intervention?

Data Collection Instruments

The data collection instrument was created by the student specifically for the project. It

was an electronic data collection sheet that was password protected and only accessed by this

student as a measure to comply with the Health Insurance Portability and Accountability Act

(HIPAA) privacy rule. The researcher assigned a numerical number from one to 75 to each

medical record with all possible patient identifiers removed. In addition, the following

information were collected from EMRs and entered into the listed columns in the data collection

sheet: (a) attended program from January 1, 2016 – December 31, 2016; (b) baseline HgA1c; (c)

baseline weight; (d) HgA1c at three to six months post educational intervention; (e) HgA1c at


nine to 12 months post intervention; (f) weight at three to six months post educational

intervention; (g) weight at nine to 12 months post educational intervention; and (h) compliance

with follow-up visits.

Analysis Plan

Data analysis is one of the most interesting and exciting phase of the scholarly project.

For quantitative data, it is where the organization and transformation of data from just numbers

into meaningful information that can be interpreted (Moran, Burson, & Conrad, 2014).

Furthermore, data analysis is meant to organize and provide structure to data that has been

collected, thereby making it easy to elicit meaningful results from the data (Polit & Beck, 2012).

Descriptive statistics and Statistical Package for the Social Sciences (SPSS) program

were used to analyze the data for this project. Descriptive statistics can be helpful to the author to

understand the data collected, especially when dealing with quantitative research (Polit & Beck,

2012). It also contributes to providing information about the sample being analyzed, data were

originally entered into Excel spreadsheet and were later imported into SPSS for data analysis.

Continuous distributions were checked for the assumption of normality using skewness and

kurtosis statistics. If either statistic was above an absolute value of 2.0, then normality was

violated. Homogeneity of variance was checked using Levene’s Test for Equality of Variances.

Box’s M test was used to assess the assumption of homogeneity of covariance. The assumption

of sphericity was tested for using Mauchly’s test. Mixed-effects ANOVA was used to test for

significant interactions between baseline HgA1c groups (0-7 vs. 8+) and baseline weight groups

(normal, overweight, and obese) and within subject observations of HgA1c and weight at three to

six months and nine to 12 months. Marginal means with 95% confidence intervals were reported


for mixed-effects analyses. Statistical significance was assumed at an alpha value of 0.05 and all

analyses were conducted using SPSS Version 22.

Resources

The resources used for this project were a computer, SPSS program, Microsoft Office

package, gasoline (for driving to and from the clinic), and Maryville University library for

references. The author was solely in charge of data collection and analysis.

Budget

The author has a computer and the software programs needed for data collection and

analysis. Furthermore, the clinic is about five minutes’ drive from the author’s home thus, there

was no budget needed for this project.

Protection of Human Subjects

This project is a retrospective chart review and the author did not have any physical

contact with the patients thus, there were no risks or concerns for physical, psychological, social,

economic, or legal risks that could result from this study. One possible risk was breach of

confidentiality. These risks are minimal as all efforts were made to protect patients’ identities by

removing all patients’ identifiers prior to entering data into the data collection sheet. Also, each

medical chart was assigned a numerical number from one to 75 on the data collection sheet. This

information was password protected and locked in a designated office assigned to this author and

was accessed by only the researcher throughout the course of data collection and analysis.

Furthermore, the author will destroy all collected data at the completion of the project.

Chapter IV: Findings

Data Collection Method


Congruence is the interconnectivity that exists between data collection method and its

intended variables and shows connectivity between the results of existing research and the

current research being studied (Polit & Beck, 2012). To determine congruence of the quantitative

or qualitative method, each target variable of the research must be examined in order to establish

a relationship between the variables and data collection method. The project is a retrospective

chart review thus, data were abstracted for patients’ electronic medical records (EMR) and

patients were not engaged throughout the data collection and analysis period. The data collected

was baseline HgA1c, HgA1c at three to six months, HgA1c at nine to 12 months, baseline

weight, weight at three to six months, weights at nine to 12 months and compliance with follow

up visits post- educational intervention. The focus of the project is Type 2 Diabetes and the data

collected were pertinent to diagnosis and management of diabetes. Hemoglobin A1c and weight

are very important to diagnosis and successful management of diabetes.

Seventy-five electronic medical records (EMR) were used for this project, these data are

appropriate and gave meaningful results at the end of the data analysis. The data for the project

were extracted from the medical records of patients that have diagnosis of T2DM at the targeted

inner-city clinic. To ensure reliability and validity of the results, data was transferred into an

Excel spreadsheet and analyzed with descriptive statistics which helps with understanding and

providing more information about the given data (Polit & Beck, 2012). Data were also analyzed

with the Statistical Package for the Social Sciences (SPSS) program. These instruments have

been tested and are known for being valid, reliable, and accurate.

