JURNAL KEPERAWATAN : Patient-Centered Group Diabetes Care

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.