A practice innovation
Abstract: The
purpose of this project was to evaluate the effi cacy of group diabetes care
for an underserved population using a patient-centered approach with the inclusion
of interactive diabetes self-management education. In place of the traditional
offi ce visit, patients attended three group visits. Improvements in diabetes knowledge
and patient-perceived self-effi cacy resulted.
Key words: diabetes, diabetes
self-management education, group care, group medical appointments
By Jana L. Esden, DNP, ARNP, FNP-BC, and
Mary R. Nichols, PhD, APRN, FNP-BC
The
purpose of this clinical Doctor of Nursing Practice (DNP) capstone project was
to implement an innovation in diabetes care by utilizing a group approach for a
patient-centered model of care that included interactive diabetes
self-management education at a free clinic in Central Florida. This group care innovation
was designed to increase diabetes knowledge and patient-perceived
self-efficacy, improve patients’ attitudes toward diabetes, and reduce barriers
to diabetes self-management behaviors for the underserved patients at the free
clinic.
■ Background
During
the early 21st century, type 2 diabetes mellitus became one of the most common
chronic diseases seen worldwide, affecting an estimated 194 million people. Currently
in the United States, 26 million people have diabetes.As result of obesity, sedentary lifestyles and increasing
age, the prevalence of type 2 diabetes is expected to surge to 333 million
people within the next 15 years.1,3 Diabetes Self-Management Education (DSME)
has long been shown to be a cornerstone of diabetes management. According to
Tang et al., DSME can help improve both metabolic and psychosocial outcomes. Although
DSME improves outcomes initially, the effect of the teaching may last
less than 6 months without ongoing support and additional educational resources. Group
care can be used to deliver interactive, patient-centered diabetes education
and care. Some models of group care, such as the Centering Model, include a
short, individual appointment with a healthcare provider for each patient prior
to group education and support.6 The 5- to 10-minute session includes a brief,
individual physical assessment and a discussion of
any clinical abnormalities, lab abnormalities, or personal concerns that the
patient does not wish to share with the group. Other models of group care, such
as those designed by Trento and colleagues, only provide individual care to patients
who request a private visit and to those with clinical or lab abnormalities. With
this model, individual assessments are not completed outside of the group for
all patients. The
Centering Model and the group visits designed by Trento and colleagues use
empowerment-based strategies. Both models have consistently demonstrated improved
physiologic and psychosocial outcomes for patients. Additionally, the evidence
suggests that such models are fi nancially and logistically feasible. Despite a
growing body of evidence suggesting that diabetes education should be
patient-centered and interactive, a local diabetes self-management education
program in Central Florida continues to be clinician-centered, either taught in
group-lecture format or as individual education given by the provider at the
time of the offi ce visit. Research also demonstrates that diabetes education
needs to be ongoing; a one-time program is not suffi cient to maintain positive
outcomes. In Central Florida, the only diabetes education program available to
the underserved population of a free clinic is a one-time, clinician-centered
diabetes education class.
■ Methods
Institutional
Review Board approval from Frontier Nursing University and a letter of support
from the clinic were obtained. Participants with type 2 diabetes were recruited
for the project via personal communication at offi ce visits and
by phone calls to patients from offi ce staff. Program participants were required
to speak, read, and write in English. To compensate participants for their
time, a $50 gift card was given to patients who attended all three sessions.The
participants completed three measurement tools pre- and post-intervention to
assess diabetes knowledge, patient perceived self-effi cacy, attitudes toward
diabetes, and barriers to diabetes self-care behaviors (see Assessment tools). All
tools were downloaded without cost from the Michigan Diabetes Research and
Training Center website. Diabetes knowledge was measured with the Michigan
Diabetes Research and Training Center’s (MDRTC) Brief Diabetes Knowledge
Test. Patient perceived self-effi cacy was measured with the Diabetes Empowerment
Scale, created at the Michigan Diabetes Research and Training Center. Diabetes attitudes
and barriers toward self-care behaviors were measured with the Diabetes Care
Profi le (DCP). All tools were analyzed
and found to be valid and reliable. In addition to the three measurement tools
administered pre- and post-intervention, participants also completed a patient
satisfaction survey administered after the fi nal session. This survey included
eight items with a Likert scale 1 through 5, 1 being “strongly disagree” and 5
being “strongly agree.” For all eight items, a high score of 5 was a positive score.
