Fluent Essays

Create a 10-15 slide PowerPoint presentation on the studys findings and how they can be used by nurses as an intervention. Include speaker notes for each slide and additional slides for the title page and references. Provide a descriptive and reflective discussion of how the new tool or intervention can be integrated into nursing practice. Provide evidence to support your decision. Nongnut Oba et al. 349Vol. 24 No. 3 Correspondence to: Nongnut Oba*, PhD, MNS, RN, Associate Professor, Faculty of Nursing, Naresuan University, Thailand. E-mail : [email protected] Charlotte D. Barry, PhD, RN, NCSN, FAAN, Professor, Florida Atlantic University, Christine E. Lynn College of Nursing, USA. E-mail: [email protected] Shirley C. Gordon, PhD, RN, NCSN, AHN-BC, Professor, Florida Atlantic University, Christine E. Lynn College of Nursing, USA. E-mail: [email protected] Navarat Chutipanyaporn, MNS, RN, Bangrahum Hospital, Phitsanulok, Thailand. E-mail: [email protected] Development of a Nurse-led Multidisciplinary Based Program to Improve Glycemic Control for People with Uncontrolled Diabetes Mellitus in a Community Hospital, Thailand Nongnut Oba*, Charlotte D. Barry, Shirley C. Gordon, Navarat Chutipanyaporn Abstract: A multidisciplinary approach is strategy for glycemic control management for diabetes care, yet the type of health workforce at each level of the healthcare system is unequal. This participatory action research was designed in three phases and undertaken in a community hospital in Thailand. Phase 1 aimed at discovering the causes of uncontrolled blood glucose by two focus group discussions with healthcare providers and people with diabetes. In Phase 2, focus group discussion with stakeholders were undertaken to learn from the Phase 1 data to build a program for improving glycemic control among uncontrolled diabetes. Phase 3 aimed at implementing and evaluating the effectiveness of the developed program using a quasi-experimental design. Data from focus group discussions were analyzed by content analysis while the data before and after intervention were analyzed by percentages, mean, standard deviation, and paired t-test. Four categories related to causes of uncontrolled glycemia: poor hypoglycemic drug adherence, high energy dietary consumption, limitation on physical activity, and vigorous stress in life event. The improving glycemic control program developed in Phase 2 was the Nurse-led Multidisciplinary Based Program for People with Uncontrolled Diabetes. The Program goal was a decreased fasting blood glucose and an A1C of >8\% and no hospital admission with either a hypoglycemic or hyperglycemic crisis. Program outcomes included significantly lower A1C compared with baseline levels (p<.01), and no hospital admissions. This Program provides an avenue for nurses to manage glycemic control in diabetes within a cooperative program in the community hospital. Pacific Rim Int J Nurs Res 2020; 24(3) 349-362 Keywords: Glycemic Control, Multidisciplinary Approach, Nurse, Participatory Action Research, Uncontrolled Diabetes Mellitus Introduction Globally, more than 400 million people live with diabetes mellitus (DM), a serious, chronic disease.1 The International Diabetes Federation has predicted that the number of Thai people with diabetes will Received 30 July 2019; Revised 3 November 2019; Accepted 19 December 2019 Development of a Nurse-led Multidisciplinary Based Program to Improve Glycemic Control 350 Pacific Rim Int J Nurs Res • July-September 2020 increase from 6.4\% in 2013 to 8.3\% by 2035.2 Changes in lifestyle towards urbanization, combined with rapid economic development, increased survival from communicable diseases, and genetic susceptibility, have led to rising numbers of diabetes case and is a major and growing health care problem in Thailand. 3,4 The goal of diabetes care is that people with diabetes have on testing a A1C<7\% and no acute and chronic complications.5,6 When diabetes is not well managed, hypoglycemia, diabetic ketoacidosis and hyperosmolar coma complications could develop that threaten health and endanger life. People with diabetes who can manage their medication taking and behavioral life style well until they achieve an A1C <7\% are defined as having controlled diabetes, while others having an A1C >7\% have uncontrolled diabetes.5,6 The prevalence rate of controlled diabetes is one of the 11 criteria of non- communicable diseases (NCD) clinic of each hospital that should be reported online to the Health Disease Control (HDC) dashboard of the Ministry of Public Health (MOPH), Thailand.7,8 In the HDC data during 2017-2019, it was found that the prevalence rate of controlled diabetes was lower than 50\% in cumulative data of district, provincial and national levels. Bangrahum Hospital, a small community hospital in Phitsanulok province, Service area 2, MOPH developed a new plan to improve diabetes care by increasing the number of controlled diabetes rates in their responsible area. Managing diabetes care by maintaining a A1C <7\% is paramount. From previous research, it was found that the factors