Digital Repository Masters Projects Spring 2023 Inpatient Diabetes Self-Management Education and Support Emily J. Murray Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Murray, E.J. 2023. Inpatient diabetes self-management education and support. Weber State University Masters Projects. https://dc.weber.edu/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact scua@weber.edu. WSU REPOSITORY MSN/DNP Inpatient Diabetes Self-Management Education and Support Project Title by Emily J. Murray, BSN, RN, MSN Student Student’s Name A project submitted in partial fulfillment of the requirements for the degree of MASTERS OF NURSING Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, UT April 1, 2023 Date Emily J. Murray, BSN, RN, MSN Student April 1, 2023 Student Name, Credentials Date (electronic signature) 4/4/2023 MSN Project Faculty (electronic signature) Date Melissa NeVille Norton (electronic signature) Date DNP, APRN, CPNP-PC, CNE Graduate Programs Director Note: The program director must submit this form and paper. Inpatient Diabetes Self-Management Education and Support Emily J. Murray, BSN, RN, MSN Student Weber State University Annie Taylor Dee School of Nursing Abstract Diabetes is a chronic metabolic disease requiring people to learn skills and knowledge to manage their long-term condition. Hospitalization provides an opportunity to receive this diabetes selfmanagement education and support (DSMES). However, most hospitals do not have a set standard for inpatient DSMES. Nurses are often charged with providing this education to patients. Unfortunately, many nurses are not aware of available DSMES resources. The objective of this project is to create a plan to train nurses on how to teach DSMES. In addition, this project aims to create a standard protocol for nurses to use to assess and teach impatient DSMES founded on evidence-based guidance. Furthermore, this project showcases nurses as leaders and patient educators. Findings from this project support a recommendation that all acute care facilities implement a standard for inpatient DSMES. The overall impact of this project will be enhanced knowledge and increased self-efficacy for nurses and patients, leading to improved health outcomes for people with diabetes. Keywords: diabetes, self-management, education, support, dsmes, diabetes education, hospital readmission, inpatient, acute care, hospital Inpatient Diabetes Self-Management Education and Support Diabetes mellitus is a chronic metabolic disorder affecting how the body regulates sugar for fuel and can lead to additional circulatory, nervous system, and immune disorders (Mayo Clinic, 2022b). The number of people affected by diabetes is substantial and increasing. According to the Centers for Disease Control and Prevention (2022) National Diabetes Statistics Report, 37.3 million people in the United States have diabetes (11.3% of the population), and an additional 96 million people aged 18 years or older have prediabetes (38.0% of the adult population). In addition, data from the 2001-March 2020 National Health and Nutrition Examination Survey show a significant (p<0.05) trend increase in total diabetes diagnoses in adults aged 18 or older (CDC, 2022). The American Diabetes Association recommends that all persons with diabetes receive diabetes self-management education and support (DSMES) to learn the knowledge, skills, and behaviors needed to manage this lifelong disease (Davis et al., 2022). Four critical opportunities for DSMES are diagnosis, annual check-ups, when complications develop, and when a life transition occurs (Davis et al., 2022). Hospital admissions often involve one of these four critical times, making proper diabetes education imperative in the hospital setting. Individuals diagnosed with diabetes have high hospital admission rates for diabetes and non-diabetes diagnoses (Nassar et al., 2019). Additionally, persons with diabetes are 20% more likely to be readmitted to the hospital within 30 days of being discharged from an inpatient unit than persons without diabetes, accounting for approximately $24.6 billion in annual hospital costs (Nassar et al., 2019; Soh et al., 2020). The American Diabetes Association 2022 Clinical Practice Guidelines for hospitalized patients with diabetes recommends that clinicians assess the patients' self-management knowledge and behaviors on admission and provide education as needed. As the number of patients with diabetes increases, hospitals must meet the challenge of delivering inpatient diabetes education. Statement of Problem Many patients admitted to the Intermediate Care/Medical/Surgical unit of a rural community hospital in Utah exhibit a diabetes knowledge deficit as evidenced by a new diagnosis, unstable blood glucose levels, or diabetes complications (ADA, 2022). As a result, medical practitioners often write "diabetes teaching" orders for these patients. Unfortunately, according to the hospital's unit director, the unit has no set standard or protocol for diabetes teaching, so patients receive inconsistent diabetes education (B. Imlay, personal communication, May 10, 2022). Goals for hospitalized patients with diabetes include assessing the patient's educational needs and addressing any knowledge deficits (Inzucchi, 2021). Numerous studies demonstrate that the benefits of diabetes education include increased quality of life, improved clinical outcomes, and decreased hospitalizations and healthcare costs (Davis et al., 2022). In addition, diabetes knowledge deficits increase the risk of hospital readmissions (Timple & Kawar, 2022). Although evidence links diabetes education to improved outcomes and leading organizations recommend inpatient education, few hospitals provide standardized, structured inpatient diabetes education (Nassar et al., 2019). This Master of Science in Nursing (MSN) in Education project aims to create a patient-centered, standardized education program tailored to the learning needs of hospitalized adult patients with diabetes. In addition, the unit nursing staff will receive instruction on assessing patient educational needs and teaching diabetes selfmanagement education and support to patients. Examining existing literature to identify evidence-based practices will guide the creation of an education plan for the unit to accomplish this goal. Ways Project Contributes to Intended Recipients A need exists to improve diabetes education and support in the immediate community serviced by the hospital. For instance, in this rural community, the age-adjusted rate per 100,000 population for diabetes as an underlying cause of death (2014-2020) was 35.5 compared to the state rate of 25.6 (Utah Department of Health, 2022). In addition, the age-adjusted percentage of adults with diabetes in this community is 8.5%, higher than the state percentage of 8.1% (Utah Department of Health, 2022). Furthermore, the National Standards for Diabetes SelfManagement Education and Support (DSMES) identifies