The setting of the project is an inner-city clinic that provides healthcare services to low income

African-American patients, the setting is appropriate for the project because this project was

looking at the rise of diabetes diagnoses among the African American population and also


trying to see if the educational intervention being provided at diagnosis had positive impacts on

these patients. The author had a designated office and computer that could only be accessed by

her thus, there was no risk of bias or influence with regards to data collection and outcome.

Target Variables

The target variables were hemoglobin A1c, weights, and adherence to follow up visit.

There is congruence between the target variables and the research question because the target

variables answer the research question, these variables would show if there is a positive or no

impact on the variables post- educational intervention. Furthermore, there is adequate

information about the target variables to determine transferability to other contexts. For example,

the data collected were baseline hemoglobin A1c and weights prior to educational intervention,

then hemoglobin A1c and weights at three, six, nine, and 12 months post intervention to see if

there are improvements or no improvements. Also, adherence to follow up visit was determined

by reviewing at the patients’ charts to see their attendance records. These data can be collected or

transferred to other contexts and they do show congruence between the target variables and the

scholarly project question.

Study Replication

This project is a retrospective chart review using a quantitative study design and can be

replicated in any other health care setting. Data replication is the ability to repeat research

procedures in a different setting or second investigation in order to assess and determine whether

earlier results can be confirmed (Polit & Beck,2012). A quantitative research design allows the

author to analyze objective data without becoming emotionally invested thus, the risk of bias is

minimal. It is concerned with observed unique patterns in a target population which can then be

investigated with regards to a chosen intervention to determine effectiveness (Terry, 2015).


There is adequate information provided by the author about the setting, research design, data

collection methods, variables, and data analysis instruments for other researchers to be able to

replicate the study in a different health care setting.

Validity and Reliability

Validity and reliability are very important aspects of a research study especially during

the data collection period. Information collected during the data collection period must be

accurate and consistent with the purpose of the research (Polit & Beck, 2012). Reliability of data

means the degree of consistency with which an instrument measures an attribute of a research

study (Polit & Beck, 2012). In addition, it means the instrument being used is consistent enough

and will give the same results if the research is replicated in other health care settings (Terry,

2015). To ensure reliability of the data, this author made sure that the required data collected

from patients’ medical records were measured with the right instruments. For example,

hemoglobin A1c value was drawn and measured at the lab to get accurate numbers for patients’

values and the same laboratory was used for all the participants. To ensure accuracy of patients’

weights, they were measured with the same digital standing scale at each visit. The digital scale

being used for the measurement was tested multiple times: (1) scale was zeroed and re-zeroed for

accurate calibration and (2) prior to weighing patients, a four-pound bag of flour was weighed

and re-weighed multiple times throughout the day to determine if results were consistent. The

results showed that the digital scale was reliable and gave accurate results.

To establish validity, the research needs to measure what it is purported to measure and

there should also be congruence between the data being collected and the measurements (Polit &

Beck, 2012). Also, there should be context transferability and the data should show the

relationship between the target variables and the research questions. This project fulfilled all the


elements of validity because it showed that the data was collected at an appropriate facility, data

measurements tools were reliable and the results can be generalized. Furthermore, data collection

for this project did not start until the author received approval from both Maryville University

IRB and her project chair.

At the conclusion of data collection, data were entered into an Excel spreadsheet and later

imported into SPSS for analysis and all patients’ identifiers were removed prior to entering data

into the data collection sheet. A retrospective research design tries to find a correlation between

an existing phenomenon (dependent variables, for example, HgA1c, weight) and phenomena that

occurred in the past (independent variable; two-day diabetic educational class) (Terry, 2015).

Finding the correlation that exists between these two phenomena to determine if the two-day

diabetic education being provided at in the clinic promoted positive changes in both HgA1c and

weight at three, six, nine, and 12 months post- educational intervention.

Descriptive Statistics

Descriptive statistics were used to analyze the collected data for this project. Descriptive

statistics provides information about the sample being analyzed. Seventy-five EMRs were used

for this project, with age ranging from 18 to 72. The mean age range was 44-54 and out of all the

participants used with 72% females while 28% males. All of the participants were African

Americans, no other racial group was included in this study.

