Home Uncategorized differences and similarities between the three forms of nursing inquiry: quality improvement (QI), research, and evidence-based practice (EBP).

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differences and similarities between the three forms of nursing inquiry: quality improvement (QI), research, and evidence-based practice (EBP).

Instructions:

Read the evidence representing the three forms of nursing inquiry (QI, research, and EBP) on provided articles (attached). selected problem/ articles: (Improving the control of blood sugar in diabetic patients). Analyze the aim, methods used, and outcomes sought for each type of inquiry. Determine how teamwork and critical thinking processes were implemented. Create a PowerPoint presentation using Microsoft PowerPoint.

Material provided (attached): three articles related to Diabetes using QI, research, and EBP approach:

– American Diabetes Association. (2018). Diabetes Care in the Hospital: Standards of Medical Care in Diabetes-2019. doi: 10.2337/dc19-S015 Link (Links to an external site.)

– Russell, N.M., Vess, J., Durham, C., & Johnson, E. (2017). Text-messaging to support diabetes self-management in a rural health clinic: A Quality Improvement project. Online Journal of Nursing Informatics, 21(2). Link (Links to an external site.)

– Whitehead, L.C., Crowe, M.T., Carter, J.D., Maskill, V.R., Caryle, D., Bugge, C., & Frampton, C.M.A. (2017). A nurse-led education and cognitive behavior therapy-based intervention among adults with uncontrolled type 2 diabetes: A randomized controlled trial. Journal of Evaluation in Clinical Practice, 23(4). 821-829. doi: 10.1111/jep.12725 Link (Links to an external site.)

Purpose: The purpose of this assignment is to analyze the differences and similarities between the three forms of nursing inquiry: quality improvement (QI), research, and evidence-based practice (EBP). This assignment will allow for a discovery into the aim, methods and outcomes associated with each type of inquiry, including how these forms of inquiry are distinct yet similar in addressing a nursing practice problem. Formulation of a PowerPoint presentation which is inclusive of comprehensive speaker notes that supports professional formation, communication, and dissemination skills relevant to the DNP practice scholar.

Include the following sections addressing the three forms of nursing inquiry (detailed criteria listed below and in the Grading Rubric).

– Introduction (1-2 slides)

– Describes purpose of the presentation

– Identifies selected nursing problem

– Includes significance and scope of the practice problem (including citation)

– Differentiation of the three forms of nursing inquiry (2-4 slides)

– Compares and contrasts QI, research, and EBP as forms of nursing inquiry

– Discusses the impact of each form of inquiry on nursing practice

– Describes how the DNP practice scholar applies each form of inquiry

– Analyses of the evidence representing the three forms of nursing inquiry (5-7 slides)

– Identifies selected evidence representing the three forms of nursing inquiry (including citations)

– Compares and contrasts the aims of the selected evidence in addressing the practice problem

– Compares and contrasts the methods used in the selected evidence

– Examines the impact of teamwork, when used, in the selected evidence

– Compares outcomes in the selected evidence

– Conclusion (2-3 slides)

– Includes an evaluation of the impact of the three forms of evidence on the selected nursing practice problem /

– Includes a summative statement of the impact of the forms of inquiry on nursing

– Includes a summative statement of the impact of the forms of inquiry on the role of the DNP practice scholar

– References (1-2 slides). Includes all references cited in the presentation. Can be the three provided for analysis (attached material) and at least another to address the differences between quality improvement (QI), research, and evidence-based practice (EBP).

PowerPoint Requirements:

– Includes 10-18 PowerPoint slides

– Maintains the 6 x 6 rule for a professional PowerPoint presentation: (no more than 6 lines per slide, 6 words per line).

– Include speaker notes that support professional formation, communication, and dissemination skills.

– Grammar and mechanics are free of errors

– Uses appropriate APA format (6th ed.) and is free of errors

15. Diabetes Care in the Hospital:
Standards of Medical Care in
Diabetesd2019
Diabetes Care 2019;42(Suppl. 1):S173–S181 | https://doi.org/10.2337/dc19-S015

The American Diabetes Association (ADA) “Standards of Medical Care in Diabetes”
includes ADA’s current clinical practice recommendations and is intended to provide
the components of diabetes care, general treatment goals and guidelines, and tools
to evaluate quality of care.Members of theADAProfessional Practice Committee, a
multidisciplinary expert committee, are responsible for updating the Standards of
Care annually, or more frequently as warranted. For a detailed description of ADA
standards, statements, and reports, as well as the evidence-grading system for
ADA’s clinical practice recommendations, please refer to the Standards of Care
Introduction. Readers who wish to comment on the Standards of Care are invited
to do so at professional.diabetes.org/SOC.

In the hospital, both hyperglycemia and hypoglycemia are associated with adverse
outcomes, including death (1,2). Therefore, inpatient goals should include the
prevention of both hyperglycemia and hypoglycemia. Hospitals should promote
the shortest safe hospital stay and provide an effective transition out of the hospital
that prevents acute complications and readmission.
For in-depth review of inpatient hospital practice, consult recent reviews that

focus on hospital care for diabetes (3,4).

HOSPITA

CARE DELIVERY STANDARDS

Recommendation

15.1 Perform an A1C on all patients with diabetes or hyperglycemia (blood
glucose.140 mg/dL [7.8 mmol/L]) admitted to the hospital if not performed
in the prior 3 months. B

High-quality hospital care for diabetes requires both hospital care delivery stan-
dards, often assured by structured order sets, and quality assurance standards for
process improvement. “Best practice” protocols, reviews, and guidelines (2) are
inconsistently implemented within hospitals. To correct this, hospitals have estab-
lished protocols for structured patient care and structured order sets, which include
computerized physician order entry (CPOE).

Considerations on Admission
Initial orders should state the type of diabetes (i.e., type 1 or type 2 diabetes) or no
previous history of diabetes. Because inpatient insulin use (5) and discharge orders
(6) can be more effective if based on an A1C level on admission (7), perform an A1C
test on all patients with diabetes or hyperglycemia admitted to the hospital if the
test has not been performed in the prior 3 months (8). In addition, diabetes
self-management knowledge and behaviors should be assessed on admission and

Suggested citation: American Diabetes Associa-
tion. 15. Diabetes care in the hospital: Standards
of Medical Care in Diabetesd2019. Diabetes
Care 2019;42(Suppl. 1):S173–S181

© 2018 by the American Diabetes Association.
Readers may use this article as long as the work
is properly cited, the use is educational and not
for profit, and the work is not altered. More infor-
mation is available at http://www.diabetesjournals
.org/content/license.

American Diabetes Association

Diabetes Care Volume 42, Supplement 1, January 2019 S173

15.
D
IA
B
ETES

C
A
R
E
IN

TH
E
H
O
SP
ITA

https://doi.org/10.2337/dc19-S015

http://care.diabetesjournals.org/lookup/doi/10.2337/dc19-sppc01

http://care.diabetesjournals.org/lookup/doi/10.2337/dc19-sint01

http://professional.diabetes.org/SOC

http://crossmark.crossref.org/dialog/?doi=10.2337/dc19-S015&domain=pdf&date_stamp=2018-12-03

http://www.diabetesjournals.org/content/license

diabetes self-management education
should be provided, if appropriate.
Diabetes self-management education
should include appropriate skills needed
after discharge, such as taking antihyper-
glycemic medications, monitoring glu-
cose, and recognizing and treating
hypoglycemia (2).

Physician Order Entry

Recommendation

15.2 Insulin should be administered
using validated written or com-
puterized protocols that allow
for predefined adjustments in
the insulin dosage based on
glycemic fluctuations. E

The National Academy of Medicine rec-
ommends CPOE to prevent medication-
related errors and to increase efficiency
in medication administration (9). A Co-
chrane review of randomized controlled
trials using computerized advice to im-
prove glucose control in the hospital
found significant improvement in the
percentage of time patients spent in
the target glucose range, lower mean
blood glucose levels, and no increase in
hypoglycemia (10). Thus, where feasible,
there should be structured order sets
that provide computerized advice for
glucose control. Electronic insulin order
templates also improve mean glucose
levels without increasing hypoglycemia
in patients with type 2 diabetes, so
structured insulin order sets should be
incorporated into the CPOE (11).

Diabetes Care Providers in theHospital

Recommendation

15.3 When caring for hospitalized
patientswith diabetes, consider
consulting with a specialized di-
abetes or glucose management
team where possible. E

Appropriately trained specialists or spe-
cialty teams may reduce length of stay,
improve glycemic control, and improve
outcomes, but studies are few (12,13). A
call to action outlined the studies needed
to evaluate these outcomes (14). People
with diabetes are known to have a higher
risk of 30-day readmission following hos-
pitalization. Specialized diabetes teams
caring for patients with diabetes during
their hospital stay can improve readmis-
sion rates and lower cost of care (15,16).

Early evidence suggests that virtual glu-
cose management services may be used to
improve glycemic outcomes in hospital-
ized patients and facilitate transition of
care after discharge (17). Details of team
formation are available from the Joint
Commission standards for programs and
the Society of Hospital Medicine (18,19).

Quality Assurance Standards
Even the best orders may not be carried
out in a way that improves quality, nor
are they automatically updated when
new evidence arises. To this end, the
Joint Commission has an accreditation
program for the hospital care of dia-
betes (18), and the Society of Hospital
Medicine has a workbook for program
development (19).

GLYCEMIC TARGETS IN
HOSPITALIZED PATIENTS

Recommendations

15.4 Insulin therapy shouldbe initiated
for treatment of persistent hyper-
glycemia starting at a threshold
$180 mg/dL (10.0 mmol/L).
Once insulin therapy is started,
a target glucose range of 140–
180 mg/dL (7.8–10.0 mmol/L) is
recommended for the majority
of critically ill patients and non-
critically ill patients. A

15.5 More stringent goals, such as
110–140mg/dL (6.1–7.8 mmol/L),
may be appropriate for se-
lected patients, if this can be
achieved without significant
hypoglycemia. C

Standard Definition of Glucose
Abnormalities
Hyperglycemia in hospitalized patients
is defined as blood glucose levels .140
mg/dL (7.8 mmol/L) (2,20). Blood glu-
cose levels that are persistently above
this level may require alterations in diet
or a change in medications that cause
hyperglycemia. An admission A1C value
$6.5% (48 mmol/mol) suggests that
diabetes preceded hospitalization (see
Section 2 “Classification and Diagnosis
of Diabetes”) (2,20). Level 1 hypoglyce-
mia in hospitalized patients is defined
as a measurable glucose concentration
,70 mg/dL (3.9 mmol/L) but $54 mg/dL
(3.0 mmol/L). Level 2 hypoglycemia
(defined as a blood glucose concentration
,54 mg/dL [3.0 mmol/L]) is the threshold

at which neuroglycopenic symptoms
begin to occur and requires immediate
action to resolve the hypoglycemic event.
Lastly, level 3 hypoglycemia is defined as
a severe event characterized by altered
mental and/or physical functioning that
requires assistance from another person
for recovery. See Table 15.1 for levels of
hypoglycemia (21). Hypoglycemia is dis-
cussed more fully below.

