THE FINAL EVIDENCE BASED PROPOSAL
Diabetes is a non-communicable chronic health condition, which is associated with
significant mortality and morbidity rates. It is a major health concern in both developed and
developing countries. The disease imposes large economic burden to the patient’s relatives
and the entire healthcare system at large. Uncontrolled diabetes type 2 is associated with
multiple comorbidities such as hypertension, stroke, renal disorders and limb amputation. The
disease is associated with decreased quality of life and a leading risk factor for psychosocial
disorder (Kirk et al., 2011).
The disease affects virtually all the aspects of life. However, diabetes type 2 care
regimen is usually a complex process because it explores many health issues that are beyond
glycaemic control. Patient education using teach-back system approach is a cost effective
element which should be integrated in this healthcare facility. This approach is supported by
evidence based research, which indicates the effectiveness of education in reducing
glycosylated haemoglobin, depression, risk for further complication and it enhances patient’s
attitude and performance (American Diabetes Association, 2013). Evidence based research
indicates that patients with sufficient knowledge on care and coping strategies tend to have
excellent glycaemic control. However, the reality in doctor’s clinical settings indicates that
most of the patients have problems in achieving of proper glycaemic control, which often
results into further complication. Therefore, there is need to integrate a comprehensive
patient education in the clinical settings, in order to reduce diabetes type 2 patient knowledge
insufficiency (American Diabetes Association, 2013).
THE FINAL EVIDENCE BASED PROPOSAL 2
Quality measures
The quality measures used by this proposal are as governed by various advisory
bodies including NICE, American Diabetes Association, and National Collaborating Centre
for Chronic Conditions (NCCCC). Notably, these institutions lay a lot of emphasis patient
education in managing the complexities, lifestyle modification (nutrition and physical
activeness) and therapeutic measures. They recommend that patient diagnosed with diabetes
type 2 should have continuous education from the time the disease is diagnosed. The
education plans should be tailor made to meet the individualized needs. These institutions
have developed a strategic framework known Diabetes Self- Management education
(DSME), which provides the key quality measures and standards in the management of
patients diagnosed with diabetes (American Diabetes Association, 2013).
The standards are designed in a manner that they define quality of diabetes self-
management education and ways they can be implemented in the various clinical settings to
improve the healthcare outcomes of diabetic patients. To ensure quality, the health care
facility is expected to document its organization structure, mission and strategic goals that
promote quality care as integral part of diabetes management (Al-Akour et al., 2011).
The organization structure consists of committee, advisory body and the governing
board. This established system is provides a forum and mechanism that is essential for
management of diabetic patients. Despite the fact that my organizations have required
established system, documentation of its organizational structure, goals and mission
statement, the documentation process seems not to delineate effective channels of
communication, which impacts adversely on the patient health outcome (Ahmad Ali, 2014).
For effective delivery of services, the healthcare facility should determine the target
population to assess their health needs and to also to identify the necessary resources that will
THE FINAL EVIDENCE BASED PROPOSAL 3
promote self-management of population needs. This quality measure has been met partially
by this healthcare facility. For instance, the pharmacological demands for the diabetic
patients are met effectively. However, the clinic has been focusing more in disease
management/treatment rather than evaluating the health risks factors associated with the
disorder. This has resulted to knowledge insufficiency in diabetic management in patients
enrolled in this health care facility. This is exacerbated by the fact that there has been little
community involvement in planning and evaluation of clinical outcomes, which has reduced
the healthcare facility responsiveness to community identified needs (Tomar, 2016). The
reduced cultural competency has overlooked the benefits of giving greater interests to the
consumers; this is a safety issue of concern as it is associated with deterioration of the patient
health. This calls for the need to integrate change in clinical practice to ensure that the
facility quality measures correspond to those established by DSME (Inzucchi, et al., 2012).