Results

For data analysis, data from Excel were exported into SPSS and continuous distributions

were checked for the assumption of normality using skewness and kurtosis statistics. If either

statistic was above an absolute value of 2.0, then normality was violated. Homogeneity of

variance was checked using Levene’s Test for Equality of Variances. Box’s M test was used to


assess the assumption of homogeneity of covariance. The assumption of sphericity was tested for

using Mauchly’s test. Mixed-effects ANOVA was used to test for significant interactions

between baseline HgA1c groups (0-7 vs. 8+) and baseline weight groups (normal, overweight,

and obese) and within subjects’ observations of HgA1c and weight at 3-6 months and 9-12

months. Marginal means with 95% confidence intervals were reported for mixed-effects

analyses. Statistical significance was assumed at an alpha value of 0.05 and all analyses were

conducted using SPSS Version 22.

The assumptions of normality, homogeneity of variance, homogeneity of covariance, and

sphericity were met for both analyses. There was a non-significant interaction effect between the

baseline HgA1c groups and observations at three to six months and nine to 12 months, F(1,73) =

0.42, p = 0.52, η2 = 0.01, power = 0.10. A non-significant interaction effect between baseline

weight groups was also observed at three to six months and nine to 12 months, F(2,72) = 0.18, p

= 0.83, η2 = 0.01, power = 0.08.

Chapter V: Discussion

Summary of Findings

T2DM is a deadly disease, symptoms can slowly develop overtime and if care is not

taken, it becomes uncontrollable bringing with it all the vascular complications that can

predispose patients to early mortality and morbidity. Effective and culturally-sensitive diabetic

education is the key to making sure patients understand and remain compliant with diabetes care

plan and self-care practices. The results of the study showed that, despite attending the two-day

diabetes education class, most of these patients still do not understand how to manage T2DM.

This shows that the education being provided is not effective and revisions are necessary.

Providers need to be educated about how to accurately assess their target population for


their education needs, understand their cultural beliefs, socioeconomic status, ethnic and

religious beliefs in order to provide appropriate culturally-sensitive diabetes education that can

help patients understand what diabetes is and the importance of compliance with medications,

lifestyle and diet modifications in conjunction with self-care practices. Lack of adequate

knowledge about diabetes pathophysiology, complications, and self-management is one of the

major factors that lead to increase in mortality and morbidity rates of T2DM. Provision of

adequate and effective patient education can help reduce incidents of micro vascular and macro

vascular complications from T2DM and this is what this population needs to survive the increase

in T2DM diagnosis. (Dias, Rodriguez, Sales, Oliveira, & Nery, 2016).

Interpretation of the Findings

Effective diabetes education can improve outcomes for patients and the clinical practice

as a whole. The findings of this study showed that the patients in the clinic did not receive

optimal education; the educational intervention was not effective and that was the reason there

were no positive changes in HgA1c, weights, and follow-up visits post-educational intervention.

Furthermore, the results also showed that adherence to follow-up visit had no significant impact

on the patients’ HgA1c and weights because the education being provided was not effective

enough. Providing effective culturally sensitive education is key to improving the quality of life

of people that have been diagnosed with diabetes and people with pre-diabetes. Presenting

education in ways that is easy to understand complications and disease management can go a

long way in reducing the morbidity and mortality rates from diabetes and other cardiovascular

diseases. Progression of T2DM to multiorgan failure can be avoided with effective diabetes

education and can help improve compliance and ensure positive outcomes for patients. It is of

utmost importance for healthcare providers to be able to assess a population or patients’ needs


accurately in order to provide care and education in accordance with the needs of the targeted

patient population, thereby improving compliance and decreasing the incidents of mortality and

morbidity from T2DM. The findings of this study are congruent with what multiple literatures

have said and established about effective diabetes education, it goes on to show that if patients

do not understand the education being provided, there will not be positive changes noted in their

health status and patients will continue to have negative outcomes.

Analysis

The findings from this study corroborate other research findings and place emphasis on

the importance of effective diabetes education tailored towards the community or individual

needs. The results of the study were interpreted based on the given data and existing research

about the importance of effective patient education. There were no unwarranted causal

inferences or other supplementary analyses taken into consideration when interpreting the results

of this study. Results were interpreted based on the given data and are believed to be valid and

accurate. The results showed that the educational intervention was not effective, the patients did

not have an understanding of how to manage T2DM. The program needs revising in order to

improve practice and patients’ outcomes.