Moderate Versus Tight Glycemic
Control
A meta-analysis of over 26 studies, includ-
ing the Normoglycemia in Intensive Care
Evaluation–Survival Using Glucose Algo-
rithm Regulation (NICE-SUGAR) study,
showed increased rates of “severe hy-
poglycemia” (defined in the analysis as
blood glucose,40 mg/dL [2.2 mmol/L])
andmortality in cohortswith tight versus
moderate glycemic control (22). Recent
randomized controlled studies and meta-
analyses in surgical patients have also
reported that targeting perioperative
blood glucose levels to,180 mg/dL (10-
mmol/L) is associatedwith lower rates of
mortality and stroke compared with a tar-
get glucose ,200 mg/dL (11.1 mmol/L),
whereas no significant additional benefit
was found with more strict glycemic
control (,140 mg/dL [7.8 mmol/L])
(23,24). Insulin therapy should be initiated
for treatment of persistent hyperglyce-
mia starting at a threshold $180 mg/dL
(10.0 mmol/L). Once insulin therapy is
started, a target glucose range of 140–
180 mg/dL (7.8–10.0 mmol/L) is recom-
mended for the majority of critically ill
and noncritically ill patients (2). More
stringent goals, such as ,140 mg/dL
(7.8 mmol/L), may be appropriate for
selected patients, as long as this can be
achieved without significant hypoglyce-
mia. Conversely, higher glucose ranges
may be acceptable in terminally ill patients,

Table 15.1—Levels of hypoglycemia
(21)

Level
Glycemic

criteria/description

Level 1 Glucose ,70 mg/dL (3.9 mmol/L)
and glucose $54 mg/dL
(3.0 mmol/L)

Level 2 Glucose ,54 mg/dL (3.0 mmol/L)

Level 3 A severe event characterized
by altered mental and/or
physical status requiring
assistance

S174 Diabetes Care in the Hospital Diabetes Care Volume 42, Supplement 1, January 2019

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in patients with severe comorbidities, and
in inpatient care settings where frequent
glucose monitoring or close nursing su-
pervision is not feasible.
Clinical judgment combined with on-

going assessment of the patient’s clinical
status, including changes in the trajec-
tory of glucosemeasures, illness severity,
nutritional status, or concomitant med-
ications that might affect glucose levels
(e.g., glucocorticoids), should be incor-
porated into the day-to-day decisions
regarding insulin dosing (2).

BEDSIDE BLOOD GLUCOSE
MONITORING

Indications
In the patient who is eating meals, glu-
cose monitoring should be performed
before meals. In the patient who is not
eating, glucose monitoring is advised
every 4–6 h (2). More frequent blood
glucose testing ranging from every
30 min to every 2 h is required for
patients receiving intravenous insulin.
Observational studies have shown that
safety standards should be established
for blood glucose monitoring that pro-
hibit the sharing of fingerstick lancing
devices, lancets, and needles (25).

Point-of-Care Meters
Point-of-care (POC) meters have limi-
tations for measuring blood glucose.
Although the U.S. Food and Drug Ad-
ministration (FDA) has standards for
blood glucose meters used by lay per-
sons, there have been questions about
the appropriateness of these criteria,
especially in the hospital and for lower
blood glucose readings (26). Significant
discrepancies between capillary, venous,
and arterial plasma samples have been
observed in patients with low or high
hemoglobin concentrations and with hy-
poperfusion. Any glucose result that does
not correlate with the patient’s clinical
status should be confirmed through con-
ventional laboratory glucose tests. The
FDA established a separate category for
POCglucosemeters for use in health care
settings and has released guidance on
in-hospital use with stricter standards
(27). Before choosing a device for in-
hospital use, consider the device’s ap-
proval status and accuracy.

Continuous Glucose Monitoring
Real-time continuous glucose monitor-
ing (CGM) provides frequent measure-
ments of interstitial glucose levels, as

well as direction andmagnitude of glucose
trends, which may have an advantage
over POC glucose testing in detecting and
reducing the incidence of hypoglycemia
in the hospital setting (28,29). Several in-
patient studies have shown that CGM use
did not improve glucose control but
detected a greater number of hypogly-
cemic events than POC testing (30,31).
However, a recent review has recom-
mended against using CGM in adults in
a hospital setting until more safety and
efficacy data become available (30). For
more information on CGM, see Section 7
“Diabetes Technology.”

ANTIHYPERGLYCEMIC AGENTS IN
HOSPITALIZED PATIENTS

Recommendations

15.6 Basal insulin or a basal plus bolus
correction insulin regimen is the
preferred treatment for noncriti-
cally ill hospitalized patients with
poor oral intake or those who are
taking nothing by mouth. An in-
sulin regimen with basal, pran-
dial, and correction components
is the preferred treatment for
noncritically ill hospitalized pa-
tients with good nutritional in-
take. A

15.7 Sole use of sliding scale insulin in
the inpatient hospital setting is
strongly discouraged. A

In most instances in the hospital setting,
insulin is the preferred treatment for
hyperglycemia (2). However, in certain
circumstances, it may be appropriate to
continue home regimens including oral
antihyperglycemic medications (32). If
oral medications are held in the hospital,
there should be a protocol for resuming
them 1–2 days before discharge. Insulin
pens are the subject of an FDA warning
because of potential blood-borne dis-
eases, and care should be taken to follow
the label insert “For single patient use
only” (33). Recent reports, however,
have indicated that the inpatient use
of insulin pens appears to be safe and
may be associated with improved nurse
satisfaction compared with the use of
insulin vials and syringes (34–36).

Insulin Therapy

Critical Care Setting

In the critical care setting, continuous
intravenous insulin infusion has been

shown tobe thebestmethod for achieving
glycemic targets. Intravenous insulin infu-
sions should be administered based on
validated written or computerized proto-
cols that allow for predefined adjustments
in the infusion rate, accounting for glyce-
mic fluctuations and insulin dose (2).

Noncritical Care Setting

Outside of critical care units, scheduled
insulin regimens are recommended to
manage hyperglycemia in patients with
diabetes. Regimens using insulin analogs

and human insulin result in similar gly-

cemic control in the hospital setting (37).
The use of subcutaneous rapid- or short-

acting insulin beforemeals or every 4–6 h

if no meals are given or if the patient is

receiving continuous enteral/parenteral

nutrition is indicated to correct hyper-

glycemia (2). Basal insulin or a basal plus

bolus correction insulin regimen is the

preferred treatment for noncritically ill

hospitalized patients with poor oral in-

take or those who are taking nothing by

mouth (NPO). An insulin regimen with

basal, prandial, and correction compo-

nents is the preferred treatment for

noncritically ill hospitalized patients with

good nutritional intake.
If the patient is eating, insulin injec-

tions should align with meals. In such

instances, POC glucose testing should

be performed immediately before meals.

If oral intake is poor, a safer procedure is

to administer the rapid-acting insulin

immediately after the patient eats or

to count the carbohydrates and cover

the amount ingested (37).
A randomized controlled trial has

shown that basal-bolus treatment im-

proved glycemic control and reduced

hospital complications compared with

sliding scale insulin in general surgery

patients with type 2 diabetes (38). Pro-

longed sole use of sliding scale insulin in

the inpatient hospital setting is strongly

discouraged (2,14).
While there is evidence for using pre-

mixed insulin formulations in the out-

patient setting (39), a recent inpatient

study of 70/30 NPH/regular insulin ver-

sus basal-bolus therapy showed compa-

rable glycemic control but significantly

increased hypoglycemia in the group re-

ceiving premixed insulin (40). Therefore,

premixed insulin regimens are not rou-

tinely recommended for in-hospital use.

care.diabetesjournals.org Diabetes Care in the Hospital S175

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Type 1 Diabetes

For patients with type 1 diabetes, dosing
insulin based solely on premeal glucose
levels does not account for basal insulin
requirements or caloric intake, increas-
ing both hypoglycemia and hyperglyce-
mia risks. Typically, basal insulin dosing
schemes are based on body weight, with
some evidence that patients with renal
insufficiency should be treated with lower
doses (41). An insulin regimen with basal
and correction components is necessary
for all hospitalized patients with type 1
diabetes, with the addition of prandial
insulin if the patient is eating.

Transitioning Intravenous to

Subcutaneous Insulin

When discontinuing intravenous insu-
lin, a transition protocol is associated
with less morbidity and lower costs of
care (42) and is therefore recommended.
A patient with type 1 or type 2 diabetes
being transitioned to outpatient subcu-
taneous insulin should receive subcuta-
neous basal insulin 2–4 h before the
intravenous insulin is discontinued. Con-
verting to basal insulin at 60–80% of the
daily infusion dose has been shown to be
effective (2,42,43). For patients continu-
ing regimens with concentrated insulin
(U-200, U-300, or U-500) in the inpatient
setting, it is important to ensure the
correct dosing by utilizing an individual
pen and cartridge for each patient, me-
ticulous pharmacist supervision of the
dose administered, or other means
(44,45).

Noninsulin Therapies
The safety and efficacy of noninsulin
antihyperglycemic therapies in the hos-
pital setting is an area of active research.
A few recent randomized pilot trials in
general medicine and surgery patients
reported that a dipeptidyl peptidase 4
inhibitor alone or in combination with
basal insulin was well tolerated and
resulted in similar glucose control and
frequency of hypoglycemia compared
with a basal-bolus regimen (46–48).
However, an FDA bulletin states that
providers should consider discontinu-
ing saxagliptin and alogliptin in people
who develop heart failure (49). A review
of antihyperglycemic medications con-
cluded that glucagon-like peptide 1 re-
ceptor agonists show promise in the
inpatient setting (50); however, proof
of safety and efficacy awaits the results
of randomized controlled trials (51).

Moreover, the gastrointestinal symp-
toms associated with the glucagon-like
peptide 1 receptor agonists may be
problematic in the inpatient setting.

Regarding the sodium–glucose trans-
porter 2 (SGLT2) inhibitors, the FDA
includes warnings about diabetic keto-
acidosis (DKA) and urosepsis (52), urinary
tract infections, and kidney injury (53) on
the drug labels. A recent review suggested
SGLT2 inhibitors be avoided in severe
illness, when ketone bodies are present,
and during prolonged fasting and surgical
procedures (3). Until safety and effec-
tiveness are established, SGLT2 inhibitors
cannot be recommended for routine
in-hospital use.

HYPOGLYCEMIA

Recommendations

15.8 A hypoglycemia management
protocol should be adopted and
implemented by each hospital or
hospital system. A plan for pre-
venting and treating hypoglyce-
mia should be established for
each patient. Episodes of hypo-
glycemia in the hospital should
be documented in the medical
record and tracked. E

15.9 The treatment regimen should
be reviewed and changed as nec-
essary to prevent further hypogly-
cemiawhen a blood glucose value
of ,70 mg/dL (3.9 mmol/L) is
documented. C

Patients with or without diabetes may ex-
perience hypoglycemia in the hospital set-
ting. While hypoglycemia is associated
with increased mortality (54), hypoglycemia
may be a marker of underlying disease
rather than the cause of increased mor-
tality. However, until it is provennot to be
causal, it is prudent to avoid hypoglycemia.
Despite the preventable nature of many
inpatient episodes of hypoglycemia, insti-
tutions are more likely to have nursing pro-
tocols for hypoglycemia treatment than
for its prevention when both are needed.

A hypoglycemia prevention and man-
agement protocol should be adopted
and implemented by each hospital or
hospital system. There should be a stan-
dardized hospital-wide, nurse-initiated
hypoglycemia treatment protocol to
immediately address blood glucose lev-
els of ,70 mg/dL (3.9 mmol/L), as well
as individualized plans for preventing

and treating hypoglycemia for each pa-
tient. An American Diabetes Association
(ADA) consensus report suggested that
a patient’s overall treatment regimen
be reviewed when a blood glucose value
of ,70 mg/dL (3.9 mmol/L) is identified
because such readings often predict im-
minent level 3 hypoglycemia (2).