affecting A1C levels of people with diabetes had both client and health service aspects. In the client aspect, the factors associated with poor glycemic control of diabetes indicated by A1C values were insufficient physical activity9, being overweight or obese9, level of education10 and regularity of follow up.10 In the health service aspect, previous glycemic control interventions influenced the lowering A1C levels were diabetes self-management education (DSME)11, self-monitoring of blood glucose (SMBG)12, self-care management interventions13, and multidisciplinary interventions managed by a nurse.14 The above interventions reviewed showed diverse health providers such as physician, nurses, pharmacists, nutritionists, and physical therapists who address people with diabetes individually according to their own areas of expertise. Because diabetic conditions are very complicated, a uniform intervention approach based on a single profession has limitations. Although diabetes guidelines are recommended, pharmacological and behavioral modification strategies using a multidisciplinary approach are key successes of management to control the A1C.5 However, the number and type of health workforce at each level of the healthcare system is unequal.15 A multidisciplinary approach to improve diabetes care in a small community hospital which does not employ a diabetes expert is a unique health service delivery that needs to be studied as there are insufficient health personnel resources. Literature review and Conceptual Framework The differing multidisciplinary approaches in the literature reviewed varied in the makeup of specialists participating, hospitals and healthcare levels, and outcomes measured. However, the nurse is still the central person of a multidisciplinary team for diabetes care with complicated problems.16 Existing nursing research below proposes a nurse-led multidisciplinary team to be effective in the glycemic control of uncontrolled diabetes. A previous study found that a nurse-led DSME Program showed significant improvement in A1C levels among Iranian adults.17 After receiving nurse case management, patients with DM in a primary care cluster had significant lower average blood glucose level than before intervention.18 After three months follow up, people with type 2 diabetes (T2D) who visited at a university hospital had significantly improved A1C.19 In another study the A1C levels at 6 months of people who attended a health services dropped significantly in response to a multidisciplinary intervention managed by a nurse and remained low in the last half year of Nongnut Oba et al. 351Vol. 24 No. 3 follow up.14 A group of patients with diabetes who received medication education intervention, a group counseling session and individual follow-up telephone counseling by physician and nurse in a general hospital had significantly lower A1C than the comparison group.20 Patients with diabetes who received Multidisciplinary Team-Based Education at a university hospital showed an improvement in A1C level.21 Five of 11 studies in a systematic review of diabetes nurse case management had positive effects on patients by reducing A1C compared to standard care,22 although, there are some nursing interventions which did not significantly lower A1C levels. Another study found that the advanced practice nurse-led diabetes support group members had no significantly lower A1C in T2D in a tertiary care hospital.23 During the two-year follow up, an intervention group who received DSME by multidisciplinary team of a tertiary medical center had similar mean differences in A1C reduction to the control group.24 All of these studies showed multidisciplinary approaches using different personnel at different healthcare levels but there was no previous research in a small community hospital which has no diabetes expert working there. Yet, health providers in small community hospitals must provide suitable diabetes care to improve glycemic control and also show the overall potential in diabetes management by presenting prevalence rates showing the control of DM in the HDC dashboard in Thailand. The literature reviewed is synthesized into a conceptual framework in Figure 1. Identification of the causes of uncontrolled plasma glucose Fasting blood glucose A1C Admission Development of a Nurse-led Multidisciplinary Based Program for people with Uncontrolled Diabetes Figure 1 Conceptual framework of this study Study objectives The objectives of this study in a small Thai community hospital were to (a) understand the causes of uncontrolled plasma glucose among individuals with diabetes, (b) develop a program for improving glycemic control among people with uncontrolled diabetes using a multidisciplinary approach, and (c) implement and evaluate the effectiveness of the developed program. Method Study Design This participatory action research (PAR) was designed in three phases. Phase 1 aimed at discovering the causes of uncontrolled blood glucose by 2 focus group discussions (FGDs)with healthcare providers and people with diabetes. In Phase 2, stakeholders of FGD were