the hospitalization of persons with diabetes as a critical opportunity to provide patient-centered education to improve health outcomes with diabetes (Davis et al., 2022). Therefore, providing diabetes education and support to persons with diabetes during an inpatient hospital stay will benefit persons with diabetes in this rural Utah community. Equally important, implementing a structured self-management education plan will benefit the nursing staff in the hospital unit. Coonfare and Miller (2020) noted increased nurse knowledge and confidence levels when the researchers initiated a diabetes self-management toolkit through a quality improvement project. Before toolkit implementation, the unit lacked a defined process to assess knowledge levels and deliver diabetes education to patients; as a result, nurses lacked confidence in providing patients with appropriate self-management support (Coonfare & Miller, 2020). Hutchinson et al. (2018) evaluated the efficacy of initiating an educational resource for nurses providing end-of-life care. Hutchinson et al. (2018) noted positive workplace behavior changes and increased nurse confidence in communicating end-oflife matters with patients. Patients and nurses benefit through defined processes of providing patient education. Rationale for the Importance of Project There is a current gap in knowledge and uniformity of administered diabetes education and teaching in this hospital unit. The goal is to create a patient-centered structured toolkit following evidence-based diabetes self-management education and support standards. Patients who receive structured inpatient diabetes education show substantial improvements in 90-day hemoglobin A1C values (Chakraborty et al., 2020; Magny-Normilus et al., 2021; Rubin et al., 2022). Healthcare practitioners use hemoglobin A1C levels, also known as glycated hemoglobin, glycosylated hemoglobin, HbA1c, or A1C levels, which reflect the percentage of hemoglobin in the blood coated with sugar, to monitor the average blood sugar levels in persons with diabetes (Mayo Clinic, 2022a). In addition, patients display increased medication adherence and safety behaviors after participating in structured inpatient diabetes education programs (MagnyNormilus et al., 2021; Nassar et al., 2019). Diabetes education also decreases hospital readmission rates which are costly for hospitals and patients (Bansal et al., 2018; Mandel et al., 2019; Timple & Kawar, 2022). Literature Review and Framework Evidence-based practice (EBP) is essential to clinical and academic nursing. An evidence-based practice change framework guides individuals through changing organizational practices (Melnyk & Fineout-Overholt, 2019). The John Hopkins Evidence-Based Practice Model was selected to direct this MSN project. Conducting a literature review is an integral step in the change model. A literature review aids the learner in developing an understanding of the existing body of evidence on a chosen topic (Galvan & Galvan, 2017). Therefore, a literature review was conducted to identify evidence about the relationship between inpatient diabetes education and hospital readmission rates of patients with diabetes. Framework The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model serves as the change framework for this MSN project. The JHNEBP model is a tool that guides nurses in the translation of evidence-based practice (EBP) into clinical, educational, and operational nursing practice by utilizing the practice question, evidence, and translation (PET) process (Melnyk & Fineout-Overholt, 2019). The PET process promotes learning to gain new knowledge and insights by working through the steps of the process (Melnyk & Fineout-Overholt, 2019). First, in the practice question phase, the nurse creates and refines a PICOT question (population, intervention, comparison, outcome, time frame) and identifies stakeholders for the project (Dang et al., 2022). Next, in the evidence phase, the nurse conducts a literature search to identify relevant evidence and then appraises, summarizes, and synthesizes the evidence to develop evidence-based recommendations (Dang et al., 2022). In the final translation phase, the nurse creates an action plan, secures resources, implements the plan, evaluates and reports outcomes, and disseminates the findings (Dang et al., 2022). The JHNEBP model provides 18 steps of the PET process to help guide this MSN project (Melnyk & Fineout-Overholt, 2019). The use of the JHNEBP model in the MSN project began with an inquiry if a best practice for inpatient diabetes education exists (Dang et al., 2022). This inquiry led to developing a PICOT question and refining it throughout the project. The PICOT question asks: in adult patients with type 2 diabetes admitted to the hospital, how does receiving structured inpatient diabetes self-management education and support (DSMES) compared to unstructured diabetes education affect 30-day readmission rates? The practice question phase also involves identifying stakeholders, including hospital administration, unit nurses, hospitalists, dieticians, pharmacists, outpatient diabetes education specialists, patients, and their caregivers. Tools within the JHNEBP model guided the search for evidence in this project to include peerreviewed publications, professional standards, clinical practice guidelines, and evidence-based professional organization position statements (Dang et al., 2022). The JHNEBP model also allows users to conduct internal and external evidence searches. The model also provides tools that help to appraise the level and quality of evidence, summarize the evidence, and synthesize the strength and quality of evidence used in the project (Dang et al., 2022). In the final translation phase, tools in the JHNEBP model guide the evaluation of the appropriateness and fit of recommendations found in the evidence search (Melnyk & Fineout-Overholt, 2019). These tools will also direct the implementation of the unit education plan for staff members and patients in the unit. Additional tools will help evaluate the project's outcomes, report outcomes to stakeholders, and disseminate the findings (Dang et al., 2022). Strengths and Limitations The Johns Hopkins Nursing Evidenced-Based Practice model has many strengths, leading to its selection to guide this MSN project. This project aims to improve the quality of patient diabetes education, and the JHNEBP model provides a straightforward step-by-step, linear process to ease the process of implementing change (Dang et al., 2022). Notwithstanding, the model allows for flexibility and reevaluation (Dang et al., 2022). Another strength of the JHNEBP model is that it emphasizes the critical appraisal of the literature to identify evidencebased practices to guide the change process (Medicine and Health Sciences at Bethel University, 2021). In addition, the JHNEBP model provides ten tools to support critical steps of the change process (Dang et al., 2022). One such tool, the evidence level and quality guide tool, is beneficial for evaluating the strengths and weaknesses of the evidence used (Dang et al., 2022). Another benefit of the JHNEBP model is that it applies in any nursing field, from clinical settings to academics and beyond. Hence, this model is helpful in this project and can guide additional projects in the future (Melnyk & Fineout-Overholt, 2019). However, one limitation of the JHNEBP model is that it lacks a patient-centered quality improvement focus found in other EBP models like the Iowa Model and the Iowa Model Revised (Melnyk & Fineout-Overholt, 2019). A stronger patient-centered focus would be helpful since this project aims to improve the quality of patient education. Analysis of Literature Within the evidence step of the JHNEBP, a literature review was conducted to identify evidence-based diabetes education strategies and information about the relationship between diabetes education and hospital readmission rates. Next, the quality and level of each piece of evidence were appraised. Moreover, the evidence was synthesized to develop evidence-based recommendations for the MSN project. Search Strategies A literature search was conducted using Google Scholar, CINAHL, ERIC, Pubmed, Medline, COCHRANE, and Weber State University's Stewart Library's OneSearch and Advanced Search, which span multiple databases to identify pertinent information. The literature search was restricted to articles from 2018 to 2022 to keep evidence current. The search included keywords of diabetes, education, diabetes education, diabetes self-management education and support, barriers, obstacles, risk factors, quantitative, qualitative, standards of care, standards of medical care in diabetes, clinical practice guidelines, systematic review, risks, inpatient, hospital, readmission, and readmission rates. In addition, various Boolean combinations were created to search existing evidence comprehensively. The literature search resulted in several themes: standards for diabetes education, barriers to diabetes education, the effect of education on readmission rates, and the need to identify risks for readmission. Standards for Diabetes Education The American Diabetes Association (ADA, 2022), Association of Diabetes Care and Education Specialists (ADCES & Kolb, 2021), and Centers for Disease Control and Prevention (CDC, 2021) recommend diabetes self-management education and support (DSMES) for persons with diabetes. Studies show that DSMES improves health outcomes, yet it is underutilized (CDC, 2021). For example, less than 5% of Medicare beneficiaries and 6.8% of privately insured individuals with diagnosed diabetes use DSMES services (CDC, 2021). National Standards for DSMES provide guidance and evidence-based practice for DSMES (Davis et al., 2022). Persons with diabetes should be assessed for their current knowledge of the disease, their A1C, complications or comorbidities, and risk factors before providing DSMES (ACDES & Kolb, 2021; Davis et al., 2022). National standards outline information to include with all DSMES, namely the pathophysiology of diabetes and treatment options (Davis et al., 2022). In addition, DSMES should discuss the ADCES7 self-care behaviors, which include healthy coping, healthy eating, being active, taking medication, monitoring, reducing risks, and problem-solving (ACDES & Kolb, 2021; Davis et al., 2022). Traditionally, outpatient DSMES is preferred (Nassar et al., 2019), but with the underutilization and non-use of outpatient DSMES, hospital admissions provide a pivotal opportunity to provide DSMES. Barriers to Diabetes Education When creating a structured diabetes education program, the program developer should understand any barriers to education faced by patients or those providing the education. Studies identified a lack of education and training in delivering DSMES as an obstacle individuals face when teaching DSMES to patients (Nassar et al., 2019; Preechasuk et al., 2019; Smith et al., 2019; Yazdanzi et al., 2021). Nurses, physicians, pharmacists, and dieticians that teach DSMES reported challenges with a lack of time to provide education while meeting other patient obligations (Preechasuk et al., 2019; Smith et al., 2019). Additionally, Smith et al. (2019) noted that educational materials need to be presented in multiple languages and adapted for individuals with low literacy and low health literacy levels. Understanding barriers to education for persons with diabetes and their caretakers will also help when creating an education plan. Yazdanzi et al. (2021) interviewed individuals with diabetes and caretakers of people with diabetes (n=9) to understand the barriers patients face to receiving DSMES. Common themes identified by receivers of DSMES were a limited time for classes, an unwelcoming class environment, and financial obstacles to self-management (Yazdanzi et al., 2019). In addition, Preechasuk et al. (2019) and Yazdanzi et al. (2021) noted that providers identified patient disinterest in education and reluctance to change unhealthy behaviors as the leading deterrents to successful DSMES. Understanding the challenges to patients and providers for DSMES helps facility educators make accommodations and plan interventions when implementing a structured diabetes education program. Effect of Education on Readmission Rates Hospital readmissions within 30 days of discharge (30-day readmission) affect patient quality outcomes and payer costs (Rubin et al., 2022). As a result, government entities, insurance companies, and hospitals track readmission rates as quality and cost measures (Rubin et al., 2022). Unfortunately, individuals with diabetes are more likely to be readmitted to a hospital than persons without diabetes, affecting patient costs and health outcomes (Soh et al., 2020). Results of reviewed studies showed a conflicting significance of DSMES on readmission rates. Some studies did not show a statistically significant effect of educational interventions on hospital readmission rates (Chakraborty et al., 2020; Magny-Normilus et al., 2021; Rubin et al., 2022). A randomized control trial conducted by Magny-Normilus et al. (2021) comparing patients receiving structured education and interventions (n=88) versus the usual care (N=180) revealed a significant difference between admission and 90-day HbA1C values (p=0.04) and mean medication adherence (p=0.06). However, educational interventions did not significantly affect 30-day readmission rates (p=0.25). A systematic review by Chakraborty et al. (2020) revealed similar findings of substantial improvements in patient HbA1C values but no significant impact on readmission rates. Rubin et al. (2022) conducted a randomized control trial to evaluate the effect of educational interventions. They noted that participants in the intervention group reported high levels of satisfaction with the interventions provided, but there was no