Strengths and Limitations

The strength of this study lies in the fact that this study is a retrospective chart review

using a quantitative exploratory design that did not engage participants. Data were abstracted

from patients charts who had been diagnosed of T2DM thus, eliminating the risk of bias. Also,

data collected were verified to be accurate and straight from patients’ EMRs, confidentiality and

HIPAA law were upheld because only the author had access to these EMRs and patients’

identifying/sensitive information were removed prior to transferring data into the data collection


sheet. The author utilized a consecutive sampling method which encompassed every patient

above 18 years of age with diagnosis of T2DM and who attended the two-day educational

intervention program from January 1, 2016 to December 31, 2016. Consecutive sampling is less

likely to be biased and is often the best choice when dealing with participants in a clinic that has

rolling enrolments all year long (Polit & Beck, 2012). The only limitation with this project was

the author did not engage participants to assess them and understand why it is difficult for them

to remain compliant with the plan of care, engaging the patients might give a different

perspective on the project and shed more light into the reasons for increased T2DM diagnosis

and complications among this population. Also, the population was 100% African American, no

other racial or ethnic group was included in the study.

Implications for Research and Practice

The purpose of this project was to determine if a two-day diabetes education promoted

positive changes in baseline HgA1c and weight at three to six months and nine to 12 months

post- educational intervention. Patient education needs to be effective, culturally-sensitive and

specifically tailored towards the population or individual needs to effect positive changes and

improve patients’ outcomes. Furthermore, at the conclusion of the project, the author plans to

hold a meeting with medical director of the clinic and health care professionals in the clinic to

discuss the implications of the research study and determine what needs to be changed in the

education program to make it more effective. The clinic already puts a lot of work into the two-

day diabetes education class but more needs to be done. Considering the fact that about 10% of

the clinic population are African immigrants, they need to be thoroughly assessed and barriers to

educational compliance need to be identified in order to provide effective culturally sensitive

education to the population.


Also, utilizing texting to remind patients appointment dates can be beneficial as this can

help with compliance. Incorporating the volunteer program into the clinic’s educational program

can also help. The author’s sons volunteer at the clinic and have started helping to bridge the

cultural gap that exists among African immigrants, African Americans and the American culture,

with this program in place, compliance should improve among the population. Starting a follow-

up visit program is another way of helping the patients remain compliant and willing to take the

necessary steps to be healthy. All the suggestions mentioned above will be discussed with

medical director at the conclusion of the project.

Nursing and Healthcare

It is essential for the Advanced Practice Nurse (APN) to make sure that patients

diagnosed with T2DM receive optimal education about diabetes self-management. Diabetic self-

management education and support have been proven to decrease incidents of complications and

readmission among diabetic patients (Tracey, McHugh, Buckley, Canavan, Fitzgerald, &

Kearney, 2016). APNs are at the forefront of healthcare due to their advanced educational

background and experience. Working to foster positive change that translates into positive

outcomes for the patients is a component of their scope of practice (American Association of

Colleges of Nursing, 2006). This project is no exception; knowledge acquired from this scholarly

project would be translated into practice to improve and provide quality care to the patients.

Benefit of Project to Practice

It has been proven that self-care practices like diet and lifestyle modifications can prevent

the progression of pre-diabetes to diabetes and reduce incidents of complications (Yates, Davies,

Henson, Troughton, Edwardson, Gray, & Khunti, 2012). Complications such as diabetes

retinopathy, nephropathy, neuropathy, lower limb amputation, and cardiovascular issues can be


avoided with effective diabetes education and patients’ compliance. Results from this project

will lead to improvement of the educational two-day workshop. This would benefit the patients

at the inner-city clinic by providing better ways of managing T2DM and decreasing the risk of

complications.

Recommendations

There is a great need for future studies on effective diabetes education, patients continue

to experience complications from T2DM due to lack of effective diabetes education, mortality

and morbidity rates continue to rise. The next step is determining what needs to be changed in

the educational program; why is it not working? Does it have to do with consistency, was patient

education delivered the same way each time? Furthermore, follow-up educational visit is another

option that needs to be explored in order to make this educational intervention effective. Training

the providers on how to provide effective diabetes education can help reduce the rates of

complications; having a designated diabetic educator that can provide effective education and

can also follow up with patients is key to curbing the rise of T2DM and its complications.

Conclusion

Type 2 diabetes has become a menace to our society and effective control of this

disease depends on being aggressive when it comes to educating the public about the dangerous

effects it has on all the body systems. Its sequelae can be seen in atherosclerosis, myocardial

infarction, peripheral arterial/vascular disease, renal failure, and hypertension. Providing

effective culturally sensitive education is key to improving the quality of life of people that have

been diagnosed with diabetes and people with pre-diabetes; providing education in a way that is

easy to understand complications and disease management can go a long way in reducing the

morbidity and mortality rates from diabetes and other cardiovascular diseases. Effective diabetes


education can help improve/increase compliance, it can also ensure positive outcomes for

patients. It is of utmost importance for healthcare providers to be able to assess a

population/patient’ needs accurately to provide care/education in accordance with the needs of

the targeted patient population.