Step 1: Assess the need for change in practice
My experiences in this health care facility have been very informative about the
various aspects expected of me as a nurse. One distinct area that has attracted my interest
concerns the management of Diabetes Type 2 patients. In this healthcare facility, there
somewhat effective lack support systems used to empower patients so that they can manage
or cope with this chronic disorder. Approximately, two thirds of the patients that I have
interacted with during their clinical visits seem to lack adequate knowledge on effective
strategies that can be applied to manage Diabetes Type 2 (Al-Akour et al., 2011).
The strategy of advice- giving technique in this health care facility assumes that
patient must change their behaviour and they want to change behaviour. This method
completely undermines autonomy and generated resistance and has failed to be effective.
This is because the intervention fails to consider what is or not important to the patient. There
THE FINAL EVIDENCE BASED PROPOSAL 4
is need to implement change on this issue, as the comfort of the patient (in all three states of
life i.e. physical, mental and spiritual) is vital so as to sustain quality delivery of care (Ahmad
Ali, 2014).
Diabetes is a challenging disorder because the care regimen is usually complex.
Despite the fact that patients with good self-care have excellent glyemic control, most of the
patients do not achieve proper glycemic control and as a result, they suffer associated health
complications. Generally, the evidence based practice indicate that diabetes regimen as a
multidimensional as adherence in one component is usually unrelated to the adherence of the
other regimen. Therefore, with proper education of the patients diagnosed with type II
diabetes quality of life is improved (Ahmad Ali, 2014).
Problem
The clinical problem that will be addressed in the EBP is lack of proper education in
patients diagnosed with diabetes Type 2. This will involve establishing strategies that will
ensure proper education on ways to manage their health complication among Type 2 diabetes
patients is delivered (Ahmad Ali, 2014).
Possible solutions/intervention
The proposed effective interventions is the application of teach back method in
enhancing effective behavioural interventions is recommended. This education strategy helps
the healthcare provider understand how, why, and when the patient fails to engage in optimal
diabetes self-management practices. The training topics that should be covered continuously
include the action of insulin, blood glucose monitoring, nutrition requirements, ketone testing
and diabetic ketoacidosis (DKA), and physical activity (Al-Akour et al., 2011).
THE FINAL EVIDENCE BASED PROPOSAL 5
This assessment is very important as it shapes the care plan by identifying strategies
that could fail if specific regimen are not understood or dealt with effectively as part of the
intervention. This is because in some cases, the disease related knowledge could be lacking,
or in other cases the patients could be having negative attitudes and health beliefs that hinder
effective care. There could be environmental or even psychological barriers. The use of teach
back education model helps in screening of these potential problems, and offers
comprehensive training on the appropriate therapies and medication is achieved (Kirk et al.,
2011).
The critical outcomes expected include improved and valuable mentoring of the type
2 diabetes patients and improved patient satisfaction. This will translate into lower hospital
associated health complications. This is because the peer support of the nurses will ensure
delivery of quality care (Al-Akour et al., 2011).
Goals and purpose
To understand the impact of proper education of patients with Type II diabetes in promoting
quality care management regimen.
Purpose statement: Elimination of barriers to patient education by developing proper
algorithm that can promote effective patient education.
Step 2: Locate best evidence based practice
(Literature review)
Evidence based research indicates that physical activity and diet are the most
important aspect in controlling ABCs of Type 2 diabetes. The ABCs includes (HbA1c, Blood
pressure and Cholesterol). Effective management of the glycated haemoglobin (HbA1c) and
to attain constant blood sugar regulation, it is very significant for the patients to comprehend
THE FINAL EVIDENCE BASED PROPOSAL 6
how to balance the intake of food and physical fitness. This involves patient education using
teach back technique (Reinehr, 2013).
Anticipatory patient education and counselling of lifestyle modification are routine
care is critical especially during the developmental transitions. Evidence base studies indicate
that successful management of diabetes type 2 will need heterogeneous interventions
including cognitive behavioural therapy, general diabetes education and skills training. This
increases diabetes knowledge which correlates with significant improvements on emotional,
physical and developmental outcomes (Stranieri, Yatsko, Jelinek & Venkatraman, 2015).