gathered to learn from the Phase 1 data with the objective of using that data to build a program for improving glycemic control among uncontrolled diabetes. Phase 3 aimed at implementing and evaluating the effectiveness of the developed program by using a quasi-experimental design. In PAR, qualitative and quantitative methods can be used. People were engaged in such a study to improve health may help to frame the research question(s), plan the processes, collect the data, decide on actions to be taken, and are often involved in implementing these, as well as taking part in the project evaluation.25(p1) This current PAR process used qualitative: 2 FGDs in Phase 1 and a FGD in Phase 2 and quantitative approaches: implementation and evaluation in Phase 3 of study. Development of a Nurse-led Multidisciplinary Based Program to Improve Glycemic Control 352 Pacific Rim Int J Nurs Res • July-September 2020 Participant Descriptions by Phase Phase 1. Using a purposeful sampling technique, a group of participants’ healthcare provider and a group of participants with diabetes were recruited. The 13 healthcare provider participants included one each of physician, pharmacist, physical therapist, and Thai traditional medical practitioner, 5 nurse practitioners (NPs) from the chronic disease clinic and 4 NPs from a sub-district health promotion hospital (SHPH), selected on their work experience in diabetes care for at least 1 year. Twelve participants with diabetes were selected based on the following inclusion criteria: diagnoses with diabetes in the previous 12 months, and history of receiving services from the SHPH, prior to receiving services from the community hospital. Phase 2. In this phase, an FGD was undertaken with 13 stakeholders included one physician, pharmacist, physical therapist, Thai traditional medical practitioner, 2 NPs from chronic disease clinic, 2 NPs from SHPH and 5 participants with uncontrolled diabetes who did not participate in Phase 1. Phase 3. Inclusion criteria included people who had an A1C>8\% and had been sent from SHPH to the community hospital. They also had time to follow the activities of the program and read and write in Thai fluently. Forty participants with uncontrolled diabetes who did not participate in Phases 1 or 2 were selected to participate in this phase. Data gathering and data analysis Research Instruments In Phase 1, two semi-structured FGD guidelines for health providers and the participants with diabetes were used to discover the causes of uncontrolled blood glucose from their perspectives. The open questions of the health provider guideline focused on professional knowledge and experiences of diabetes care, causes of uncontrolled blood glucose among diabetes, experiences in resolving diabetes care, overall satisfaction on diabetes care, and the model of expected diabetes care. The open questions for participants with diabetes’ guideline related to causes of uncontrolled blood glucose, feelings/needs of attending the health service, their views of the diabetes care services, and model of expected diabetes care. The intentional use of two discussion groups, separating the participants with diabetes and health providers, provided the milieu for group members to talk more freely. A study on sample sizes of focus groups found that the first FGD generated 60\% of code development and eventually reached saturation (with over 90\%) at the 4th FGD. 26 In Phase 2, the FGD guideline was composed of characteristics of expected multidisciplinary approach on diabetes care, and development of a suitable program for uncontrolled diabetes which included: (a) target group, (b) goals, (c) outpatient resources, (d) time, (e) care process interactions and (f) the outcome measures of the program. In Phase 3, the developed program was the research intervention tool while clinical data record form included A1C, FBS, and number of admissions was the research collection tool. In Phase 1, the researchers conducted two FGDs: health provider (FG1) and those with diabetes (FG2) in the studied hospital. Interviews were recorded digitally and written notes were taken by a researcher. Transcription of the recordings in Thai words, rereading the typed words and written notes and rewriting the transcription were undertaken. Descriptive content analysis; preparing, organizing, and reporting processes in accordance with the United States Agency for International Development27 was used for content analysis. In Phase 2, the researchers conducted FGDs involving health providers and participants with uncontrolled diabetes in a meeting room of the studied hospital. After reviewing the data from Phase 1, brainstorming of all participants in each part of program were audio-recorded and by writing notes while one participant wrote and rewrote the consensus results on the big chart in front of the meeting room to confirm the results. All data of this Phase were analyzed by content analysis.27 Nongnut Oba et al. 353Vol. 24 No. 3 In Phase 3, 40 outpatients with uncontrolled DM were enrolled and participated in schedule of the developed Program during