Episodes of hypoglycemia in the hos-
pital should be documented in the med-
ical record and tracked (2).

Triggering Events
Iatrogenic hypoglycemia triggers may in-
clude sudden reduction of corticosteroid
dose, reduced oral intake, emesis, new
NPO status, inappropriate timing of short-
or rapid-acting insulin in relation to meals,
reduced infusion rate of intravenous
dextrose, unexpected interruption of oral,
enteral, or parenteral feedings, and al-
tered ability of the patient to report
symptoms (3).

Predictors of Hypoglycemia
In one study, 84% of patients with an
episode of “severe hypoglycemia” (de-
fined as,40 mg/dL [2.2 mmol/L]) had a
prior episode of hypoglycemia (,70
mg/dL [3.9 mmol/L]) during the same ad-
mission (55). In another study of hypo-
glycemic episodes (defined as,50 mg/dL
[2.8 mmol/L]), 78% of patients were
using basal insulin, with the incidence
of hypoglycemia peaking between mid-
night and 6 A.M. Despite recognition of
hypoglycemia, 75% of patients did not
have their dose of basal insulin changed
before the next insulin administration
(56).

Prevention
Common preventable sources of iatro-
genic hypoglycemia are improper pre-
scribing of hypoglycemic medications,
inappropriate management of the first
episode of hypoglycemia, and nutrition–
insulin mismatch, often related to an
unexpected interruption of nutrition.
Studies of “bundled” preventative ther-
apies including proactive surveillance of
glycemic outliers and an interdisciplinary
data-driven approach to glycemic man-
agement showed that hypoglycemic epi-
sodes in the hospital could be prevented.
Compared with baseline, two such stud-
ies found that hypoglycemic events fell
by 56% to 80% (57,58). The Joint Com-
mission recommends that all hypogly-
cemic episodes be evaluated for a root

S176 Diabetes Care in the Hospital Diabetes Care Volume 42, Supplement 1, January 2019

cause and the episodes be aggregated
and reviewed to address systemic issues.

MEDICAL NUTRITION THERAPY IN
THE HOSPITAL

The goals of medical nutrition therapy in
the hospital are to provide adequate
calories to meet metabolic demands,
optimize glycemic control, address per-
sonal food preferences, and facilitate
creation of a discharge plan. The ADA
does not endorse any single meal plan or
specified percentages of macronutrients.
Current nutrition recommendations ad-
vise individualization based on treatment
goals, physiological parameters, andmed-
ication use. Consistent carbohydrate meal
plans are preferred by many hospitals as
they facilitate matching the prandial in-
sulin dose to the amount of carbohydrate
consumed (59). Regarding enteral nutri-
tional therapy, diabetes-specific formu-
las appear to be superior to standard
formulas in controlling postprandial glu-
cose, A1C, and the insulin response (60).
When the nutritional issues in the

hospital are complex, a registered di-
etitian, knowledgeable and skilled in
medical nutrition therapy, can serve as
an individual inpatient team member.
That person should be responsible for
integrating information about the pa-
tient’s clinical condition, meal planning,
and lifestyle habits and for establishing
realistic treatment goals after discharge.
Orders should also indicate that the meal
delivery and nutritional insulin coverage
should be coordinated, as their variability
often creates the possibility of hypergly-
cemic and hypoglycemic events.

SELF-MANAGEMENT IN THE
HOSPITAL

Diabetes self-management in the hospi-
tal may be appropriate for select youth
and adult patients (61,62). Candidates
include patients who successfully conduct
self-management of diabetes at home,
have the cognitive and physical skills
needed to successfully self-administer
insulin, and perform self-monitoring of
blood glucose. In addition, they should
have adequate oral intake, be proficient
in carbohydrate estimation, use multi-
ple daily insulin injections or continuous
subcutaneous insulin infusion (CSII),
have stable insulin requirements, and
understand sick-day management. If
self-management is to beused, a protocol
should include a requirement that the

patient, nursing staff, and physician agree
that patient self-management is appro-
priate. If CSII is to be used, hospital policy
and procedures delineating guidelines
for CSII therapy, including the changing
of infusion sites, are advised (63).

STANDARDS FOR SPECIAL
SITUATIONS

Enteral/Parenteral Feedings
For patients receiving enteral or paren-
teral feedings who require insulin, insulin
should be divided into basal, prandial,
and correctional components. This is
particularly important for people with
type 1 diabetes to ensure that they
continue to receive basal insulin even if
the feedings are discontinued. One may
use the patient’s preadmission basal in-
sulin dose or a percentage of the total
daily dose of insulin when the patient is
being fed (usually 30–50% of the total
daily dose of insulin) to estimate basal
insulin requirements. However, if no
basal insulin was used, consider using
5 units of NPH/detemir insulin subcuta-
neously every 12 h or 10 units of insulin
glargine every 24 h (64). For patients
receiving continuous tube feedings, the
total daily nutritional component may be
calculated as 1 unit of insulin for every
10–15 g carbohydrate per day or as a
percentage of the total daily dose of
insulin when the patient is being fed
(usually 50–70% of the total daily dose
of insulin). Correctional insulin should
also be administered subcutaneously
every 6 h using human regular insulin
or every 4 h using a rapid-acting insulin
such as lispro, aspart, or glulisine. For
patients receiving enteral bolus feedings,
approximately 1 unit of regular human
insulin or rapid-acting insulin per 10–15 g
carbohydrate should be given subcuta-
neously before each feeding.

Correctional insulin coverage should
be added as needed before each feeding.
For patients receiving continuous periph-
eral or central parenteral nutrition, hu-
man regular insulin may be added to
the solution, particularly if .20 units of
correctional insulin have been required
in the past 24 h. A starting dose of 1 unit
of human regular insulin for every 10 g
dextrose has been recommended (65),
to be adjusted daily in the solution.
Correctional insulin should be admin-
istered subcutaneously. For full enteral/
parenteral feeding guidance, the reader

is encouraged to consult review articles
detailing this topic (2,66).

Glucocorticoid Therapy
Glucocorticoid type and duration of ac-
tion must be considered in determining
insulin treatment regimens. Once-a-day,
short-acting glucocorticoids such as
prednisone peak in about 4–8 h (67),
so coverage with intermediate-acting
(NPH) insulin may be sufficient. For
long-acting glucocorticoids such as dexa-
methasone or multidose or continuous
glucocorticoid use, long-acting insulin
may be used (32,66). For higher doses
of glucocorticoids, increasing doses of
prandial and correctional insulin may be
needed in addition to basal insulin (68).
Whatever orders are started, adjust-
ments based on anticipated changes in
glucocorticoid dosing and POC glucose
test results are critical.

Perioperative Care
Many standards for perioperative care
lack a robust evidence base. However,
the following approach (69) may be
considered:

1. Target glucose range for the perioper-
ative period should be 80–180 mg/dL
(4.4–10.0 mmol/L).

2. Perform a preoperative risk assess-
ment for patients at high risk for
ischemic heart disease and those
with autonomic neuropathy or renal
failure.

3. Withhold metformin the day of sur-
gery.

4. Withhold any other oral hypoglycemic
agents the morning of surgery or pro-
cedure and give half of NPH dose or
60–80% doses of long-acting analog
or pump basal insulin.

5.Monitor blood glucose at least
every 4–6 h while NPO and dose
with short- or rapid-acting insulin as
needed.

A review found that perioperative
glycemic control tighter than 80–
180 mg/dL (4.4–10.0 mmol/L) did not
improve outcomes and was associated
with more hypoglycemia (70); therefore,
in general, tighter glycemic targets are
not advised. A recent study reported
that, compared with the usual insulin
dose, on average an approximate 25%
reduction in the insulin dose given the
evening before surgery was more likely
to achieve perioperative blood glucose

care.diabetesjournals.org Diabetes Care in the Hospital S177

http://care.diabetesjournals.org

levels in the target range with decreased
risk for hypoglycemia (71).
In noncardiac general surgery patients,

basal insulin plus premeal short- or rapid-
acting insulin (basal-bolus) coverage has
been associated with improved glycemic
control and lower rates of perioperative
complications compared with the tradi-
tional sliding scale regimen (short- or
rapid-acting insulin coverage only with
no basal insulin dosing) (38,72).

Diabetic Ketoacidosis and
Hyperosmolar Hyperglycemic State
There is considerable variability in the pre-
sentation of DKA and hyperosmolar hyper-
glycemic state, ranging fromeuglycemia
or mild hyperglycemia and acidosis to
severe hyperglycemia, dehydration, and
coma; therefore, treatment individualiza-
tion based on a careful clinical and lab-
oratory assessment is needed (73–76).
Management goals include restora-

tion of circulatory volume and tissue
perfusion, resolution of hyperglycemia,
and correction of electrolyte imbalance
and ketosis. It is also important to treat
any correctable underlying cause of DKA
such as sepsis.
In critically ill and mentally obtunded

patients with DKA or hyperosmolar hy-
perglycemic state, continuous intrave-
nous insulin is the standard of care.
Successful transition of patients from
intravenous to subcutaneous insulin re-
quires administration of basal insulin 2–
4 h prior to the intravenous insulin being
stopped to prevent recurrence of keto-
acidosis and rebound hyperglycemia (76).
There is no significant difference in out-
comes for intravenous human regular
insulin versus subcutaneous rapid-acting
analogs when combined with aggressive
fluid management for treating mild or
moderate DKA (77). Patients with un-
complicated DKA may sometimes be
treated with subcutaneous insulin in
the emergency department or step-
down units (78), an approach that may
be safer and more cost-effective than
treatment with intravenous insulin (79).
If subcutaneous administration is used,
it is important to provide adequate fluid
replacement, nurse training, frequent
bedside testing, infection treatment if
warranted, and appropriate follow-up
to avoid recurrent DKA. Several studies
have shown that the use of bicarbonate
in patients with DKA made no difference
in resolution of acidosis or time to

discharge, and its use is generally not
recommended (80). For further informa-
tion regarding treatment, refer to recent
in-depth reviews (3).

TRANSITION FROM THE ACUTE
CARE SETTING

Recommendation

15.10 There should be a structured
dischargeplan tailored to the in-
dividual patient with diabetes. B

A structured discharge plan tailored to
the individual patient may reduce length
of hospital stay and readmission rates
and increase patient satisfaction (81).
Therefore, there should be a structured
discharge plan tailored to each patient.
Discharge planning should begin at ad-
mission and be updated as patient needs
change.

Transition from the acute care setting
is a risky time for all patients. Inpatients
may be discharged to varied settings,
including home (with or without visiting
nurse services), assisted living, rehabili-
tation, or skilled nursing facilities. For the
patient who is discharged to home or to
assisted living, the optimal program will
need to consider diabetes type and se-
verity, effects of the patient’s illness on
blood glucose levels, and the patient’s
capacities and preferences. See Section
12 “Older Adults” for more information.

An outpatient follow-up visit with the
primary care provider, endocrinologist,
or diabetes educator within 1 month of
discharge is advised for all patients hav-
ing hyperglycemia in the hospital. If
glycemic medications are changed or
glucose control is not optimal at dis-
charge, an earlier appointment (in 1–2
weeks) is preferred, and frequent con-
tact may be needed to avoid hypergly-
cemia and hypoglycemia. A recently
described discharge algorithm for glyce-
mic medication adjustment based on
admission A1C found that use of the
algorithm to guide treatment decisions
resulted in significant improvements in
the average A1C after discharge (6).
Therefore, if an A1C from the prior 3
months is unavailable,measuring the A1C
in all patients with diabetes or hyper-
glycemia admitted to the hospital is
recommended.