Although patient education is an important strategy in the National Diabetes
Prevention and Control program, there exist gaps and holes in the evidence based research
which justifies the need to improve knowledge in this research. There lacks necessary
investment that will facilitate its achievement. Additionally, patient education structure is not
specific enough. It fails to identify the exact component of patient education that should be
focused on i.e. Nutritional status or pharmacotherapy. It seems that there is need to conduct a
closer surveillance to develop training programs for diabetic patients to overcome the
prevailing inconsistences and shortcomings that impede effective patient education (Inzucchi,
et al., 2015).
Step 3: Critically analyse the evidence based practice
(Synthesis)
From the analysis; it is evident that diabetes is a chronic disease that needs proper
coping strategies in order to manage the disease effectively. This helps in management of
symptoms and delays disease progression. One of these coping strategies is patient
empowerment through education. This will help in ensuring that the patient is well informed
about his/her nutritional requirements and the appropriate lifestyle modifications. From the
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articles analysed, they agree on establishing cooperation between the patient and health
personnel to identify the best diabetic education (Steinsbekk, et al., 2012).
The evidence based studies inconstancies are observed mainly on reasons behind the low
patient knowledge. For instance, Inzucchin and colleagues identify that the source of these
challenges are due to unequipped trainers who have insufficient knowledge of education for
patient with diabetes. The trainers fail to identify individual specific needs and address
education program in a generalised structure. This fails to improve patient knowledge
sufficiently. On the other hand, Steinsbekk and colleagues indicate that there is reduced
educational facilities and lack of infrastructures that will facilitate adequate training. The
articles call for funding from the government and no governmental institutions to facilitate
adequate establishment of resources. Therefore, is need to establish the main source of low
efficacy patient education programs, so as they can be addressed in totality
The possible explanations of these inconsistencies is probably because most of the studies
are done within a small cohort or controlled environment; and in most cases, these beneficial
interventions are not translated to individuals lining outside the community. Although
pertinent in realization of the benefits of the research findings, the translational studies on
role of patient education among diabetic patient is lacking. This poses challenges during
training, and in the identification of the exact causative agent attributable to ineffective
patient education strategies (Inzucchi, et al., 2012).
The evidence found supports the identified practice change in that it supports that the
main reason for increased complications among diabetes type 2 patients is reduced
knowledge on coping strategies. There is no treatment for diabetes Type 2; and what should
be supported is providing patient education in all aspects that will regularize the patient
habits- including nutritional habits and medication management (Steinsbekk, et al., 2012).
This will reduce complications attributed to the metabolic control as it will empower the
THE FINAL EVIDENCE BASED PROPOSAL 8
patient to learn essential information as well as capabilities that will ensure improved quality
of life. Additionally, it is important to have long term follow-ups to monitor patient
capabilities and address new challenges that they could be facing. Additionally, it is
important to establish a good relationship between the patient, physician and dietician. The
improved monitoring systems will ensure that the education program is structured and also
provide an opportunity to overcome any shortcomings that would prevail (Kayshap et al.,
2013).
Feasibility, risks and benefits
Feasibility
Undeniably, several studies have reported on the dramatic increase of Diabetes type
2, especially among people below 30 years. This dramatic increase and complications
associated with the disease are important public health issues that must be addressed
amicably. Recent surveys have recommended that the application of education strategies
facilitates changes in lifestyle among patients diagnosed with diabetes Type 2. This is
specifically in subjects identified as high risk of developing diabetes type 2. Research
indicates that integration of the proposed practice in the clinical setting will reduce
approximately 60% risk of developing diabetes Type 2 within 3 years of intervention.
Secondly, the effects of these interventions are long- term (Inzucchi, et al., 2012).
One of the major barriers for the implementation of the practice is inadequate
resources. This will make it difficult for the healthcare providers to balance between their
workloads and the demand of practicing proposed intervention- integrative patient education.
Other potential barriers are organizational cultural and policy barriers that could lead to staff
resistance. Due to the low level of research in the clinical setting, most of the healthcare
providers would be sceptical regarding the evidence based research. Therefore, prior to the
THE FINAL EVIDENCE BASED PROPOSAL 9
onset of the research, the healthcare providers will be trained to ensure they understand the
concept and project outcomes (Inzucchi, et al., 2015).