their out-patient department (OPD) visits every 4 months. Participants’ A1C and FBS measure were collected before implementation of the program. All participants were encouraged to actively participate in the four care processes: 1) group health education on diabetes self-management, 2) medication adherence monitoring, 3) case management, and 4) consideration of the overall participants’ outcome and treatment of the Program. At the end of the intervention, the participants’ A1C, FBS and hospital admissions were collected. Outcome measures before and after intervention were analyzed using number, percentage, mean, standard deviation, and paired t-test. Ethics Consideration Ethics clearance for this research was obtained from the Naresuan University Ethics Committee for Research and Human Studies in Thailand (number COA No.240/2014, October 3, 2017). The researchers provided details of the study to participants prior to obtaining informed consent. Confidentiality was assured by code numbering all data and only the lead investigator was able to identify names with individual participant responses. The researchers obtained written consent and participants understood they could withdraw from the study at any time without penalty to assure protection of participant rights. Results Phase 1. Causes of uncontrolled plasma glucose Four categories emerged from the two FGDs (healthcare providers and people with diabetes) which were related to the causes of uncontrolled plasma glucose among people with diabetes: 1) poor hypoglycemic drug adherence, 2) high energy dietary consumption, 3) limitation of physical activity, and 4) vigorous stress from life events. The following lists the causes and participants’ description consensus as follow: 1. Poor hypoglycemic drug adherence Participants described various factors that influenced their ability to adhere to their prescribed diabetes medication. Participants described buying medications without provider oversight, missing medications that were schedule to be taken during follow up appointments, and misunderstandings about the importance of taking medications as prescribed to be the causes. “Some patients bought hypoglycemic drugs from drug stores by themselves.”[#12F, FG1] “When we went to visit elderly patients in their home, we found a lot of hypoglycemic drugs kept in the bag [from pharmacy]. This meant that the patient took medication irregularly”. [#7F, FG1] “I do not take my medicine on time. It makes my blood glucose swing up and down quickly.” [#3F, FG2] 2. High energy dietary consumption Participants described various factors that influenced their ability to adhere to their prescribed diabetic diets. They described eating high energy [high calorie] food, sweets and drink that was prepared for them, readily available or needed to sustain the hard physical work of farming. Some healthcare providers reported that people with DM followed their prescribed diet only when preceding a scheduled fasting blood glucose (FBG) test. “In rural areas, people frequently eat a lot of high energy food, sweets and drink in village cultural ceremonies (3-7 times/month).” [#10F, FG1] “People with diabetes controlled their eating only 2 or 3 days before visiting the hospital for checking their FBG. However, their A1C, which is checked once a year, is more than 10\%. [#3M, FG1] Development of a Nurse-led Multidisciplinary Based Program to Improve Glycemic Control 354 Pacific Rim Int J Nurs Res • July-September 2020 “I couldn’t cook food by myself, so my daughter cooks every meal for me but I frequently have meals with curry and coconut milk.” [#4M, FG2] “ I need high energy food for working hard in the rice field.” [#7F, FG2] “Although I ate only one fried egg, fried fish and chicken, my blood glucose was still up.” [#9F, FG2] “I eat a lot of fruits such as mango, jack fruit, and banana in season because they are grown in my backyard.” [#12F, FG2] 3. Limitation on physical activity Participants described various factors that influenced their ability to adhere to their prescribed exercise plans. They limited their physical activity due to being overweight, had difficulty in ambulating or believed that farm work was sufficient physical activity. “Overweight limits exercise in some patients. Blood glucose control in this group is very difficult” [#1F, FG1] “Almost all patients are farmers. They work on the farm every day. So they feel they have already exercised.” [#13F, FG1] “I had an eye problem 2 years ago. I use a walker every time I walk. What way can I exercise?” [#8M, FG2] “I work in the farm for 4 hours every day. I have no need to exercise.” [#10F, FG2] 4. Vigorous stress in life events Participants described various stressful live events that influenced their ability to adhere to their plan of care for DM. They described house floods, sleep disruptions, economic crisis events, and other major health concerns. “The houses of two patients were flooded. They couldn’t sleep deeply for several days. We referred them to consult a psychologist.” [#5F, FG1] “One patient worked in Bangkok but the economic crisis fell. He