Clear communication with outpatient
providers either directly or via hospital
discharge summaries facilitates safe

transitions to outpatient care. Providing
information regarding the cause of hy-
perglycemia (or the plan for determining
the cause), related complications and
comorbidities, and recommended treat-
ments can assist outpatient providers as
they assume ongoing care.

The Agency for Healthcare Research
and Quality (AHRQ) recommends that,
at a minimum, discharge plans include
the following (82):

Medication Reconciliation
○ The patient’s medications must be

cross-checked to ensure that no
chronic medications were stopped
and to ensure the safety of new
prescriptions.

○ Prescriptions fornewor changedmed-
ication should be filled and reviewed
with the patient and family at or
before discharge.

Structured Discharge Communication
○ Information on medication changes,

pending tests and studies, and follow-
up needs must be accurately and
promptly communicated to outpa-
tient physicians.

○ Discharge summaries should be
transmitted to the primary care pro-
vider as soon as possible after dis-
charge.

○ Appointment-keeping behavior is en-
hanced when the inpatient team
schedules outpatient medical follow-
up prior to discharge.

It is recommended that the following
areas of knowledge be reviewed and
addressed prior to hospital discharge:

○ Identification of the health care pro-
vider who will provide diabetes care
after discharge.

○ Level of understanding related to the
diabetes diagnosis, self-monitoring of
blood glucose, home blood glucose
goals, and when to call the provider.

○ Definition, recognition, treatment, and
prevention of hyperglycemia and hy-
poglycemia.

○ Information on making healthy food
choices at home and referral to an
outpatient registered dietitian nutri-
tionist to guide individualization of
meal plan, if needed.

○ If relevant, when and how to take
blood glucose–lowering medications,
including insulin administration.

S178 Diabetes Care in the Hospital Diabetes Care Volume 42, Supplement 1, January 2019

http://care.diabetesjournals.org/lookup/doi/10.2337/dc19-S012

○ Sick-day management.
○ Properuseanddisposal ofneedles and

syringes.

It is important that patients be pro-
vided with appropriate durable medical
equipment, medications, supplies (e.g.,
blood glucose test strips), and prescrip-
tions along with appropriate education
at the time of discharge in order to
avoid a potentially dangerous hiatus
in care.

PREVENTING ADMISSIONS AND
READMISSIONS

Preventing Hypoglycemic Admissions
in Older Adults
Insulin-treated patients 80 years of age
or older are more than twice as likely to visit
the emergency department and nearly
five times as likely to be admitted for
insulin-related hypoglycemia than those
45–64 years of age (83). However, older
adults with type 2 diabetes in long-term
care facilities taking either oral antihy-
perglycemic agents or basal insulin have
similar glycemic control (84), suggesting
that oral therapy may be used in place of
insulin to lower the risk of hypoglycemia
for some patients. In addition, many
older adults with diabetes are over-
treated (85), with half of those maintain-
ing an A1C ,7% (53 mmol/mol) being
treated with insulin or a sulfonylurea,
which are associated with hypoglycemia.
To further lower the risk of hypoglyce-
mia-related admissions in older adults,
providers may, on an individual basis,
relax A1C targets to 8% (64 mmol/mol)
or 8.5% (69 mmol/mol) in patients with
shortened life expectancies and signifi-
cant comorbidities (refer to Section 12
“Older Adults” for detailed criteria).

Preventing Readmissions
In patients with diabetes, the hospital re-
admission rate is between14 and20% (86).
Risk factors for readmission include
lower socioeconomic status, certain ra-
cial/ethnic minority groups, comorbid-
ities, urgent admission, and recent prior
hospitalization (86). Of interest, 30% of
patients with two or more hospital stays
account for over 50% of hospitalizations
and their accompanying hospital costs
(87). While there is no standard to pre-
vent readmissions, several successful
strategies have been reported, including
an intervention program targeting ketosis-
prone patients with type 1 diabetes (88),
initiating insulin treatment in patients

with admission A1C.9% (75 mmol/mol)
(89), and a transitional care model (90).
For people with diabetic kidney dis-
ease, patient-centered medical home
collaboratives may decrease risk-adjusted
readmission rates (91).

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OR I G I N A L A R T I C L E

A nurse‐led education and cognitive behaviour therapy‐based
intervention among adults with uncontrolled type 2 diabetes: A
randomised controlled trial

Lisa C. Whitehead PhD1 | Marie T. Crowe PhD2 | Janet D. Carter PhD3 |

Virginia R. Maskill MHealSc4 | Dave Carlyle PhD5 | Carol Bugge PhD6 |

Chris M. A. Frampton PhD7

1Associate Dean Research, School of Nursing

and Midwifery, Edith Cowan University,

Joondalup, Australia

2Associate Dean, Centre for Postgraduate

Nursing Studies & Department of

Psychological Medicine, University of Otago,

Christchurch,

New

Zealand

3Head of Department, Department of

Psychology, University of Canterbury,

Christchurch,

New Zealand

4Lecturer, Centre for Postgraduate Nursing

Studies, University of Otago, Christchurch,

New Zealand

5Senior Lecturer, School of Health Sciences,

University of Otago, Christchurch, New

Zealand

6Senior Lecturer, School of Health Sciences,

University of Stirling, Stirling, UK

7Biostatistician, Department of Psychological

Medicine, University of Otago, Christchurch,

New Zealand

Correspondence

Lisa C. Whitehead, School of Nursing and

Midwifery, Edith Cowan University, 270

Joondalup Drive, Joondalup, Western

Australia, Australia.

Email: l.whitehead@ecu.edu.au

Abstract

Rationale, aims and objectives Diabetes mellitus is associated with significant morbidity,

mortality, and escalating health care costs. Research has consistently demonstrated the impor-

tance of glycaemic control in delaying the onset, and decreasing the incidence, of both the

short‐term and long‐term complications of diabetes. Although glycaemic control is difficult to

achieve and challenging to maintain, it is key to reducing negative disease outcomes.

The aim of this study was to determine whether a nurse‐led educational intervention alone or a

nurse‐led intervention using education and acceptance and commitment therapy (ACT) was

effective in reducing hemoglobin A1c (HbA1c) in people living with uncontrolled type 2 diabetes

compared to usual care.

Methods Adults over the age of 18 years, with a confirmed diagnosis of type 2 diabetes and

HbA1c outside of the recommended range (4%‐7%, 20‐53 mmol/mol) for 12 months or more,

were eligible to participate. Participants were randomised to either a nurse‐led education inter-

vention, a nurse‐led education plus ACT intervention, or a usual care. One hundred and eighteen

participants completed baseline data collection (N = 34 education group, N = 39 education plus

ACT, N = 45 control group). An intention to treat analysis was used.

Results A statistically significant reduction in HbA1c in the education intervention group was

found (P = .011 [7.48, 8.14]). At 6 months, HbA1c was reduced in both intervention groups (edu-

cation group −0.21 and education and ACT group −0.04) and increased in the control group

(+0.32). A positive change in HbA1c (HbA1c reduced) was noted in 50 participants overall. Twice

as many participants in the intervention groups demonstrated an improvement as compared to

the control group (56% of the education group, 51% education plus ACT, and 24% control

group.

Conclusions At 6 months post intervention, HbA1c was reduced in both intervention groups

with a greater reduction noted in the nurse‐led education intervention.

KEYWORDS

nursing, randomised controlled trial, type 2 diabetes mellitus

1 | INTRODUCTION

Daily management of diabetes is essential in controlling blood glu-

cose, however, many people living with diabetes are unable to main-

tain glycaemic control within the recommended levels (4%‐7%,

20‐53 mmol/mol).1 Diet, exercise, stress, and medication management

are the key mediators of glycaemic control2 and areas strongly influ-

enced by self‐management through individual behaviour and action.3

The short‐term and long‐term effects of hyperglycaemia are multiple,

including microvascular changes (eg, retinopathy, nephropathy, and

Received: 1 July 2016 Revised: 18 January 2017 Accepted: 18 January 2017

DOI: 10.1111/jep.12725

http://orcid.org/0000-0002-6395-0279

mailto:l.whitehead@ecu.edu.au

https://doi.org/10.1111/jep.12725

http://wileyonlinelibrary.com/journal/jep

neuropathy) and macrovascular (eg heart disease).4,5 Uncertainty does

remain around the extrapolation of population‐based risk reduction

estimations to individual predictions,6 where evidence relating to

glycaemic control and long‐term outcomes have been established

through large prospective cohorts. Further, tight glycaemic control can

result in harmful effects, for example an increase in hypoglycaemic

events.7

In addition to a global guideline on diabetes management,8 evi-

dence‐based guidelines exist across many countries on the treatment

of type 2 diabetes (eg, in another reference2) with a consistent focus

on patient education, dietary advice, managing cardiovascular risk,

managing blood glucose levels, and managing the risk of long‐term

complications. Optimal management, however, is only thought to be

reaching the minority8 with reasons such as the size and complexity

of the evidence base, the complexity of diabetes care itself, a lack of

proven cost‐effective resources for diabetes care, and diversity in

standards of clinical practice cited as driving disparities in clinical care.

The evidence on interventions to support self‐management for

people with long‐term conditions is large and attempts to draw

together individual study findings to clarify what works, for whom,

and in what contexts are available (eg, in the work of Taylor et al9).

Interventions directly related to improving the self‐management of

glycaemic control can be broadly categorised into individual and

group‐based interventions, educational and behavioural interventions,

with fewer interventions combining the latter 2 elements.10 A review

of all self‐management programmes or multicomponent interventions

aimed at self‐management; education, both group based and individ-

ual; behavioural or counselling interventions; and social support for

people living with type 2 diabetes9 reported good evidence that self‐

management support improves blood glucose control in the short‐

term, with a reduction in mean difference of around 0.4%. The

effectiveness of interventions longer term was not as strong, although

this was attributed to fewer studies reporting data at 12 months and

beyond. The impact of self‐management interventions on individuals’

quality of life and their psychological well‐being was not supported,

although equally, interventions did not have a detrimental effect. The

meta‐review was not able to pin point effective elements across inter-

ventions, instead suggesting that self‐management support may be

delivered in many ways, by different professionals and lay people,

and that in light of the large number of randomised controlled trials

and reviews included within the meta‐review the failure to reach any

conclusion on the optimal model of delivery could reflect that there

is no one way.9 The authors suggest that multiple models of delivery

may be equally effective, and consideration may instead need to be

given to other factors that may influence effectiveness, such as the

real‐world context.

Reviews with a less diverse focus have made recommendations

relating to effective elements of interventions. In relation to interven-

tions for women of African/Caribbean and Hispanic/Latin ethnicity

living in industrialised countries, 5 intervention features (hospital‐

based intervention setting; group intervention format; situational

problem‐solving; high intensity, 10 or more sessions; and incorporating

dieticians as interventionalists) were found to have a broad impact on

the majority of outcomes assessed (diet, anthropometrics, physical

activity, and hemoglobin A1c [HbA1c]). A review of behavioural

interventions (Health Quality11), found that the interventions with

the largest effects were those with higher baseline HbA1c (≥9%) and

in which the interventions were of at least 1 year in duration. A review

and meta‐analysis10 on motivational interventions in the management

of HbA1c noted that the small number of studies and issues of hetero-

geneity indicated the need for caution in interpreting the findings, and

the contribution of motivational interventions may be better assessed

by outcomes such as behaviour change.

The current study aimed to contribute to the evidence on the

effectiveness of motivational interventions and the interrelation

between self‐management behaviours and glycaemic control. Accep-

tance and commitment therapy (ACT) is a form of cognitive

behavioural therapy. The premise of ACT is the existence of a constant

interplay between the internal and external environment affecting the

individual’s overall functioning.12 Overt behaviour (actions), cognitions

(thoughts, beliefs, and perceptions), feelings, and physiology are closely

and interactively integrated, and could therefore impact the way in

which a patient manages his or her diabetes overall. Acceptance and

commitment therapy can take a holistic approach to diabetes manage-

ment including addressing psychological and motivational barriers,

acceptance of elements of management, and focuses patients on

moving in the direction of their values.13

A previous study comparing an ACT and education intervention

with an education only intervention13 found a significant improvement

in HbA1c and in acceptance of diabetes (attitudes and values) and self‐

management skills for those completing the ACT plus education inter-

vention. Building on this work, it was hypothesised that for people with

long‐term hyperglycaemia, ACT could raise participants’ awareness of

the interaction between cognitions, feelings, and behaviour and so

enable people to better self‐manage, leading to improved glycaemic

control. The objective of this study was to determine whether a

nurse‐led educational intervention alone or a nurse‐led intervention

using education and ACT were effective in reducing HbA1c in people

living with uncontrolled type 2 diabetes compared to usual care.

2 | METHODS

2.1 | Study design

The design was a 3 arm parallel group randomised controlled trial com-

paring 2 active treatment groups with a control condition. This design

was chosen over a factorial design (education alone versus ACT alone

versus education and ACT versus neither) on the premise that a certain

level of diabetes knowledge would be essential for individuals to use

the strategies developed through the ACT intervention. The half day

education intervention aimed to provide all participants in the group

with the same level of knowledge to apply the ACT strategies.

Three pairwise comparisons were planned for the analysis of out-

comes (education versus control, education plus ACT versus control,

and education versus education plus ACT). A total of 32 participants

were required in each group to achieve 80% power to detect as statis-

tically significant (2‐tailed α = 0.05) an absolute difference between

groups at 6 months in HbA1c levels of 0.5%, assuming an SD of

0.7%. The choice of effect size for power analyses was based on data

822 WHITEHEAD ET AL.

from the United Kingdom Prospective Diabetes Study14 with a 0.5%

difference in HbA1c levels regarded as being clinically significant. The

same effect size was chosen for both interventions based on the

assumption that a reduction in HbA1c of the same magnitude would

be as clinically significant for both groups. The study was granted eth-

ical approval from the Upper South B Regional Ethics Committee, New

Zealand, reference number URB/09/08/039.

2.2 | Recruitment

The inclusion criteria were a clinical diagnosis of type 2 diabetes for

12 months or more, age 18 years and over, and persistent, suboptimal

glycaemic control. This was defined as HbA1c >7%, 53 mmol/mol in the

past 12‐18 months, with at least 2 records of HbA1c >7%,

53 mmol/mol, during this period and HbA1c >7%, 53 mmol/mol on

recruitment. Exclusion criteria were non‐English speaking, pregnancy,

short‐term or serious medical conditions, and currently in psychother-

apy or participation in a diabetes education programme in the past

12 months. Following ethical approval, a range of recruitment avenues

were used including radio advertisements, adverts in community news-

letters, and newspapers and letters sent to patients who met the study

criteria through medical centres, across 1 city in New Zealand. Those

people who contacted the research assistant as interested in participa-

tion were sent a study information sheet, a consent to be contacted

form, and a stamp addressed envelope. All those who returned a con-

sent to be contacted form were called by the research assistant to

confirm inclusion eligibility, and written consent was gained to partici-

pate in the study and for the research assistant to contact the medical

centre at which they were registered to obtain HbA1c results.

Permuted block randomisation using a computer‐generated

randomisation sequence with a block size of 24 allowed for timely

randomisation of participants, where recruitment took place across a

12‐month period. A biostatistician completed the randomised alloca-

tion. The biostatistician was independent from all other study proce-

dures. The biostatistician sent information on the allocation to the

research assistant. Data were collected at baseline, 3 months following

baseline and 6 months following baseline. All study questionnaires

were sent by post together with a prepaid envelope for return.

2.3 | Description of the interventions

The decision to run the intervention on 1 day was pragmatic. The

intention was to make the intervention as cost effective and conve-

nient as possible for participants and looking to the future, for

providers who may wish to take up the intervention in practice.

Both workshops consisted of a 1 day workshop held at a central

city location. The workshop ran from 10AM to 5.30PM with a 1 hour

lunch break. The interventions were developed by the research team,

primary care nurses, and an advisory group. The main content was

based on the topic areas deemed to be important cross 3 diabetes edu-

cation programmes.12,13,15 The research team included experienced

educators and clinicians who developed a format for delivery that were

felt to promote engagement in learning and discussion and included

visual learning and active exercises, such food labelling. The interven-

tions were developed into work books for the participants and a

PowerPoint slide presentation for the presenters. The package was

reviewed by the advisory group, who included a consumer, clinicians,

and Maori and Pacific Island advisors. Both interventions were piloted

with a small group of volunteers who were diagnosed with type 2 dia-

betes but who had experienced hyperglycaemia for just less than 1 year

and so did not fully meet the study criteria. Feedback on the content

and delivery from the participants and the nurses were incorporated.

Changes were minimal and related to using 1 diagram over another,

for example, rather than changes to the topics covered.

2.4 | The education intervention

The education intervention sessions were run by 2 primary health care

based nurses who were trained in the delivery of the intervention by 2

of the study investigators. The education intervention covered the

topics of the basic pathophysiology of diabetes, understanding diabe-

tes and glucose, understanding the risk factors and complications asso-

ciated with diabetes, food groups, portion sizes, self‐management of

diabetes through diet, exercise, medication, and stress management,

monitoring diabetes, including awareness of hypo and hyperglycaemia,

and when to seek help. Underpinning the content were the themes of

increasing understanding, how to take control and planning for the

future. The intended changes related to increasing understanding of

diabetes, satisfaction with diabetes management, an increase in self‐

management activities, and maintenance or improvement of mental

health, as

measured through anxiety and depression.

2.5 | The education plus ACT intervention

In the education plus ACT intervention, time was divided equally

between the education intervention and the ACT intervention to main-

tain the same amount of contact time between participants and the

nurses. Participants received the same content in education but did

not have the opportunity to discuss the material in as much depth as

the education only group nor spend as much time on self‐directed

exercises in the handbook during the workshop. The ACT component

addressed mindfulness and acceptance training in relation to difficult

thoughts and feelings about diabetes, exploration of personal values

related to diabetes, and a focus on the ability to act in a valued direc-

tion while contacting difficult experiences. The ACT component drew

on material developed in a previous study.13 The workshop was led

by a mental health nurse with expertise in ACT who received supervi-

sion from a clinical psychologist. The education component was

delivered by one of the nurses providing the education intervention.

The intended changes related to increased acceptance of diabetes‐

related thoughts and feelings and a reduction in the extent to which

thoughts and feelings interfere with valued action, increase in under-

standing of diabetes, satisfaction with diabetes management, an

increase in self‐management activities, and maintenance or improve-

ment of mental health, as measured through anxiety and depression.

2.6 | Fidelity

The fidelity of the intervention was enhanced through the develop-

ment of a manual for both interventions; all sessions were recorded

and reviewed by LW and JC for adherence to the protocol and

WHITEHEAD ET AL. 823

manuals, and 1 nurse participated in all of the intervention sessions to

enhance continuity of style and content of the sessions.

2.7 | Control group

The control groups were mailed the questionnaires at the same time

points as the 2 intervention groups. Participants in the control group

continued to receive routine diabetes care. Routine care generally

comprised visits to the GP/practice nurse as initiated by the patient

with an annual invitation by the practice to attend for a health check

involving measurement of HbA1c (goal ≤7%), weight, blood pressure

(goal 13/80), total cholesterol (goal ≤4), HDL cholesterol (goal ≥1),

LDL cholesterol (goal <2), triglycerides (goal <1.7), microalbuminuria

(ratio < 3), date of last eye examination (at least every 2 years), foot

check, and sensation and pulses. The control groups were not offered

the opportunity to participate in an intervention posttrial.

2.8 | Outcome measures

The primary outcome variable was glycaemic control (HbA1c). The sec-

ondary outcome variables were acceptance of diabetes‐related

thoughts and feelings and extent to which thoughts and feelings inter-

fere with valued action, increase in understanding of diabetes, satisfac-

tion with diabetes management, an increase in self‐management

activities, and maintenance or improvement of mental health, as

measured through anxiety and depression.

2.9 | Glycaemic control

HbA1c was analysed by a local medical laboratory. Participants were

asked to either visit their local medical laboratory, widely distributed

throughout the city, or if required a mobile phlebotomist who took

the sample at the participant’s home. The phlebotomist was blinded

to the group allocation of participants. Time points for measurement

were at baseline, 3 months and 6 months. A 2‐week window was

allowed around the designated data collection time points.

The questionnaires were self‐administered. They were sent to the

participant’s postal address and returned in a stamp addressed enve-

lope. The pack contained information on who to contact if assistance

was required (the research assistant), however, no one made contact

for support to complete the questionnaires.

2.9.1 |

Acceptance of diabetes

The Acceptance and Action Diabetes Questionnaire (AADQ)13 is an 11

item Likert type scale to measure acceptance of diabetes‐related

thoughts and feelings and the extent to which they interfere with

valued action (eg, I avoid thinking about what diabetes can do to

me). The scale has demonstrated good inter‐rater reliability (Cronbach

α = .94). Scores range from 11 to 55 with a higher score reflecting

greater nonacceptance.

2.9.2 | Anxiety and depression

Anxiety and depression were measured through the Hospital

Anxiety

and Depression Scale (HADS).16 The HADS has been used extensively

in research and has been shown to have good validity, specificity and

sensitivity,17 and good test‐retest reliability.18 Although the HADS is

a screening tool, it correlates well with clinical assessments of anxiety

and depression. A score is generated for anxiety and depression, both

ranging from 0 to 21 with a score of 0‐7 indicating subclinical symp-

toms, 8‐10 possible clinical levels and a score of 11 or over probable

clinical levels.

2.9.3 | Understanding of the management of diabetes

Understanding of the management of diabetes was assessed by a sub-

scale of the Diabetes Care Profile (Cronbach α = .60‐.95).19 The Diabe-

tes Care Profile comprises 14 subscales in total. The understanding

subscale comprises 10 items and explores understanding of key

aspects of the management of diabetes, eg, “How do you rate your

understanding of diet and blood sugar control?” Reliability was

explored in 2 large studies, a community study (n = 440) and medical

centre study (n = 352). Reliabilities (Cronbach alpha) of the under-

standing subscale were reported as .92 and .92 respectively.19 Scores

range from 10 to 50, with a higher score indicating better self‐rated

understanding of diabetes.