significant difference between readmission rates between the two groups. However, Rubin et al. (2022) noted that a subgroup of patients with admission HbA1C levels greater than 7.0% receiving the intervention showed a more significant reduction in readmission rates. This study provided novel information about a subgroup of patients with HbA1C values >7.0%; however, data to differentiate this group was limited. In contrast to the previously mentioned findings, other studies noted significant decreases in readmission rates with diabetes teaching (Bansal et al., 2018; Mandel et al., 2019; Timple & Kawar, 2022). Timple and Kawar (2022) conducted a retrospective data review of the electronic health records of 400 hospitalized persons with diabetes. Chi-square tests revealed a significant relationship (p=0.006) between DSMES and no 30-day readmission (Timple & Kawar, 2022). Retrospective cohort studies by Bansal et al. (2018) and Mandel et al. (2019) compared readmission rates of patients receiving usual diabetes education versus those seen by a specialized diabetes team; both studies reported decreased readmission rates but differing effects on hospital length of stay. Bansal et al. (2018) reported a 30.5% decrease in readmission rates to medical services (p<0.001) with no change in length of stay, while Mandel et al. (2019) reported a 27% decrease in length of stay and a 10.71% median 30-day readmission rate decrease (p=0.048). A review of multiple studies shows that the significance of the efficacy of diabetes education on readmission rates depends on the complexity level of the patient and the specialty level of the individual providing the diabetes education. Risks for Readmission As hospital readmissions create costly physical and financial burdens to patients and healthcare organizations, a need exists to understand the causes and risks of readmissions. Multiple researchers conducted studies to identify causes and risk factors for 30-day hospital readmissions for patients with diabetes. The research showed that requiring insulin use, age of 65 years or older, non-White race, male gender, and comorbidities were all significant factors for readmission (Karunakaran et al., 2018; Robbins et al., 2019; Soh et al., 2020). Karunakaran et al. (2018) noted that additional risk factors included not having a follow-up visit within 30 days or being disabled, retired, or unemployed. In addition, patients with longer hospital lengths of stay or with Medicare or Medicaid insurance are at higher readmission risk (Robbins et al., 2019; Soh et al., 2020). Soh et al. (2020) identified comorbidities of heart failure, respiratory disease, depression, and renal disease as significant complications for readmission. The hospital care team needs to be aware of identified risk factors for readmission to target added evidence-based interventions for patients with these characteristics. Summary of Literature Review Findings and Application to the Project The literature on readmissions of persons with diabetes supports the need for a structured inpatient diabetes education program. Hospital admissions present an opportunity to provide DSMES and make referrals for continued outpatient support. When developing the education plan for the unit, identifying and mitigating barriers to DSMES to improve the efficacy of patient education is imperative. In addition, this MSN project will address the lack of staff knowledge about inpatient diabetes education. The literature noted that the significance of DSMES on readmission rates is more profound when provided to higher-risk patients and by trained diabetes educators than when provided to low-risk patients and when administered by untrained medical staff. Studies also revealed comorbidities, demographics, and insulin use as risk factors for hospital readmissions. Since the hospital unit involved in the project does not have inpatient diabetes education specialists, educators will need to train staff nurses to identify high-risk patients that require added support. Project Methodology This MSN project aims to improve the nursing process of providing inpatient diabetes self-management education and support. Following the steps of the JHNEBP model (practice question, evidence, translation), after reviewing the evidence, the next step is the translation phase which incorporates creating an action plan, securing resources, implementing the plan, evaluating the plan, and reporting outcomes (Dang et al., 2022). An analysis of the current literature produced evidence-based reasoning for the process change. Deliverables developed using the evidence from the literature facilitate the improvement process. Planning for the project includes considering the care team involved, an expected timeline for completion, and an evaluation strategy. The team must also review the plan to ensure ethical standards are sustained. Description and Development of Project Deliverables Deliverables for this project support the execution of this project. The following discourse provides a detailed description of each deliverable. In addition, the discussion explains the importance of each deliverable and its application to the project. Providing Inpatient Diabetes Self-Management Education and Support PowerPoint The team lead will present an educational PowerPoint presentation (see Appendix A) in a unit staff meeting. This presentation aims to teach the unit nurses how to assess and teach DSMES to patients. Lack of provider education is a common barrier to DSMES, but this instruction would eliminate this obstacle (Nassar et al., 2019; Preechasuk et al., Smith et al., 2019; 2019; Yazdanzi et al., 2021). In addition, the presentation will teach the patient care team how to use the inpatient diabetes assessment and education tool. Nurses who receive training demonstrate increased confidence and knowledge when providing patient education and support (Coonfare & Miller, 2020). Inpatient Diabetes Assessment and Education Tool The following deliverable was created to improve the assessment and teaching of patients with diabetes (see Appendix B). This tool was developed using information from national diabetes organizations about what nurses should assess before providing DSMES to patients (ACDES & Kolb, 2021; Davis et al., 2022). This tool also helps nurses identify patients with significant risk factors for readmission (Karunakaran et al., 2018; Robbins et al., 2019; Soh et al., 2020). Nurses in this hospital unit must use Krames, a hospital-approved resource, for patient education. This resource integrates with the patient's electronic health record (EHR) for legal documentation, is updated regularly, and has been approved by the corporation's medical board (K. Hall, personal communication, January 18, 2023). The education tool provides a list of Krames patient handouts that should be printed and discussed based on the assessed needs of each patient. Patient education handouts are available in