left to work at home. He was worried about his decreased income. His FBS was very high every month.” [#8F, FG1] “After I had a stone in my gall bladder, I was stressed and had high glucose in my blood.” [#5M, FG2] “My left eye bleeds and can’t see clearly. The physician is considering whether to apply laser for this problem or not. Does a laser shot to the eye hurt?” [#1M, FG2] Phase 2. Development of a program for improving glycemic control The developed program aimed at improving glycemic control among uncontrolled diabetes was called the Nurse-led Multidisciplinary based Program for People with Uncontrolled Diabetes (NMPUD or the Program). Multidisciplinary resources involved were (1) physician: consider overall participant’s outcome, (2) pharmacist: taking of hypoglycemic agent monitoring, (3) Thai traditional practitioner: diet education, (4) physical therapist: exercise education, and (5) NP: case manager. Four months of Program care processes were 1) group health education on diabetes self-management, 2) medication adherence monitoring, 3) case management, and 4) considering overall participants’ outcome and treatment. The Program plans were as follows: 1. The topics of group health education, including dietary practices, physical activity and exercise, home medication taking, SMBG practice, and stress management, were provided by the health team. 2. Medication adherence monitoring; the pharmacist checked the remaining medication of participants on each visit. If some participants were found to have a large amount of medications remaining, it meant that they had not taken the medicine as prescribed. Pharmacists wrote a small note in the participant’s diabetes record for the NP and the physician review, and re-educated them on how to take the medication as prescribed. Nongnut Oba et al. 355Vol. 24 No. 3 3. NPs have a role in both direct and indirect case management care. They individually examined the participant’s SMBG record and office FBS, reviewed participant’s practices (nutrition, exercise and general care) and provided education or counseling as needed and considered as direct care. Indirect care included the designing of the topic of group health education and inviting health providers to share experiences in each topic, mobile phone call reminders of missed visits to set new follow-up appointments, and planning, implementing and evaluating the Program’s services on schedule. 4. The physician considered the laboratory data, diet and exercise practices from the records of the NP and current treatment and medication notes from pharmacist and made decisions to continue or adjust medication. Phase 3. Implementation and Evaluation of the Effectiveness of the Developed Program At the time of each visit, the health care team started by providing group health education on diabetes self-management for 30-45 minutes/session, medication taking monitoring by the pharmacist, individual motivation of lifestyle changes by the NP, and consideration of the overall client’s clinical outcomes by the physician. The NMPUD was well implemented according to the scheduled time but there were two participants who did not complete the activity and were withdrawn from the program. Therefore, Phase 3 had 38 participants. Table 1 displays the FBS and A1C levels before the program intervention and four months following the intervention. The results showed A1C was significantly lower than the baseline levels (p<.01) while FBS was not significantly lower. Table 2 displays pre and post intervention A1C levels and the percentage of the participants in each range. All (100\%) participant A1C levels before the intervention were 8.1 or higher. Post intervention, A1C level ranges demonstrated greater variability and the number of participants with A1C levels of 8.1 and higher decreased. In addition, no participants were admitted into the hospital with signs and symptoms of hyperglycemic or hypoglycemic crisis during the intervention period. Table 1 A1C and FBS among people with diabetes before and after intervention Clinical laboratory Mean S.D. Paired-t test p-value A1C Before intervention After intervention 9.789 8.521 1.238 1.983 3.420 .002 FBS Before intervention After intervention 194.69 180.42 68.133 52.024 1.587 .121 Table 2 Amount and percentage of A1C among people with uncontrolled diabetes before and after intervention A1C (\%) Ranges Before intervention After intervention # Participants Percentage # Participants Percentage 5.1-6.0 0 0 1 2.63 6.1-7.0 0 0 10 26.32 7.1-8.0 0 0 7 18.42 8.1-9.0 12 58.31 7 18.42 9.1-10.0 13 21.34 7 18.42 > 10.0 13 21.34 6 15.79 Total 38 100.00 38* 100.00 * No participant admitted in hospital with signs and symptoms of crisis hyperglycemia and hypoglycemia Development of a Nurse-led Multidisciplinary Based Program to Improve Glycemic Control 356 Pacific Rim Int J Nurs Res • July-September 2020 Discussion Phase 1: Causes of uncontrolled plasma glucose People with diabetes were involved in one of the FGDs in this phase because they are able to understand their own causes which were beneficial to use as information for creating