2.9.4 | Diabetes treatment satisfaction

The DiabetesTreatment Satisfaction Questionnaire (DTSQ)20 was used

to measure satisfaction with diabetes treatment. The 6 item scale

assesses treatment satisfaction and 2 items assess perceived frequency

of hyperglycaemia and hypoglycaemia. Ceiling effects have been noted

with the DTSQ and the DTSQ change (DTSQc) was developed to over-

come these.21 The authors recommend using the DTSQ first to anchor

the findings, followed the DTSQc to explore how people’s satisfactions

with perceived hypoglyacaemia and hyperglycaemia have changed. The

DTSQ has been widely used and is recommended by the World Health

Organisation and the International Diabetes Federation as useful in

assessing outcomes of diabetes care.22 On the DTSQ, each of the 8

items are scored on a scale of 0‐6 with a higher score indicating greater

satisfaction. For the DTSQc, each item is scored on a scale of −3 to +3

with a higher score indicating greater satisfaction.

2.9.5 | Diabetes self‐care activities

The summary of diabetes self‐care activities measure was used to

assess self‐care activity.23 Three of the 8 subscales; general diet, exer-

cise, and blood glucose testing were used in this study. The inter‐rater

reliability, measured by means of the Cronbach alpha coefficient,

ranged from 0.66 to 0.80 for the 3 subscales independently24,25 and

a Cronbach alpha of 0.71 for the 3 subscales collectively as measured

using all baseline data from this study.

The subscale general diet includes 2 questions: How many of the

last 7 days have you followed a healthy eating plan? And over the past

month, how many days/week have you followed your eating plan? The

exercise component questions on how many of the last 7 days did you

participate in at least 30 minutes of physical activity? On how many of

the last 7 days did you participate in a specific exercise session other

than what you do around the house/work? And the blood glucose sub-

scale, on how many of the last 7 days did you test your blood sugar?

and On how many of the last 7 days did you test your blood sugar

the recommended number of times? The derived scores reflect the

number of days within a week recommended activity related to diet,

824 WHITEHEAD ET AL.

exercise, and blood glucose monitoring have been followed. The range

is 0‐42, with a higher score reflecting greater self‐management.

2.9.6 | Data analysis

Statistical analyses were performed using the Statistical Package for

the Social Sciences, version 19 (Statistical Package for the Social Sci-

ences In, Chicago, Illinois). Standard descriptive statistics were used

to summarise demographic and clinical characteristics for the

randomised groups. Analyses were conducted on an intention‐to‐treat

basis, which included all participants who completed the baseline ques-

tionnaires, a blood test for HbA1c and in the intervention groups, who

attended the workshop. Missing values were handled according to the

guidelines for each scale. An analysis of covariance (ANCOVA) was

used to compare the HbA1c levels at 6 months between randomised

groups where the randomised group was treated as a fixed factor

and the baseline value for HbA1c (taken within 3 months of commenc-

ing the study) as a covariate. If a significant effect (P < .05) of

randomised group was identified from the ANCOVA, then pairwise

comparisons of each intervention group with the usual care were

undertaken. The ANCOVA was also used to compare the secondary

outcomes using randomised group as a fixed factor and the relevant

baseline level as a covariate.

2.10 | Results

2.10.1 | Recruitment outcomes and sample description

Over a 12‐month period, 303 people responded and following assess-

ment for eligibility; 172 people who met the study criteria were

approached. One hundred and fifty seven participants with glycaemic

control outside of the recommended range for over 12 months gave

informed consent and were randomised to one of 3 groups, education,

education plus ACT, or usual care (control). In total, 51 participants

were randomised to the education only intervention, 54 to the educa-

tion plus ACT intervention, and 52 to the control group. A total of 34

participants declined to participate postrandomisation; 14 participants

had moved away or were no longer contactable, and 25 participants

had changed their minds, mostly related to lack of time.

The differences in baseline characteristics across the 3 randomised

groups were not significantly different (Table 1).

At 6 months, 21 people did not complete a blood test for HbA1c

level and 12 participants did not complete and return the question-

naires. Baseline analysis found no difference between those lost to fol-

low up and those who completed the study. Intention to treat analysis

was conducted. Figure 1 outlines the trial profile.

2.10.2 | Effects on glycaemic control

At 6months, HbA1cwas reduced in both intervention groups (Education

group −.21, education plus ACT group −.04) and increased in the control

group (+.32). The primary outcome results are presented inTables 2, 3.

An ANCOVA using HbA1c prescores as the covariate found signif-

icant differences between the participants’ HbA1c at 6 months

(F (2,114) = 3.29, P = .04). Planned contrasts found no statistical differ-

ence in HbA1c at 6 months between the control group and the educa-

tion plus ACT group (P = .079 [7.61, 8.23]). The mean difference in

HbA1c between the control group and education intervention group

at 6 months was statistically significant (P = .011 [7.48, 8.14]).

Exploring change in HbA1c by direction (positive, none, or negative)

showed that, proportionally, twice as many participants in the inter-

vention groups demonstrated a reduction in HbA1c compared to the

control group (Table 3).

A positive change in HbA1c (HbA1c reduced) was noted in 50 par-

ticipants overall (56% education group, 51% education and ACT, and

24% control group).

2.10.3 | Effects on secondary and safety outcomes

The analyses of the secondary measures are presented in Table 4. No

significant differences between the conditions in participants’ accep-

tance of diabetes (AADQ), anxiety and depression, understanding of

diabetes, satisfaction with treatment, or satisfaction with blood glu-

cose control. Close to significant between group differences were

noted in self‐management practices. Self‐management activities

improved in the education plus ACT group but decreased in the educa-

tion group to a result reflective of the control group.

Potential adverse events such as episodes of hypoglycaemia were

not systematically recorded. Based on episodically reported informa-

tion, no serious events of hypoglycaemia were recorded in either study

group.

TABLE 1 Demographic details

Age, mean in
years (SD)

Education (N = 34) Education & ACT (N = 39) Usual Care (N = 45)
53.76 (8.68) 56.1 (6.91) 56.4 (6.97)

Gender N % N % N %

Male 20 59 17 44 26 58

Female 14 41 22 56 19 42

Ethnicity

NZ European 24 71 35 90 36 80

Maori 3 9 0 0 5 11

Time since diagnosis

<5 years 13 38 10 26 14 31

5‐9 years 9 26 14 36 14 31

>10 years 12 36 15 38 17 38

Abbreviation: ACT, acceptance and commitment therapy.

WHITEHEAD ET AL. 825

3 | DISCUSSION

In this study, the HbA1c level was reduced in both intervention groups

and this change was statistically significant in the education only group

at 6 months postintervention. No effects on secondary outcomes were

found. The results of this study indicate that a 1 day nurse‐led group

intervention can have an impact on diabetes management up to

6 months postintervention. An earlier study13 found a significant

decrease in HbA1c in an education plus ACT group and a significant

change (improvement) in acceptance of diabetes as measured by the

AADQ and in self‐management. In this study, no significant changes

on any variable were noted for the education plus ACT group as com-

pared to the control group or education only group. Although the cur-

rent study did not seek to replicate the Gregg et al study, we did use

similar principles and material in developing the intervention. A

difference in the characteristics of participants by mean years since

diagnosis was noted between the studies, 5.3 years13 vs 10.03 years

in the current study. It could be hypothesised that the difference in

outcome between the studies was related to time since diagnosis

and that this influenced the ability to change attitudes and values

towards diabetes. The potential impact of time since diagnosis on

study design and outcome requires further consideration.

In the interventions in this study, and especially so in the educa-

tion plus ACT group, participants were asked to deal with attitudes

towards diabetes and self‐care, to observe negative feelings and to

reflect on values in life. While this could be challenging and result in

increased worry and anxiety about life and diabetes, participants

showed stable or improved scores on all psychological variables.

FIGURE 1 Trial profile. ACT, acceptance and commitment therapy; HbA1c, hemoglobin A1c

TABLE 2 HbA1c levels at baseline, 3 months and 6 months

Baseline 3 months 6 months Difference

Usual care 8.08 8.13 8.40 +0.32

Education 8.13 7.80 7.92 ‐0.21

Education + ACT 7.78 7.73 7.74 ‐0.04

Abbreviations: ACT, acceptance and commitment therapy; HbA1c,
hemoglobin A1c.

TABLE 3 Direction of change in HbA1c

Direction of change

Positive N (%) None N (%) Negative N (%) Total

Control 11 (24) 4 (9) 30 (67) 45

Education 19 (56) 2 (6) 13 (38) 34

Education + ACT 20 (51) 1 (3) 18 (46) 39

50 7 61 118

Abbreviations: ACT, acceptance and commitment therapy; HbA1c, hemo-
globin A1c.

826 WHITEHEAD ET AL.

Any intervention seeking to reduce HbA1c levels raises concern

around increase of hypoglycaemic episodes. In this study, there was

no evidence that participants experienced episodes of hypoglyacaemia

and no reports of a medical emergency related to hypoglycaemia,

although we did not specifically collect data on blood glucose levels

outside of the primary measure of HbA1c nor did we directly seek feed-

back on experiences of hypoglycaemia nor of fear of hypoglycaemia.

Both individual and group settings have been used for cognitive‐

behavioural interventions, with no definitive conclusion as to which

setting is more effective.26,27 The literature on educational interven-

tions for diabetes self‐management favours the group setting,28

although the specific aspects of group intervention that are effective

have not been isolated. It is unclear how the group process contributed

to outcomes, and this requires further investigation.

The delivery of interventions in a group setting has obvious cost

advantages in the clinical setting. This study has also shown that a

nurse‐led intervention is effective in reducing HbA1c. The nurses in

this study did not receive costly training and although specialists pro-

vided oversight, they did not contribute to the intervention. These

findings are of significance in the clinical setting where the ability to

draw on staff involved in the regular care of the patient in the primary

care setting is both cost‐effective and more realistic in embedding

interventions into clinical practice. What is not known is whether the

input of specialists or of peer leadership would have been more effec-

tive and remains an area for future exploration.