Participants were also given an opportunity to describe what they liked most about
the sessions and what they liked least. The
first of three group sessions was held in January 2012, and 10 of 12 scheduled
patients arrived at the clinic to participate. After obtaining written informed
consent from each patient, participants completed the pre-intervention assessment
tools. The nurse practitioner (NP) program facilitator was available to answer
any questions. Patients had free access to restrooms and to complimentary food
and beverages during this time. Diabetes
group care sessions were held once monthly for three sessions, and each session
lasted approximately 2.5 hours. The first and last sessions included an
additional hour to complete pre- and post-intervention assessment tools.
When participants arrived, they had assistance in measuring their own vital signs,
including temperature, BP, pulse, height, and weight. The participants
completed a review of systems form and brought the information to the NP
project coordinator for a brief individual assessment and focused physical
exam. In addition to a focused physical exam, abnormal lab fi ndings were
discussed with each patient. Following individual time with the NP, patients
had the opportunity to interact with other participants, review information
from their diabetes course binders, and snack on healthy food and beverages.
During this time, participants also completed a self-directed tool for the
development of personalized goals for the next month. This contributed to
the patient-centered approach to care, as patients choose these goals to fi t
with their priorities, resources, and culture. At each of the three sessions,
group diabetes education consisted of an opening activity that promoted group cohesiveness,
interactive diabetes education, and a refl ective closing activity. For
example, at the fi rst session’s opening activity, patients paired off, and after
10 minutes of discussion, each patient introduced his or her partner to the
group and
included interesting facts about the person. In the opening activities for the
second and third sessions, patients shared challenges they had faced since the
last session. For closing activities, patients discussed changes they would make
to control their diabetes and shared one aspect of group care that had helped
them meet their health goals. Group education at the fi rst session consisted
of pathophysiology of diabetes and extensive information on diet changes
and choices. For example, a group activity helped patients identify foods as
carbohydrates, proteins, fruits, or vegetables. This was followed by a
discussion about dietary needs, portion sizes, and barriers to a healthy diet
with suggestions about how to overcome those barriers (see Group education topics by session). Group
education at the second session focused on an explanation of the different
types of medications prescribed
for
diabetes, barriers to the proper administration of medications, and ways to
overcome those barriers. Participants compared medications with other members
of the group, and group members were often the source of ideas for overcoming barriers
to medication adherence. The group also discussed self-monitoring blood glucose
levels and managing hypoglycemia and hyperglycemia. At this visit, all
participants received a package of glucose tablets as an example of a proper
remedy for hypoglycemic episodes. At
the final session, participants received a copy of their most recent lab
results. They recorded their most current BP, hemoglobin A1C, fasting glucose,
triglycerides, high-density lipoprotein, and low-density lipoprotein levels in
their personal binder, so they could determine whether or not they were at
goal. These results were then used for a discussion on risk factor reduction.
This particular activity was designed to help patients understand how to read
their lab results and to serve as a future reference in assessing goal
attainment.
During
the last session, group members identifi ed types of exercise they enjoyed.
Walking was highlighted as a lowcost, low-impact, and feasible activity for the
patients. Each participant received a free pedometer to encourage them to walk
for exercise. Finally, the group discussed preventive care,
such as eye and foot exams, and played a diabetes quiz game prior to a fi nal
closing activity. The fi nal refl ective closing activity was a group-bonding activity
using a yarn web where each participant held a yarn ball and stated what the
group had meant to him or her. The participant then tossed the yarn ball to
another participant across from them, which created a yarn web representing the
connection between group members. At the end of the final session, participants
again completed the Short Diabetes Knowledge Test.
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