service programs that are expected to fix it. From Phase 1, it was found that the causes of uncontrolled plasma glucose were explained by the four themes below. Poor hypoglycemic drug adherence This research results found that buying medications without the healthcare provider’s oversight, missing medications due to follow-up appointments that were not on time, and misunderstandings about the importance of taking medications were information of poor hypoglycemic drug adherence. In the diabetes care service, the doctor prescribed the amount of medication ordered to fit with the time of the next appointment. Taking medication by wrong route, dose and time affected the action of hypoglycemic agent to be higher or lower than expected. Missed doctor appointments was significantly associated with increased odds of poor glycemic control (p<.05).28 Lack of understanding of the long-term benefits of treatment, and the complexity of the medication regimen influences poor medication adherence29. High energy dietary consumption Participants often ate high energy [high calorie] food, and followed their prescribed diet only when preceding a scheduled FBG test. The responses of participants were deceptive behaviors in an attempt to lower blood glucose levels only on the day of collection but had no benefit for overall glycemic control. The Thai culture of food consumption is traditionally eating rice, beef, pork or chicken curry with coconut milk for the main dish and followed by sweets. Various ingredients of Thai curry and desserts such as coconut, flour, and milk are high energy substances while fruits such as mango, durian and grapes have a high glycemic index.30 Hyperglycemia can be considered a consequence of the energy imbalance, that is, energy intake is greater than energy spent during a certain period.31 Limitation on physical activities The limitation of physical activities due to being overweight and difficulty in ambulating were causes of poorly controlled diabetes. During exercises, glycogen in the muscle of a person converts to glucose for providing energy. On the contrary, if the person does not exercise, converting glucose to energy is reduced, causing high blood glucose.5 Multivariate analysis shows inadequate physical activity is significantly associated with increased A1C.32 However, medium physical activity can reduce poor glycemic control more than low and high physical activity.33 Weight loss defined as a sustained reduction of 5\% of initial body weight, has been shown to improve glycemic control in some overweight and obese people with T2D.34 Vigorous stress in life events This research found that the house floods, economic crises, and sleep disruptions were stressful live events that interrupted participants’ adherence to their diabetes care plan. High levels stress due to life events is significantly linked to variability in A1C levels, and behaviors related to dietary and exercise choices.35 Addressing the psychosocial needs of the people with diabetes helps to overcome the psychological barriers associated with adherence and self-care, while achieving long-term benefits in terms of better health outcomes and glycemic control.36 Therefore, understanding the causes of uncontrolled blood glucose among people with diabetes allows healthcare providers to formulate strategies focusing on the improvement in diabetes care outcomes. Phase 2: Development of the NMPUD The NMPUD, aiming at improving glycemic control in uncontrolled diabetes included four activities as described above, were approved by discussion of providers and … CLC - Evidence-Based Practice Project: Intervention Presentation on Diabetes · My Group · Group Forum This is a Collaborative Learning Community (CLC) assignment. As a group, identify a research or evidence-based article published within the last 5 years that focuses comprehensively on a specific intervention or new treatment tool for the management of diabetes in adults or children. The article must be relevant to nursing practice. Create a 10-15 slide PowerPoint presentation on the studys findings and how they can be used by nurses as an intervention. Include speaker notes for each slide and additional slides for the title page and references. Include the following: 1. Describe the intervention or treatment tool and the specific patient population used in the study. 2. Summarize the main idea of the research findings for a specific patient population. The research presented must include clinical findings that are current, thorough, and relevant to diabetes and nursing practice. 3. Provide a descriptive and reflective discussion of how the new tool or intervention can be integrated into nursing practice. Provide evidence to support your discussion. 4. Explain why psychological, cultural, and spiritual aspects are important to consider for a patient who has been diagnosed with diabetes. Describe how support can be offered in these respective areas as part of a plan of care for the patient. Provide examples. You are required to cite to a minimum of two sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.