It is unclear how long the positive effects of the interventions on

glycaemic control observed in this study will last. Taylor et al9 noted

diminished effects at 12 months and beyond amongst intervention

studies to improve self‐management of type 2 diabetes. Based on ear-

lier literature, it is likely that maintenance sessions would be required to

sustain the effect shown.29 Connecting with community partners and

other chronic care model programmes running in the community has

proven to be a successful adjunct to cognitive‐behavioural interven-

tions, allowing the effects to be sustained as far out as 3 years postin-

tervention.24,30,31 Incorporating booster sessions enhances the

effectiveness of self‐management interventions, however, health care

providers are challenged in providing continued self‐management sup-

port over time and as needed by individuals. Reaching patients between

visits and tailoring information and support to meet specific needs

could be addressed more successfully through the use of technology

TABLE 4 Effects on secondary outcome measures

Pretreatment Posttreatment (6 months follow‐up)

M SD 95 % CI M SD Intragroup difference 95 % CI
F‐test (ANCOVA

between groups effects)

Acceptance of diabetes

Usual care 67.8 32.02 56.17‐79.70 70.53 33.36 −1.34 63.10‐77.26 P < .21

Education 71.76 28.77 56.64‐81.26 76.42 32.97 −4.66 69.19‐84.75

Education + ACT 68.03 28.17 58.08‐85.61 69.03 27.54 −1 59.36‐75.56

Anxiety

Usual care 5.6 4.57 4.35‐7.31 5.59 4.9 0.01 4.04‐7.13 P < .98

Education 4.62 4.13 2.98‐6.48 4.81 3.82 −0.19 3.27‐6.35

Education + ACT 5.5 3.64 4.30‐6.70 5.54 3.66 −0.04 4.24‐6.65

Depression

Usual care 4.1 3.6 3.23‐5.55 3.49 3.01 0.61 2.64‐3.72 p < .95

Education 3.53 2.82 2.25‐4.52 2.73 2.68 0.8 2.69‐3.93

Education + ACT 3.87 3.45 2.73‐5.0 3.33 3.21 0.54 2.66‐3.83

Understanding

Usual care 3.4 1.31 2.92‐4.10 3.7 1.72 −.03 3.15‐3.94 P < .53

Education 3.09 0.72 2.75‐3.40 4.06 1.68 −0.97 3.50‐4.40

Education + ACT 3.13 0.78 2.85‐3.50 4.03 1.23 −0.9 3.68‐4.53

DTSQ‐satisfaction

Usual care 13.13 2.95 24.37‐28.69 6.83 6.71 −6.21 6.47‐11.24 P < .60

Education 12.13 4.5 20.03‐28.47 8.12 8.78 −4.62 7.15‐12.72

Education + ACT 13.67 3.16 24.80‐29.90 8.85 5.13 −5.57 6.26‐11.47

DTSQ‐blood glucose control

Usual care .94 1.21 3.12‐4.88 .41 2.06 1.45 −.039‐1.22 P < .48

Education 1.93 1.08 2.84‐4.86 −0.18 2.24 1.97 −1.24‐0.86

Education + ACT 1.88 1.0 2.96‐4.58 0.62 2.23 1.27 −0.23‐1.47

Self‐management

Usual care 9.77 4.62 8.33‐12.31 9.73 4.78 0.04 8.74‐11.36 P < .07

Education 10.30 4.25 9.04‐12.58 9.5 5.16 0.83 7.83‐11.09

Education + ACT 10.81 4.78 12.05‐13.28 12.17 4.05 −1.36 10.39‐13.25

Abbreviations: ACT, acceptance and commitment therapy; ANCOVA, analysis of covariance; CI, confidence interval; DTSQ, DiabetesTreatment Satisfaction
Questionnaire.

WHITEHEAD ET AL. 827

(eg, the Internet, web‐based education, text messaging, email, auto-

matic telephone reminders, and telehealth/telephone education

and reinforcement). Although the evidence on the effectiveness of

e‐health is mixed, it is gathering momentum and has been proven

effective in the management of HbA1c (eg, in other studies
25,32)

and offers a time‐efficient means of providing ongoing support.

In summary, the nurse‐led education intervention is a promising

approach in improving outcomes for those with type 2 diabetes and

long‐term, less than optimal glycaemic control. Further research to

explore the value of group sessions over individual interventions, the

relative benefits of ACT versus education, the impact of maintenance

sessions, and follow‐up over a longer time period would enhance

understanding of the value and role of interventions to support

glycaemic control.

ACKNOWLEDGEMENTS

L.W. wrote the manuscript and researched data. M.C., J.C., V.M., D.C.,

C.B., and C.F. contributed to the design and conduct of the study,

analysis of data, and write‐up. The study was funded by the Strategy

to Advance Research in Nursing and Allied Health (STAR). The funder

did not play any role in the conduct of the study.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

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et al. A nurse‐led education and cognitive behaviour therapy‐

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https://doi.org/10.1111/jep.12725

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Russell,Nina M.; Vess, Joy; Durham, Cathy; Johnson, Emily

Source: Online Journal of Nursing Informatics (ONLINE J NURS INFORM), Summer2017; 21(2): 9-1. (1p)

Publication Type: Article – research

Language: English

Major Subjects:

Text Messaging

Self Care

Diabetes Mellitus

Patient Education

Minor Subjects:

Human; Rural Health; Primary Health Care; Blood Glucose Self-Monitoring; Glycemic Control; Hemoglobin A, Glycosylated; United States

Abstract:

Diabetes is a chronic disease that requires lifelong treatment extending well beyond the primary care office. While in-office visits are an essential component in disease management, ongoing patient support is requisite to impart and strengthen the knowledge, skills, and ability necessary for diabetes self-care. Practice guidelines recommend diabetes self-management education (DSME) and support for all diabetic patients. DSME promotes active participation in disease management through education, behavior modification, and active collaboration with healthcare personnel. A quality improvement project involved interactive, bi-directional textmessaging interventions sent through a secure, messaging system. Text messages included educational information, tips, or reminders related to medication, self-monitoring blood glucose, diet, and exercise. After the intervention, a reduction in participants’ mean finger stick blood glucose (FSBG) level occurred. The findings of this project suggest that mobile phone technology is a feasible, and sustainable means to augment current diabetes management with text-messaging interventions that promote DSME.

Journal Subset:

Computer/Information Science; Core Nursing; Nursing; Peer Reviewed; USA

ISSN:

1089-9758

MEDLINE Info:

NLM UID: 9806523

Entry Date:

20180410

Revision Date:

20180410

Accession Number:

128848064

Choose Language

Text-Messaging to Support Diabetes Self-Management in a Rural Health Clinic: A Quality Improvement Project

Contents

Citation

Clinical Issue

Literature Review

Methods

Framework

Setting/Participants

Intervention

Data Collection

Results

Discussion

Recommendations

Conclusion

References

Full Text

Diabetes is a chronic disease that requires lifelong treatment extending well beyond the primary care office. While in-office visits are an essential component in disease management, ongoing patient support is requisite to impart and strengthen the knowledge, skills, and ability necessary for diabetes self-care. Practice guidelines recommend diabetes self-management education (DSME) and support for all diabetic patients. DSME promotes active participation in disease management through education, behavior modification, and active collaboration with healthcare personnel. A quality improvement project involved interactive, bi-directional text-messaging interventions sent through a secure, messaging system. Text messages included educational information, tips, or reminders related to medication, self-monitoring blood glucose, diet, and exercise. After the intervention, a reduction in participants’ mean finger stick blood glucose (FSBG) level occurred. The findings of this project suggest that mobile phone technology is a feasible, and sustainable means to augment current diabetes management with text-messaging interventions that promote DSME.

Citation

Russell, N., Vess, J., Durham, C. & Johnson, E. (Summer, 2017). Text-Messaging to Support Diabetes Self-Management in a Rural Health Clinic: A Quality Improvement Project. Online Journal of Nursing Informatics (OJNI), 21( 2), Available at http://www.himss.org/ojni

Clinical Issue

The prevalence of diabetes mellitus has more than doubled over the past 30 years nationwide (Centers for Disease Control and Prevention [CDC], 2014). In fact, diabetes afflicts 29.1 million Americans and contributes to the death of more than 200,000 individuals annually (CDC, 2014). As of 2012, the national prevalence of diabetes was 9% (South Carolina Department of Health and Environmental Control [SCDHEC], 2014) and 1.4 million Americans are diagnosed with diabetes annually. Diabetes is the seventh leading cause of death in the U.S. and is the underlying cause of many co-morbid conditions and complications (CDC, 2014). Consequently, primary care offices are inundated with an ever-expanding population of patients with diabetes who have multiple comorbid conditions and, often, one or more vascular complications.

In 2010, the hospitalization rates for strokes were 1.5 times higher in adults with diabetes than in non-diabetic adults; additionally, diabetes was cited as the primary cause in 44% of new cases of renal failure (CDC, 2014). Moreover, disease management costs an average of $245 billion each year secondary to microvascular and macrovascular complications, including stroke, myocardial infarction, diabetic retinopathy, kidney disease, and amputations, to list a few (CDC, 2014). Notably, the statistics support that current interventions are limited as evidenced by the increase in disease prevalence and associated conditions.

Diabetes is a chronic disease that requires lifelong treatment extending beyond medicinal therapy. Ongoing patient self-management and support are required to thwart or decrease diabetes associated complications and must be initiated immediately upon diagnosis. Diabetes self-management education (DSME) is an evidence-based standard and is defined as the ongoing process to improve the knowledge, skills, and ability essential for diabetes self-management (American Diabetes Association [ADA], 2014). The goal of DSME is to promote active participation in disease management through education, behavior modification, and active collaboration with healthcare personnel (ADA, 2014). Ongoing collaboration and communication with one’s healthcare team imparts and strengthens the knowledge, skills, and ability necessary for diabetic self-care and better clinical outcomes, including a reduction in hemoglobin A1c (HbA1c) values, weight, diabetes associated complications, and healthcare cost, to list a few (ADA, 2014; Nundy et al., 2012; Siminerio, 2010).

Face-to-face visits afford the opportunity for periodic DSME but often do not meet the DSME expectation of support that should occur between visits, as recommended by the American Diabetes Association (ADA, 2014). The ADA has challenged clinicians to develop and employ innovative strategies that promote ongoing DSME and support to facilitate self-management (ADA, 2014).

One innovative strategy that has shown to be effective is the use of mobile technology and text-messaging. Mobile phone technology provides a means to expand upon the current management of diabetes that has proven to be insufficient in primary care practices across the U.S. Studies reflect a synergistic relationship between the implementation of text-messaging interventions in primary care and positive behavior modification among diabetic patients (Chang et al., 2014; Fischer et al., 2012; Liang et al., 2011; Nundy et al., 2014; Nundy, Dick, Solomon, & Peek, 2013; Yeager & Menachemi, 2011). Frequent communication through text messages has been shown to foster the patient-provider relationship and, ultimately, leads to improved glycemic control (Chang et al., 2014; Fischer et al., 2012; Liang et al., 2011; Nundy et al., 2014; Nundy, Dick, Solomon, & Peek, 2013; Yeager & Menachemi, 2011). Delivery of DSME via short messaging service (SMS) can improve communication and facilitate self-care behaviors including compliance with medication, diet, exercise, and blood glucose monitoring.

Given the complexity and cost associated with diabetes management in the rural setting and the need for improved DSME utilization, technology is a proven means to meet the needs of these patients. According to Chang et al. (2014), 91% of Americans own a cell phone and 79% use phones to send and receive text messages. Furthermore, low-income households texted an average of 59 times a day compared to an average of 32 times a day in higher-income households (Smith, 2011). Therefore, mobile phone technology is an accessible and promising means to augment current diabetic management and practice. Text-messaging interventions may afford the opportunity to promote diabetes self-care, provide personal support, and empower patients to take charge of their personal health to achieve optimal glycemic control.

The use of text-messaging DSME was implemented in a quality improvement (QI) project with diabetes patients in an impoverished community. The specific clinical question was: In adult patients with diabetes seen at a rural primary care clinic, will text-messaging interventions that promote self-management lead to a decrease in mean finger stick blood glucose (FSBG) level over a 12-week period?

Literature Review

In a meta-analysis of 22 randomized trials, Liang et al. (2011) examined the impact of mobile phone interventions on diabetes self-management and ultimately, glycemic control. Collectively, 1657 participants, with either Type I or Type II diabetes mellitus, received lifestyle modification and disease management support, including glucose monitoring, diet, exercise, and medication adjustment through mobile phone short message service (SMS) alone or in conjunction to the internet or clinical counseling sessions with a diabetes nurse educator. In each trial, the researchers analyzed pre and post-intervention HbA1c values and compared the intervention to the control group. Spanning a period of six months, mobile phone intervention groups depicted a 0.5% reduction in HbA1c levels as opposed to control groups, particularly in patients with Type II diabetes (Liang et al., 2011).

In a quasi-experimental pilot study, Fisher et al. (2012) sought to evaluate the role of mobile phone technology in promoting diabetes self-management behaviors by using SMS intervention. A total of 47 adult patients with Type II diabetes received text-messaging prompts regarding glucose measurement, appointment reminders, and healthy self-care behaviors to facilitate optimal disease outcome. Results revealed that 79% of participants responded to more than 50% of the 1585 text messages, an indicator of ease of use. Moreover, 66.4% of study participants provided glucometer readings on follow-up visits when prompted via text messaging as opposed to only 12% at pre-intervention office visits. The participants affirmed that a cell-phone based text messaging program offers personal support, promotes accountability, and cultivates a bipartisan approach to diabetes management. The researchers also concluded that text-messaging interventions improve glycemic control, prevent diabetes associated complications, and enhance quality of life (Fisher et al., 2012).

In a quasi-experimental study, Nundy et al. (2014) explored the use of mobile messaging to promote behavior modification in adults with type I or II diabetes mellitus. A total of 348 participants were enrolled in the six month study, 74 in the intervention group and 274 in the control group. Researchers implemented a CareSmart software program designed to provide self-management support and education through automated text messaging. Behavioral interventions were measured including healthy eating, foot care, blood glucose monitoring, as well as medication adherence; the results depicted improvement among the CareSmart participants. In a seven-day period, healthy eating increased from 4.5 days to 5.2 days; blood glucose monitoring climbed from 4.3 days to 4.9 days, and foot care rose from 3.6 days to 4.3 days; additionally, medication adherence improved from 83% to 91%. Finally, HbA1c levels decreased in the CareSmart group from 7.9% pre-intervention to 7.2% following intervention (Nundy et al., 2014).

Yeager and Menachemi (2011) conducted a comprehensive review of 61 studies to assess the impact of text messaging interventions on healthcare outcomes. Researchers concluded that SMS interventions significantly improved quality of life, enhanced diabetes self-management skills, decreased daily blood glucose levels, and reduced HbA1c values. In fact, 50 of the 61 studies or 81% found that SMS interventions positively impact primary healthcare outcomes by enhancing DSM and improving glycemic control.

Nundy, Dick, Solomon, & Peek (2013) conducted a qualitative, post-controlled pilot study aimed to evaluate the feelings and beliefs of the individuals who participated in a text message-based diabetes self-management program. Researchers conducted audiotaped interviews lasting approximately 60 minutes. The interviews were transcribed with precision and entered into software designed to detect characteristic patterns. Researchers concluded that SMS intervention enhanced awareness of the seriousness of DM, increased feeling of support, and promoted accountability for better self-management among participants. Moreover, provider interaction and feedback fortified positive self-management behavior and redirected poor behavior (Nundy et al., 2013).

Findings from these studies suggest that SMS interventions have a positive impact on numerous aspects of health care, particularly chronic diseases such as diabetes mellitus. The implementation of text-messaging communication programs have enhanced clinical outcomes among diabetic patients by cultivating self-management behavior modification, promoting compliance and adherence to the treatment plan, improving glycemic control, and in due course, preventing or reducing diabetes associated complications. Moreover, enhancing communication among the patient, provider, and healthcare team fosters trust and commitment to improving the skills and knowledge essential for optimal management of diabetes mellitus.

Methods

The purpose of this Quality Improvement (QI) project was to use text-messaging interventions to support diabetes self-management and to improve glycemic control. The goal was to maximize the use of mobile phone technology in order to positively impact participants’ self-care knowledge and behaviors related to medication, self-monitoring blood glucose (SMBG), diet, and exercise as demonstrated by a decrease in the post-intervention mean FSBG obtained on follow-up visits in April, May, and June of 2016 compared to FSBG results in the same time period in 2015.

Framework

The Chronic Care Model (CCM) for improving diabetic management was used as the framework for this project. The CCM focuses on chronic disease management and contains key elements essential to the success of this project, including health system, community, self-management support, decision support, clinical information systems, and delivery system design (ADA, 2014). The Plan, Do, Study, Act model is a standard QI framework that allows for the rapid implementation and evaluation of the CCM QI strategies prior to implementation on an entire population (Gregg, Jirjis, & Garriss, 2007; Nundy et al., 2012).

Setting/Participants

This QI study was completed at a free clinic in the southeastern U.S. The clinic provides free primary care to the uninsured and indigent adult residents of two counties. Clinic personnel involved in the project included the clinic director, two nurse practitioners, and the medical coordinator. The QI project participants included all patients with diabetes managed at the clinic that chose to participate in the text message program. According to the clinic director, this patient population inconsistently self-monitored blood glucose levels and poorly adhered to their medication regimen with an average HbA1c of more than 9%. In addition, a review of patient charts revealed that only 10% of diabetes patients had received education regarding diet and exercise. Although most patients with diabetes treated in the clinic had a personal cell phone, any diabetic patient without a cell phone was provided with one through a prior clinic grant. The mean age of participants was 50 years old. Of the 49 participants, 65% were African American, 33% Caucasian, and 2% Hispanic. Twenty-four of the participants were female; 67% of female participants were African American, 29% were Caucasian, and 4% were Hispanic. Twenty-five participants were male, with 64% being African American and 9% Caucasian.

Intervention

A staff educational presentation was provided to all clinic personnel prior to implementation of the text-messaging intervention. The presentation included information on DSME and the use of text-messaging interventions to support and enhance current diabetes management within the clinic. The content and frequency of each text message was shared with the clinic staff. Furthermore, personnel were advised to contact the project director with any questions or concerns via email or phone for the duration of the project.

Text messages were sent through a secure, messaging system called CareMessage for a period of 12 weeks beginning April 1 and ending July 1, 2016. The CareMessage software system contains prepopulated messages that contain educational information and specific tips related to exercise and diet for patients with diabetes; however, messages within the system may be altered or created to better serve a specific population. Most text messages for this QI project were developed by the project director. Prior to project implementation, CareMessage consent forms were obtained from all participants to corroborate permission to send text messages to the participants’ personal cell phones.

The interactive bi-directional text-messaging interventions were implemented for a period of 12 weeks, with two daily reminders and two weekly educational messages or tips. The two daily messages aimed at gathering self-reported behavior data asked these questions: Did you remember to take your diabetes medication today? Did you remember to check your blood sugar today? Patients were asked to reply yes or no to each question daily. Patients who replied no to either question received a text message response that reminded or reinforced the importance of medication compliance and SMBG. Patients who replied yes to either question received a text message response that encouraged them to continue the good work (Table 1).

The bi-weekly messages contained educational information and tips pertaining to diet and exercise. The dietary text messages were distributed on Tuesday of each week, and the exercise text messages were distributed on Friday of each week. Each weekly message differed, as the following examples indicate: A healthy plate: ½ vegetables, ¼ protein, and ¼ carbs/starches (bread, rice, potatoes). You can have a piece of fruit to complete your meal. Try to exercise 30 minutes a day. If you cannot exercise 30 minutes, start with 10 minutes and slowly add more minutes (Table 2).

Data Collection

The aim of this project was to identify changes in glycemic control, as measured by the mean FSBG prior to and after text-messaging interventions were utilized. Patients’ aggregate mean FSBG for the three months of the project in 2016 were compared with patients’ mean aggregate FSBG for the corresponding three months in 2015. Graphs were created to illustrate the pre and post-intervention mean FSBG for each month during the project as compared to the mean FSBG for the corresponding three months in 2015. A frequency analysis via the CareMessage software was completed, and graphs were created to depict the following monthly data: the percentage of yes responses, no responses, or lack of patient responses to each daily question regarding SMBG and medication intake. A biostatistician was consulted prior to and during the QI project, as well as during data analysis. Microsoft Excel was utilized to calculate statistics and to produce graphs. All patient data was de-identified prior to inputting into the Excel worksheet.

Results

Participants’ aggregate mean FSBG in the pre-intervention period (npre=98) was 574.07, compared to 509.02 in the post-intervention timeframe (npost=90), representing an 11.3% reduction. Figure 1 displays monthly results. Following intervention, the mean FSBG decreased by 11.2% in April, 8.8% in May, and 14.3% in June 2016 from the pre-intervention months.

Discussion

The findings of this QI project reflect a reduction in participants’ mean FSBG level following text-messaging interventions that promoted DSME and support. The project timeline was followed as intended, and the goal or desired outcome was met. The text-messaging intervention for the proposed clinical change was consistently accepted as part of the usual care for all participants with diabetes. Clinic staff employed bi-monthly phone calls to program participants in an effort to remind them to respond to each question daily as well as to read and apply the bi-weekly educational messages and tips. Moreover, the importance of DSME and support via text message was re-emphasized on follow-up visits to facilitate patient commitment to self-management. The percentage of yes responses to the daily medication and blood sugar questions increased monthly throughout the intervention period (Figure 2 and 3).

While the project was successful, some limitations did exist. The biggest limitation was patient participation; however, despite the phone calls and encouragement during office visits, consistency remained an issue throughout the program, with four patients often failing to respond. Additional limitations were technological issues with the CareMessage software whereby the system failed to deliver the daily text messages several times throughout the project; notably, this occurred more frequently during the initial weeks and decreased significantly with help from software engineers. Still in June, the system failed to deliver the daily questions to 42 patients for two consecutive days. Furthermore, data entry errors regarding mobile phone numbers during the early weeks of the project resulted in a lack of self-reported data for five participants: three incorrect mobile numbers and two entered incorrectly in the system. Another project limitation is that diabetes control and management is best measured by HbA1c level. This blood test is routinely obtained every three to six months for all patients as part of their diabetes care at the clinic and is considered a standard of care for diabetic patients (ADA, 2014). However, the 12 week project period did not allow a viable time frame for this measurement.

Recommendations

Although this QI project was successful, further research is necessary to determine if the effects were sustainable following the conclusion of the intervention. Furthermore, HbA1c reduction is the marker for diabetes control; thus, it is vital that mobile phone interventions be implemented for a minimum of 16 weeks in order to correlate DSME and support via text-messaging to a statistically significant reduction in HbA1c. Finally, studies to identify the best program design including time-frame or length of intervention, SMS frequency, communication direction, and text message content should be conducted being certain to compare each aspect to HbA1c pre and post intervention values.

Conclusion

Currently, the approach to diabetes management includes face-to-face visits approximately every three to six months in which information, education, and encouragement are provided to patients concerning their diabetes treatment plan. Often, a time-frame of approximately 20 minutes is allotted for the patient-provider interaction leaving little time to completely discuss the aforementioned or answer questions. As such, patient-provider relations are constrained by limited or poor communication which prohibits the formation of collaborative partnerships that are fundamental for optimal diabetes management. Face-to-face visits afford the opportunity for periodic DSME; however, these brief encounters do not meet the expectation of ongoing DSME which would require support between visits, as the ADA (2014) advocates. Therefore, mobile phone technology is a promising means to augment current diabetic management which is commonly insufficient in primary care practices across the U.S.

The implementation of text-messaging interventions that promote diabetes self-management was effective in lowering the mean FSBG level during a 12-week period. Integration of an evidence-based text-messaging communication system may support diabetes self-management and promote patient adherence with daily medication regimens, SMBG, diet, and exercise in all primary care settings, leading to better patient outcomes and cost savings for diabetic care. Such low cost technological interventions in clinical practice have the potential to positively impact diabetic care and outcomes and may significantly improve the management and outcomes of other chronic conditions.

References

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By Nina M. Russell, MSN-Ed, APRN, FNP-C; Joy Vess, DNP, ACNP-BC; Cathy Durham, DNP, APRN, FNP-C and Emily Johnson, PhD

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