multiple languages, and some include QR codes with links to educational videos. Providing educational booklets in the person's native language also reduces barriers to education (Smith et al., 2019). The topics covered by the checklist within the tool were identified in current literature explaining the national standards for DSMES (ACDES & Kolb, 2021; Davis et al., 2022). Providing inpatient DSMES reduces hospital readmission rates and improves patient outcomes (Bansal et al., 2018; Mandel et al., 2019; Timple & Kawar, 2022). In addition, DSMES providers noted a lack of time as an obstacle to patient teaching (Preechasuk et al., 2019; Smith et al., 2019). The list of diabetes educational handouts available in Krames contains over 150 handouts which some unit nurses have reported is overwhelming (B. Imlay, personal communication, May 10, 2022). The checklist reduces the time required to find appropriate teaching materials for each patient. Diabetes Resource Handout The diabetes resource handout (see Appendix C) lists national and local resources for patients to seek additional education and support after hospitalization. Outpatient DSMES is preferred to inpatient teaching because patients can better process and retain instruction taught in an outpatient setting (Nassar et al., 2019). In addition, the resource flyer provides online information to locate local DSMES providers and other in-person community resources. The handout also lists national online diabetes resources. Plan and Implementation Process Within the translation phase of the JHNEBP model framework, necessary steps include securing resources by recruiting participation and buy-in from the interdisciplinary team, implementing the plan following a detailed timeline, and evaluating the plan (Dang et al., 2022). During the planning stage of the change process, key stakeholders are identified along with their unique roles and needed contributions to the project. Stakeholder analysis ensures that the necessary personnel and physical resources are available to implement the project. A project timeline outlines the steps of the process and provides a reasonable time estimate for each task. Finally, an evaluation plan highlights the project goals, provides measurable objectives, and links the activities to the intended outcomes. Interdisciplinary Teamwork Identifying and involving key stakeholders is vital in planning and implementing the project. It is essential to understand the roles of each team member and their expected contributions to the project. Integrated and connected interdisciplinary care teams improve patient outcomes, reduce hospital readmissions, and improve patient satisfaction (Katz, 2020). The success of this project relies on collaboration and communication between care team members. Unit Director. The Intermediate Care/Medical/Surgical unit director manages and directs the nursing and auxiliary staff of the unit. The unit director will approve the process change plan before implementation. Once the project is approved, the unit director will schedule a time during the next monthly staff meeting to provide the nurses with instruction. The director will also ensure copies of the assessment and education tool and resource brochure are available for staff use during implementation in the inpatient unit. The director must also determine and obtain budget funding for resource materials. Furthermore, the director will aid the project's success by encouraging care team members to implement the new process and use the newly developed resources. Chief Nurse Officer. Approval from the Chief Nurse Officer (CNO) is also required to proceed with the project. As part of the hospital administration team, the CNO is a nurse leader who sets patient care standards, establishes processes and protocols to achieve those standards, and manages nursing resources to provide patient care. The CNO offers an essential bridge between facility and division executives and the unit nursing staff members. In addition, the CNO will be instrumental in obtaining readmission metrics to evaluate project success. Hospitalist. The hospitalist is a practitioner who diagnoses, treats, and provides continuous medical care to hospitalized patients. Hospitalists prescribe medications and treatments for patients while they are inpatients and at discharge. Communication with the hospitalist about patient needs helps coordinate care, direct patient education, and obtain the necessary discharge referrals. Pharmacist. Hospital pharmacists examine patient charts, make medication therapy recommendations, work closely with medical and nursing staff to ensure proper pharmacology treatment plans, and monitor medication supplies and prescriptions. Pharmacists also teach patients about new medications prescribed during their hospitalization. Medication education is one vital topic of DSMES, especially when new prescriptions for insulin are involved. Dietician. Hospital dieticians assess inpatient nutritional needs and direct meal planning to provide nutritious food for patients consistent with prescribed diets. Dieticians also offer inpatient and outpatient dietetic educational services. In addition, dieticians provide DSMES to persons with diabetes about healthy eating, being active, and problem-solving. Registered Nurse. The unit registered nurses assess and analyze patients' status and needs, administer treatments, and educate patients. The nurses will use the assessment and educational tool to determine the educational needs of patients with diabetes and provide DSMES. In addition, the nurses will communicate with all care team members, request any additional referrals, and ensure all educational needs are addressed. Timeline A timeline for implementing this change project provides a structured sequence of events and keeps the project organized (see Appendix D). First, authorization to proceed with the project needs to be obtained from the unit director and the facility CNO. Once approval is received, the unit director will schedule a time during the next monthly staff meeting to present the resources. Unit nurses will be taught how to use the developed tool to assess and educate patients during the staff meeting. Following instruction, all unit nurses will begin using the tool to evaluate patients admitted to the department within 24 hours of admission. As deemed necessary by the assessment tool, nurses will use the checklist to provide DSMES to patients with diabetes. Two months after the staff meeting, all unit nurses may complete an anonymous survey giving feedback on the new process. Hospital leadership will evaluate readmission data and note any trends. An evaluation period of six to 12 months will be required to determine any significant changes in readmission data. According to the timeline, the team will need six to 12 months to plan, execute, and evaluate this project. Plan for Evaluation of Project An evaluation plan for the project