The proposed study is an expensive study as it involves a lot or resources such as
educating material, employment of additional nurse assistants and time. However, the
outcome of the intervention3 justifies these costs as it increases patients satisfaction, improve
the patient compliance to the regulatory standards and improve the efficiency of care. Lastly,
better informed patients are more alert and attentive, which minimizes the risk of malpractice.
Risks
The main risk involved in integration of the practice into the clinical setting is the
concern that too much content about diabetes type 2 could result in confusion and reduce its
utility. Additionally, communication barriers could reduce the opportunity for the patient-
physician interaction, which would make it difficult to realize the project’s objectives
(Steinsbekk, et al., 2012). Issues of informed concept and patient ethical implications could
arise. The researcher will seek permission from ethical review board committee at the
institution. The work will require to be approved by the IRB as it involves interaction with
human beings. This is to ensure that the study is safe and does not pose potential dangers to
the participants. Each of the participants will be required to fill in a consent form (Fain,
2012).
Benefits
Integrative patient education is beneficial as it will increase the patient’s ability of
understanding the disease pathophysiology, and in establishment of the relevant coping
strategies. This is because it will facilitate the process of diagnosis and treatment alternatives,
as well as the consequences of various patient activities. Additionally, it will help the patient
THE FINAL EVIDENCE BASED PROPOSAL 10
to make appropriate decision, thereby reducing the readmission rates, length of
hospitalization and slows the disease progression (Kayshap et al., 2013).
Step 4: Design practice change
Elements of the Practice Change
Most of the healthcare facilities have invested heavily in training the healthcare staff
to ensure quality delivery of services. However, most of the employees persist in their old
methods, which could intimidate the management and act as barrier to facilitating change in
health care. Kotter’s model change is the most effective in such scenarios. This change
management model consists of eight steps that overlap each other (Kotter & Cohen, 2012).
The first three steps describe the procedures to developing an environment that
supports climate for change. The next steps describe the steps that engage the entire staffs in
the designing of change process. The last phases involve those which implement and sustain
change. Evidence based research indicates that effective changes are attained when there is
enough commitment by the staff, a sense of urgency momentum is developed, effective
engagement with the stakeholders, clear communication, a plan that is well executed and
strong leadership (Chapman, 2013).
Step 1 involves the aspects of creating urgency. In this case, there is need to address
the issue of knowledge insufficiency of patients diagnosed with diabetes type 2. This is an
urgent issue as poor knowledge on care regimen is associated with adverse clinical outcomes
and further complication. The economic and physiological burden associated with the affects
disease the patient and the health care system. This sparks the motivation to get things
moving (Kotter, 2012).
THE FINAL EVIDENCE BASED PROPOSAL 11
Step 2 involves the formation of powerful coalition. This involves convincing the
management that the change is necessary. In this case, the key stakeholders in this
organization include Nurse Managers of the various departments, quality insurance manager
and the members of the committee advisory boards. These people from different departments
are important because the management of diabetics involves interdisciplinary fields including
physical therapists, nurses, pharmacists, psychiatrists, laboratory technicians, dieticians, and
physicians (Chapman, 2013).
Step 3 and 4 involves the creation of a vision for change. If the proposed
interventions are integrated into practice, I envision increased patient satisfaction and an
institution with low workload, no nurse burn out and no turnover rates. I envision an
institution whose competitiveness in unmatched. The vision of low economic burden
associated with the disease, reduced mortality and morbidity rates will be communicated to
the management and the organization staff. This will include anxieties and concerns,
honestly and openly (Kotter and Cohen, 2012).
Step 5 involves removal of obstacles. The key obstacles are resource inadequacy and
communication barriers. In this process, the staff opinions on ways to address these issues
will be considered. However, to effectively implement the changes, short term wins will be
created (Step 6). Change is never rapid as implicated in theoretical work. To motivate more
success, shorter time frames will be set (every three months) to attain the short term targets.
This will facilitate a thorough analysis of the pros and cons of the targets. If an early goal is
not achieved, the team and I will consider changing the initiatives (Chapman, 2013).
According to Kotter, most change projects fails because of celebration or pre-mature
victory. Step 7 will involve building on the change. It is important to understand that quick
wins are only a beginning of what needs to be achieved for long-term care. This will help in
THE FINAL EVIDENCE BASED PROPOSAL 12
identifying change threats and to transform them into opportunities. This will help in ensuring
that the changes proposed are integrated and anchored in the healthcare facility culture (Step
8) (Kotter, 2012).
Step 5: Evaluating Change
Sustaining improvements in the proposed change plan is important. The evaluation
process is important because it helps identify the outcomes especially from interventions that
are theory formed. This helps in understanding of the theory constructs impact any
difference in their relationship as well as their components. In this regard, the evaluation will
be done on quarterly bases, after the initiation of the proposed project. It is important to
understand that the interventions may not be realized immediately, as most of the intended
outcomes are long term outcomes.
Outcomes
The critical outcomes expected include improved and valuable mentoring of the type
2 diabetes patients and improved patient satisfaction. This will be indicated in terms of lower
clinical visits, morbidity, mortality, limp amputation rates, or disability for health issues
associated with diabetes (Al-Akour et al., 2011).
The data will be collected using a questionnaire to evaluate the effectiveness of
comprehensive patient education in patient diagnosed with diabetes type 2. The questionnaire
to be developed will consist of three parts with five semi-structured questions. These three
broad themes included a) threat- which will explore patient perception about diabetes type 2,
b) coping-which will evaluate the patient perceptions on vulnerability to diabetes type 2 and
c) empathy- which will explore the nurse patient interactions. During the clinical visits, the
patient will be required to fill in these questionnaires with the help of the nurses. The patient
health details and analysis of the questionnaire particulars will also be used to evaluate the
THE FINAL EVIDENCE BASED PROPOSAL 13
clinical outcomes. For comparison purposes, the data collected will be analysed using the
central measure of tendency and measures of dispersion using statistical analysis tools
(Stranieri, Yatsko, Jelinek & Venkatraman, 2015).
Step 6: Maintain Change in Practice
It is very easy to introduce something in our lives but the main challenge is
maintaining it. To sustain the practice, the organization will be required to seek input from
the frontline and engage the staff during the designing of the proposed change plan. The
organization must establish shared values that anchor the change; this will help in sustaining
personal energy levels. The organization must promote team work by engaging the staff in
building a vision (LeClair, 2013). They must develop training programs that focuses on the
weakness to improve the staff confidence in managing the task. Effective communication
must be done at various levels and with various strategies. This will help the organization
listen to the employees concerns and to make them non-judgemental. This will also help the
management to engage with individuals personal and work related concerns. Lastly, periodic
evaluations will be done to assess if the organization is in maintain the healthy track
(Steinsbekk, et al., 2012).
Final discussion
Patient education is the most cost effective intervention for patients diagnosed with
diabetes type 2. The patient education should include pharmacological basics such as insulin
action, the various modes of administrations, and the processes of blood glucose monitoring.
Nutrition therapy education should cover the appropriate diet in terms of quality and quantity.
The physical activeness training should cover issues such as the effective duration of
exercise, what should be done before and after the exercise (Fain, 2012).
THE FINAL EVIDENCE BASED PROPOSAL 14
The healthcare providers should initiate these discussions with the patient families in
order to identify the effective coping strategies. Socioeconomic needs must be addressed in
order to address underlying barriers such as cultural issues, body shape and substance use.
The intervention has been associated with increased patient satisfaction. This is because it
helps the healthcare providers to understand the perceived needs, which facilitates innovative
ways to respond to the community needs. The proposed plan is anticipated to provide positive
financial support and maintain patient health safety simultaneously. The cost of implementing
this change practice is extremely feasible, and its implication will strengthen the healthcare
expertise, productivity and quality management of care (Al-Akour et al., 2011).
Reflection
Evidently, the management of diabetes type 2 is a complex process. It is important to
promote patient education in order to empower the patient on use of pharmacological therapy,
balanced nutrition and exercises to maintain. This will help manage effective glycaemic
control and prevent disease progression or associated complications. Patient education and
training should begin at clinical site, immediately the patient is diagnosed with diabetes type
- These include conducting of comprehensive assessment of the family functioning. This
will help the healthcare provider understand the patient’s attitudes and behaviour. This is
very important when designing patient education plan and during the implementation of the
evidence based practice, which improves the coping strategies.
THE FINAL EVIDENCE BASED PROPOSAL 15
References
Ahmad Ali, S. (2014). The Role of Educational Level in Glycemic Control among Patients
with Type II Diabetes Mellitus. Int J Health Sci (Qassim).; 8(2): 177–187. PMCID:
PMC4166990
Akour N A., Khader YS., Alaoui AM. (2011). Glycemic Control and Its Determinants among
Patients with type 2 Diabetes Mellitus Attending a Teaching Hospital. J Diabetes Metab;
2:4.
American Diabetes Association. (2013). Standards of Medical Care in Diabetes. Diabetes
care. 2013 Jan; 3(supplements 1)
Chapman, A. (2013). Change management: organizational and personal change management,
process, plans, and change management and business development tips.
Fain, J. (2012). National Standards for Diabetes Self-Management Education and Support:
Updated and Revised 2012. The Diabetes Educator, 38(5), 595-595.
http://dx.doi.org/10.1177/0145721712460840
Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., &
Matthews, D. R. (2012). Management of hyperglycemia in type 2 diabetes: a patient-
centered approach position statement of the American Diabetes Association (ADA)
and the European Association for the Study of Diabetes (EASD). Diabetes
care, 35(6), 1364-1379.
Inzucchi, S. E., Bergenstal, R. M., Buse, J. B., Diamant, M., Ferrannini, E., Nauck, M., &
Matthews, D. R. (2015). Management of hyperglycemia in type 2 diabetes, 2015: a
patient-centered approach: update to a position statement of the American Diabetes
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Association and the European Association for the Study of Diabetes. Diabetes
Care, 38(1), 140-149.
Kashyap, S. R., Bhatt, D. L., Wolski, K., Watanabe, R. M., Abdul-Ghani, M., Abood, B., &
Kirwan, J. P. (2013). Metabolic Effects of Bariatric Surgery in Patients With
Moderate Obesity and Type 2 Diabetes Analysis of a randomized control trial
comparing surgery with intensive medical treatment.Diabetes care, 36(8), 2175-2182.
Kotter, J. P. (2012). The Eight step process of leading change. Kotter International.
Kotter, J. P., & Cohen, D. S. (2012). The heart of change: Real-life stories of how people
change their organizations. Harvard Business Press.
Kirk JK., Davis Stephen W, Hildebrandt, C A., Strachan EN., Peechara M L., Lord, R.
(2011). Characteristics Associated With Glycemic Control Among Family Medicine
Patients With Type 2 Diabetes. NCMJ. 11; 72(5)
LeClair, E. (2013). Type 1 Diabetes and Physical Activity in Children and Adolescents.
Journal of Diabetes & Metabolism, 01(S10).
Steinsbekk, A., Rygg, L., Lisulo, M., Rise, M. B., & Fretheim, A. (2012). Group based
diabetes self-management education compared to routine treatment for people with
type 2 diabetes mellitus. A systematic review with meta-analysis. BMC health
services research, 12(1), 213.
Stranieri, A., Yatsko, A., Jelinek, H., & Venkatraman, S. (2015). Data-analytically derived
flexible HbA1c thresholds for type 2 diabetes mellitus diagnostic. Artificial Intelligence
Research, 5(1).
Tomar, D. (2016). Detection of Diabetes Mellitus Using HbA1C as Diagnostic Criteria.
Journal Of Medical Science And Clinical Research 4(3),
Reinehr, T. (2013). Type 2 diabetes mellitus in children and adolescents. World Journal Of
Diabetes, 4(6), 270.