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Chart No

Age >18Yes (1)No (2)

Baseline HgA1c<6 (1) 6-7 (2) >8 (3)

Baseline WeightNormal (1) Overweight (2) Obese (3)

HgA1c @ 3-6 mosImproved (1)No Change (2)Worse (3)

HgA1c @ 9-12 mosImproved (1)No Change (2)Worse (3)

AttendedClinic Jan 1, 2016-Dec 31, 2016Yes (1)No (2)

Weight @3-6 mosWeight loss (1)No Change (2)Weight gain (3)

Weight @ 9-12 mosWeight loss (1)No Change (2)Weight gain (3)

Compliance with f/u visitYes (1)No (2)

1 1 2 2 2 1 1 1 1 12 1 2 2 2 3 1 3 3 23 1 3 2 1 1 1 1 1 14 1 2 3 3 1 1 2 1 15 1 3 2 1 1 1 1 1 16 1 2 1 3 3 1 3 3 27 1 3 2 3 3 1 3 3 28 1 3 2 1 1 1 1 1 19 1 2 2 1 3 1 1 3 110 1 2 1 2 2 1 2 2 111 1 1 1 1 1 1 1 1 112 1 3 2 3 3 1 3 3 213 1 2 2 2 3 1 2 3 114 1 2 3 1 3 1 1 3 215 1 3 2 1 1 1 1 1 116 1 2 1 1 1 1 1 1 117 1 2 2 1 1 1 1 1 1


18 1 2 2 2 3 1 2 3 219 1 3 2 1 1 1 1 1 120 1 3 2 1 3 1 1 3 221 1 2 2 3 3 1 3 3 222 1 2 3 2 1 1 2 1 123 1 3 3 1 1 1 1 1 124 1 3 2 1 1 1 1 1 125 1 2 2 1 2 1 1 1 126 1 2 2 1 1 1 1 1 127 1 2 2 1 1 1 1 1 128 1 2 2 2 3 1 2 3 129 1 2 3 1 1 1 1 1 130 1 3 2 3 1 1 3 1 131 1 3 3 3 3 1 3 3 232 1 3 2 3 3 1 3 3 233 1 2 2 1 1 1 1 1 134 1 3 2 1 1 1 1 1 135 1 2 1 2 2 1 2 2 136 1 2 2 1 2 1 1 2 137 1 2 2 1 2 1 1 2 138 1 2 2 1 1 1 2 1 139 1 2 2 1 1 1 1 1 140 1 2 2 1 1 1 1 1 141 1 2 2 2 2 1 2 2 142 1 2 2 1 2 1 1 2 243 1 2 2 2 2 1 2 2 244 1 2 2 1 1 1 1 1 145 1 2 3 1 1 1 1 1 146 1 2 2 1 1 1 1 1 147 1 3 3 1 1 1 1 1 148 1 2 2 1 1 1 1 1 149 1 2 2 3 3 1 3 3 250 1 2 2 2 2 1 2 2 251 1 2 3 2 1 1 2 1 152 1 2 3 3 3 1 3 3 253 1 2 2 3 1 1 3 1 154 1 2 3 3 3 1 3 3 255 1 2 3 1 1 1 1 1 156 1 2 2 1 1 1 1 1 157 1 2 2 2 2 1 2 2 258 1 2 2 1 1 1 1 1 159 1 2 3 1 1 1 1 1 160 1 2 2 2 1 1 2 1 161 1 2 3 2 1 1 2 1 162 1 3 3 3 3 1 3 3 263 1 3 2 3 1 1 3 1 1


64 1 3 3 3 3 1 3 3 265 1 2 2 1 1 1 1 1 166 1 3 2 3 3 1 3 3 167 1 2 2 2 1 1 2 1 168 1 2 3 3 3 1 3 3 169 1 3 2 3 3 1 3 3 270 1 2 2 3 3 1 3 3 271 1 3 3 1 1 1 1 1 172 1 3 3 1 2 1 1 2 173 1 2 2 1 1 1 1 1 174 1 2 3 3 3 1 3 3 275 1 3 3 2 1 1 2 1 1

Adherence to follow up visit

a quality improvement project: enhancing care of patients...

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