provides formative and summative assessments relaying information about the success and efficacy of the project. The team will evaluate the overall effectiveness of this project by analyzing patient readmission data. Metrics of readmission rates of persons with diabetes will be explored, comparing readmission rates before and after the implementation of the project. In addition, a post-implementation survey completed by unit nurses will evaluate the use and effectiveness of the assessment and teaching checklist (see Appendix E). Nurses will be encouraged to provide feedback regarding the ease of use, perceived benefit to patients, and suggestions for improvements. Ethical Considerations The project was assessed using the American Nurses Association's (2015) Code of Ethics for Nurses as a guide to ensure ethical compliance. This project aligns with the Code of Ethics Provision 2, which states that the nurse's primary commitment is to the patient; Provision 3, which states that the nurse advocates for the health and safety of the patient; and Provision 4, which says that the nurse has the authority and responsibility to promote health (ANA, 2015). Nurses have a responsibility to advocate for vulnerable populations. Persons with diabetes are a vulnerable population as they are at a higher risk for hospitalization and hospital readmission (Nassar et al., 2019; Soh et al., 2020). A structured DSEMS program will empower persons with diabetes to better care for themselves (Davis et al., 2022). A new chronic condition diagnosis may overwhelm some individuals (Davis et al., 2022). Therefore, some individuals may need repeated education and reinforcement. Nurses will be encouraged to treat all patients with kindness, patience, and respect when providing education. As with all patient care provided in the hospital, patients not wanting to receive education have a right to refuse. The unit will keep the assessment and education tools with the patients' charts to protect patient privacy. In addition, the nurses and interdisciplinary staff will communicate about patient educational needs in secure areas. This project also aligns with Provision 5 of the Code of Ethics, which protects the rights of nurses (ANA, 2015). This project is ethical as it provides nurses with more resources to accomplish their responsibility of patient education. The evaluation team will protect the rights of nurses by keeping the nurses' responses to the unit post-implementation survey anonymous to protect participant privacy and encourage honest feedback. Discussion Diabetes is a chronic disease that increases the risks for additional health complications (Mayo Clinic, 2022b). As the prevalence of diabetes increases, healthcare workers need to seize opportunities to provide education about self-care behaviors. Knowledge about self-management empowers patients to care for themselves with this chronic condition (CDC, 2021). Leading national diabetes organizations recommend providing self-management education to persons with new diagnoses or complications which often occur with hospitalizations (ACDES & Kolb, 2021; CDC, 2021; Davis et al., 2022). However, many hospital organizations do not have a standard for patient diabetes education, leaving nursing staff without a protocol to follow (Nassar et al., 2019). This project aims to create a teaching protocol for inpatient diabetes education founded on evidence-based principles. This section shares proposed strategies to disseminate findings from this project. The program's significance to nursing practice, strengths, and limitations are also discussed. In addition, recommendations for further research are suggested. Evidence-based Solutions for Dissemination Within healthcare, dissemination is a targeted distribution of evidence-based findings and interventions to a specific clinical practice or public health audience (Agency for Healthcare Research and Quality, 2012). Dissemination is most successful when various techniques are used (Dudley-Brown, 2019). Evidence-based strategies to communicate process improvement results include oral presentations, panel presentations, poster presentations, community or committee meetings, and published articles (Melnyk & Fineout-Overholt, 2019). Findings from this project will be shared with Weber State University peers and faculty through a poster and verbal presentation. Information about the progress and effectiveness of the protocol will be presented to unit nursing staff during subsequent staff meetings and in written monthly emails. Readmission statistic reports will be shared with key administrative stakeholders in hospital committee meetings. In addition, results from the project may be written and submitted to journals for published dissemination to other healthcare professionals. Finally, findings may be shared through a poster or oral presentation at local and national conferences for nurses and interdisciplinary diabetes education specialists. Significance to Advance Nursing Practice This project benefits the nursing profession as it demonstrates the strength of nurses as patient educators. Studies show that nurse-led DSMES programs improve patient diabetes knowledge, treatment adherence, and hemoglobin A1C levels (Azami et al., 2018; Macido, 2019). In addition, a study by Liu et al. (2019) noted that participants in a nurse-led diabetes education program showed significant improvements in self-management behaviors, fasting blood glucose levels, and body composition measurements. This project empowers nurses with knowledge and tools to teach patients self-management skills, which can improve long-term outcomes with this chronic disease. Implications The strengths of this project are that it fills a gap in providing patient education and empowers nurses with the knowledge to improve patient teaching. In addition, this project reduces the obstacle of a lack of understanding of what to teach. With knowledge of patient risk factors for hospital readmission, nurses can target at-risk patients with more support and resources to reduce readmission risk. In addition, a brochure for patients shares local and national resources for continued diabetes support. One limitation of this project is related to the small scope of influence. This project is limited to one unit of a rural hospital. However, if this project is successful, procedures from this project may be implemented in other hospitals within the same network. Another limitation of this project is that it only entails one encounter to teach nurses how to provide DSMES. A multidisciplinary diabetes advisory group emphasizes the need for nurses to receive continual education to retain knowledge and receive updates on evidence-based diabetes care (Phillips, 2019). Additional training through later staff meeting presentations or email updates will help keep nursing staff up to date and refresh diabetes knowledge. In addition, continuing education enhances nurses' professional development. Recommendations The literature review demonstrated that a barrier to providing DSMES is a lack of knowledge of what to teach (Preechasuk et al., 2019; Smith et al., 2019). An evidence-based list of topics to be taught was identified through the literature review (ACDES & Kolb, 2021; Davis et al., 2022). However, this project would benefit from further research about the best practices to teach the nurses that will provide patient instruction. In addition, further study about evidencebased approaches to instructing patients and assessing patient understanding would also enhance the goals of this project. Therefore, additional research about teaching methods for nurses and patients will benefit this project. Conclusions Findings from this project reveal the benefits of evidence-based inpatient diabetes education. Persons with diabetes are at higher risk for 30-day hospital readmissions (Nassar et al., 2019; Soh et al., 2020). However, patients receiving DSMES show decreased readmission rates (Bansal et al., 2018; Mandel et al., 2019; Timple & Kawar, 2022). Creating an education protocol for persons with diabetes and teaching nurses how to provide training decreases barriers to DSMES for patients and nurses (Nassar et al., 2019; Preechasuk et al., 2019; Smith et al., 2019; Yazdanzi et al., 2021). This project benefits nurses and patients by creating a standard procedure for inpatient diabetes education. References Agency for Healthcare Research and Quality. (2012). Communication and dissemination strategies to facilitate the use of health-related evidence. Department of Health and Human Services. https://effectivehealthcare.ahrq.gov/products/medical-evidencecommunication/research-protocol American Diabetes Association (ADA). (2022). Diabetes care in the hospital: Standards of medical care in diabetes-2022. Diabetes Care, 45(Supp 1), S244-S253. https://doi.org/10.2337/dc22-S016 American Nurses Association. (2015). Code of ethics for nurses with interpretive statements. American Nurses Association. https://www.nursingworld.org/coe-view-only Association of Diabetes Care and Education Specialists (ADCES) & Kolb, L. (2021). An effective model of diabetes care and education: The ADCES7 self-care behaviors™. The Science of Diabetes Self-Management and Care, 47(1), 30–53. https://doi.org/10.1177/0145721720978154 Azami, G., Soh, K.L., Sazlina, S.G., Salmiah, M.S., Aazami, S., Mozafari, M., & Taghinejad, H. (2018). Effect of a nurse-led diabetes self-management education program on glycosylated hemoglobin among adults with type 2 diabetes. Journal of Diabetes Research, 2018(1), 1-12. https://doi.org/10.1155/2018/4930157 Bansal, V., Mottalib, A., Pawar, T., Abbasakoor, N., Chuang, E., Chaudhry, A., Sakr, M., Gabbay, R., & Hamdy, O. (2018). Inpatient diabetes management by specialized diabetes team versus primary service team in non-critical units: Impact on 30-day readmission rate and hospital cost. BMJ Open Diabetes Research & Care, 6, e000460. http://doi.org/10.1136/bmjdrc-2017-000460 Centers for Disease Control and Prevention (CDC). (2021). Diabetes self-management education and support (DSEMS) toolkit. https://www.cdc.gov/diabetes/dsmes-toolkit/index.html Centers for Disease Control and Prevention (CDC). (2022). National diabetes statistics report. https://www.cdc.gov/diabetes/data/statistics-report/index.html Chakraborty, A., Pearson, O., Schwartzkopff, K., O’roucke, I., Ranasinghe, I., Mah, P., Adams, R., Boyd, M., & Wittert, G. (2020). The effectiveness of in-hospital interventions on reducing hospital length of stay and readmission of patients with type 2 diabetes mellitus: A systematic review. Diabetes Research and Clinical Practice, 174, 108363. https://doi.org/10.1016/j.diabres.2020.108363 Coonfare, L. & Miller, C. (2020). Self-management toolkit for high-risk patients with type 2 diabetes and the effect on nurses' confidence. The Journal of Continuing Education in Nursing, 51(6), 287-292. https://doi.org/10.3928/00220124-20200514-09 Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidencebased practice for nurses and healthcare professionals: Model and guidelines. 4th ed. Sigma Theta Tau International. Davis, J., Fischl, A., Beck, J., Browning, L., Carter, A., Condon, J., Dennison, M., Francis, T., Hughes, P., Jaime, S., Lau, K., McArthur, T., McAvoy, K., Magee, M., Newby, O., Ponder, S., Quraishi, U., Rawlings, K., Socke, J., Stancil, M., Uelmen, S., & Villalogos, S. (2022). 2022 National standards for diabetes self-management education and support. The Science of Diabetes Self-Management and Care, 00(0), 1-17. https://doi.org/10.1177/26350106211072203 Dudley-Brown, S. (2019). Dissemination of evidence in nursing and healthcare. In White, K.M., Dudley-Brown, S., & Terhaar, M.F. (Eds.), Translation of Evidence into Nursing and Health Care (3rd ed., pp. 255-267). Springer Publishing. https://doi.org/10.1891/9780826147370.0012 Galvin, J. L. & Galvin, M. C. (2017). Writing literature reviews: A guide for students of the social and behavioral sciences (7th ed.). Routledge Taylor & Francis Group. Hutchinson, C., Tieman, J., & Devery, K. (2018). Evaluation of a toolkit resource package to support positive workplace behaviors in relation to quality end-of-life care in Australian hospital. BMJ Open Quality, 7(4), e000286. http://doi.org/10.1136/bmjoq-2017-000286 Inzucchi, S. (2021). Management of diabetes mellitus in hospitalized patients. UpToDate. https://www.uptodate.com/contents/management-of-diabetes-mellitus-in-hospitalizedpatients Karunakaran, A., Zhao, H., & Rubin, D. (2018). Pre- and post-discharge risk factors for hospital readmission among patients with diabetes. Med Care, 56(7), 634-642. https://doi.org/10.1097/MLR.0000000000000931 Katz, B. (2020). Connecting care for patients. Jones & Bartlett Learning, LLC. Liu, Y., Jiang, X., Jiang, H., Lin, K., Li, M., & Ji, L. (2019). A culturally sensitive nurse-led structured education programme in patients with type 2 diabetes. International Journal of Nursing Practice, 25(5), e12757. https://doi.org/10.1111/ijn.12757 Macido, A. (2019). A nurse-led inpatient diabetes self-management education and support program to improve patient knowledge and treatment adherence. Journal of Health Education Teaching, 10(1), 1-10. https://files.eric.ed.gov/fulltext/EJ1236325.pdf Magny-Normilus, C., Nolido, N., Borges, J., Brady, M., Labonville, S., Williams, D., Soukup, J., Lipsitz, S., Hudson, M. & Schnipper, J. (2021). Effects of an intensive discharge intervention on medication adherence, glycemic control, and readmission rates in patients with type 2 diabetes. Journal of Patient Safety, 17(2), 73-80. https://doi.org/10.1097/PTS.0000000000000601 Mandel, S., Langan, S., Mathioudakis, N., Sidhaye, A., Bashura, H., Bie, J., Mackay, P., Tucker, C., Demidowich, A., Simonds, W., Jha, S., Ebenuwa, I., Kantsiper, M., Howell, E., Wachter, P., Golden, S., & Zibermint, M. (2019). Retrospective study of inpatient diabetes management service, length of stay and 30-day readmission rate of patients with diabetes at a community hospital. Journal of Community Hospital Internal Medicine Perspectives, 2(9), 64-73. https://doi.org/10.1080/20009666.2019.1593782 Mayo Clinic. (2022a). A1C. https://www.mayoclinic.org/diseases-conditions/type-2diabetes/symptoms-causes/syc-20351193 Mayo Clinic. (2022b). Type 2 diabetes. https://www.mayoclinic.org/diseases-conditions/type-2diabetes/symptoms-causes/syc-20351193 Medicine and Health Sciences at Bethel University. (2021). John Hopkins EBP model: Evidence appraisal [Video]. YouTube. https://www.youtube.com/watch?v=q4qqML2j4ms Melnyk, B. M. & Fineout-Overholt, E. (2019). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Lippincott, Williams, & Wilkins. Nassar, C., Montero, A., & Magee, M. (2019). Inpatient diabetes education in the real world: an overview of guidelines and delivery models. Current Diabetes Reports, 19, 103. https://doi.org/10.1007/s11892-019-1222-6 Phillips, A. (2019). Practice nurses need better diabetes education to meet service and individual needs. Practice Nursing, 30(11), 512-514. https://idealdiabetes.com/wpcontent/uploads/2019/11/Diabetes-comment-final.pdf Preechasuk, L., Sriussadaporn, P., & Likitmaskul, S. (2019). The obstacles to diabetes selfmanagement education and support from healthcare professionals' perspectives: A nationwide survey. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 2019(12), 717-727. https://doi.org/10.2147/DMSO.S195916 Robbins, T., Keung, S., Sankar, S., Randeva, H., & Arvanitis, T. (2019). Risk factors for readmission of inpatients with diabetes A systematic review. Journal of Diabetes and Its Complications, 33(2019), 398-405. https://doi.org/10.1016/j.jdiacomp.2019.01.004 Rubin, D., Gogineni, P., Deak, A., Vaz, C., Watts, S., Recco, D., Dillard, F., Wu, J., Karunakaran, A., Kondamuri, N., Zhao, H., Naylor, M., Golden, S., & Allen, S. (2022). The diabetes transition of hospital care (DiaTOHC) pilot study: A randomized controlled trial of an intervention designed to reduce readmission risk of adults with diabetes. Journal of Clinical Medicine, 11(6), 1147. https://doi.org/10.3390/jcm11061471 Smith, K., Baker, K., Bardsley, J., McCartney, P, & Magee, M. (2018). Redesigning hospital diabetes education: A qualitative evaluation with nursing teams. Journal of Nursing Care Quality, 2(34), 151-157. https://doi.org/10.1097/NCQ.0000000000000349 Soh, J., Wong, W., Mukhopadhyay, A., Quek, S., & Tai, B. (2020). Predictors of 30-day unplanned hospital readmission among adult patients with diabetes mellitus: A systematic review with meta-analysis. BMJ Open Diabetes Research & Care, 2020(8), e001227. https://doi.org/10.1136/bmjdrc-2020-001227 Timple, V.S. & Kawar, L.N. (2022). Readmission predictors in patients with type II diabetes. Journal of Nursing Care Quality, 37(4), 342-348. https://doi.org/10.1097/NCQ.0000000000000640 Utah Department of Health. (2022). Community snapshot for Brigham City, Utah, small area/state of Utah- all available indicators. Public Health Indicator Based Information System (IBIS). Utah.gov. https://ibis.health.utah.gov/ibisphview/community/snapshot/report/AllIndicators/GeoSarea/1.html?PageName= Yazdanzi, F., Abazari, P., Haghani, F., & Iraj, B. (2021). Restrictors of the effectiveness of diabetes self-management education: A qualitative content analysis. Journal of Education and Health Promotion, 10(18). https://doi.org/10.4103/jehp.jehp_914_20 Appendix A Providing Inpatient Diabetes Self-Management Education and Support PowerPoint Appendix B Inpatient Diabetes Assessment and Education Tool Patient Initials____________ Date Initiated____________ Date pt discharged________ Assess: Risk factors for readmission: A1C____________ Diagnosis (within six months?) Current knowledge level Complications/ comorbidities Risk factors for readmission • • • • • DSMES Topics to Cover: • • • • Pathophysiology of diabetes and treatment The ADCES7 self-care behaviors: • healthy coping • healthy eating • being active • taking medication • monitoring • reducing risks • problem-solving Patient education handouts to be printed from Krames hospital education resource: Newly Diagnosed (within six months) o Type 2 Diabetes o Managing Type 2 Diabetes o Diabetes- Measuring Glucose at Home o Diabetes: Sick-day plan New Medication Rx **Pharmacy Consult o Taking Medicine for Diabetes o Hypoglycemia Oral Meds: o Oral Medicines for Type 2 Diabetes Insulin: o Insulin: How to Use and Where to Inject o Types of Insulin • requiring insulin use age of 65 years or older non-White race male gender comorbidities of heart failure, respiratory disease, depression, and/or renal disease disabled retired unemployed Medicare or Medicaid insurance longer hospital lengths of stay Complications/ Comorbidities o Hyperosmolar Hyperglycemia o Diabetes and Heart Disease o Diabetes and Kidney Disease o Diabetes: Treating Severe Foot Infections o Diabetes and Drinking Alcohol o Diabetes and Sensitive Topics (depression) o Smoking and Diabetes o Managing Stress When You Have Diabetes High A1C o Understanding Type 2 Diabetes o Managing Diabetes: The A1C Test o Long-term Complications of Diabetes o Your Diabetes Toolkit Sick/Surgery Patients w/ existing diagnosis: o How to Manage Diabetes During Illness Additional Education Provided: (ACDES & Kolb, 2021; Davis et al., 2022; Karunakaran et al., 2018; Robbins et al., 2019; Soh et al., 2020) Appendix C Diabetes Resources Handout Appendix D Timelines Project Implementation Timeline Month 1 Month 2 • Meet with Unit • Staff Meeting Director and presentation (1 CNO for hour) authorization to • Begin use of implement (1 tools on unithour) educate • Schedule Staff patients Meeting • Copies of Documents (1 week) Month 4 Months 612 • Nurse post• Assess implementation readmission survey rates • Begin assessing • Continual readmission reevaluation in rates unit Unit Implementation Timeline Assess education needs within 24 hours of admission Provide education Reassess & reinforce education Continue until discharge Appendix E Inpatient Diabetes Assessment and Education Tool Post Implementation Survey Please provide anonymous feedback about the new Inpatient Diabetes Assessment and Education Tool recently implemented in the unit. Please drop off completed surveys in the designated box outside the unit director's office. 1. How often do you use the diabetes assessment and education tool? Always Often Sometimes Not at all 2. Using the tool makes my job of providing diabetes education for my patients easier. Strongly Agree Agree Neutral Disagree Strongly Disagree Disagree Strongly Disagree 3. The tool is organized and easy to use. Strongly Agree Agree Neutral 4. Are there any unclear portions of the tool? Please specify. 5. Are there any topics covered in the tool that need additional education? Please specify. 6. Are there any changes that need to be made to improve the tool? Please specify. 7. Any additional comments: