Digital Repository Masters Projects Spring 2024 Pediatric Type One Diabetic Patient and Family Educational Needs: Reducing Anxiety and Stress to Promote Diabetic Self-Care Techniques Mersadie Lloyd Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Lloyd, M. 2024. Pediatric Type One Diabetic Patient and Family Educational Needs: Reducing Anxiety and Stress to Promote Diabetic Self-Care Techniques 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 Pediatric Type One Diabetic Patient and Family Educational Needs: Reducing Anxiety and Stress to Promote Diabetic SelfCare Techniques Project Title by Mersadie Lloyd 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 26th 2024 Date Mersadie Lloyd BSN, RN, MSN Student April 26th 2024 Student Name, Credentials (electronic signature) Date JoAnn Tolman DNP, MSN-Ed, RN, CNE April 26, 2024 MSN Project Faculty Date (electronic signature) April 26, 2024 (electronic signature) DNP, N, CNE MSN Program Director Note: The program director must submit this form and paper. Date 1 Pediatric Type One Diabetic Patient and Family Educational Needs: Reducing Anxiety and Stress to Promote Diabetic Self-Care Techniques Mersadie Lloyd, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: Lack of type 1 diabetic (T1D) education and support for pediatric patients and their families increase stress and anxiety. Providing a Virtual Support Group will enhance education options to reduce stress and anxiety and improve diabetic self-care practices. Rationale/Background: A diagnosis of T1D is overwhelming. Patients and families suffer from stress and anxiety while transitioning into effective self-care practices. Routine education is necessary, and a virtual option for education is considered beneficial. This project bridges the gap between T1D patient diagnosis and the development of diabetic self-care practices by providing enhanced support and education through a virtual platform. Methods: The Johns Hopkins Nursing Model guides the outline of this project. The staff of an endocrinology clinic receive education about the Virtual Support Group and utilize a patient handout, a checklist, and an optional educational topic guide to facilitate the program. Patients and families complete questionnaires to assess Virtual Support Group’s effectiveness on stress and anxiety associated with diabetic self-care. Results: While participating in the Virtual Support Group for six months, patients and families reported feeling reduced stress and anxiety and reported a feeling of increased support in caring for the disease. Conclusions: T1D patients and their families must receive quality support and educational services. Applying a virtual option for T1D support and education will improve outcomes for these individuals. Keywords: Virtual support group, diabetic self-care practices, prolonged support and education, reduce T1D stress and anxiety. 3 Pediatric Type One Diabetic Patient and Family Educational Needs: Reducing Anxiety and Stress to Promote Diabetic Self-Care Techniques Managing type 1 diabetes (T1D) can be challenging as it is a complex chronic illness that strikes suddenly without warning (Prahalad et al., 2020). Patients and their loved ones must learn the basics of insulin dosing, including carbohydrate counting and managing glucose levels, within the first few days of diagnosis. They must also become proficient in recognizing and treating hypo and hyperglycemia incidents and operating insulin pumps and continuous glucose monitors (Thoft et al., 2022). It takes significant time and effort for medical professionals to acquire the knowledge and skills to manage and treat T1D effectively. However, T1D patients and their families must comprehend and manage this illness independently within a few weeks (Thoft et al., 2022). When T1D develops, patients and their families often experience denial, grief, and fear due to the sudden development of the disorder (Cho & Kim, 2023). Understandably, T1D patients and their families are under immense psychological stress and grief during the initial stages of T1D diagnosis (Prahalad et al., 2020). However, it is crucial to adequately control and monitor T1D to prevent severe and potentially fatal consequences, making education essential and necessary at diagnosis (LaManna et al., 2019) to develop T1D self-care behaviors (Prahalad et al., 2020). The need for thorough education to manage T1D and prevent life-threatening complications cannot be overstated. However, patients and their families can experience stress and anxiety as they try to fully comprehend this illness's intricacies and its treatment within weeks following diagnosis (Cho & Kim, 2023). Unfortunately, many patients report inadequate T1D education at and following diagnosis, with little to no available support (Thoft et al., 2022). This further contributes to excessive stress and anxiety related to diabetes management and care 4 (Ouzouni et al., 2019). The lack of support may inhibit T1D patients and their families' ability to manage the disease and develop self-care behaviors properly. Statement of Problem Patients with newly diagnosed T1D must fully grasp and understand this chronic illness within weeks of diagnosis (Thoft et al., 2022). This steep learning curve is challenging for many patients to navigate, leading to excessive stress and anxiety related to the care and management of their disease (Thoft et al., 2022). Ouzouni et al. (2019) suggest that individuals with T1D and their families experience significant mental health impacts, with excessive stress and anxiety being the most commonly reported. Moreover, Thoft et al. (2022) have found that such individuals and their families are more likely to experience stress and anxiety due to the lack of T1D education and support. Unfortunately, the current approach of providing crash course education in diabetes management is ineffective in addressing the care needs of T1D patients, and more support is needed (Hawkes et al., 2019). Evidence suggests that incorporating peer support groups effectively reduces T1D-related stress and anxiety (Edraki et al., 2020). Furthermore, virtual support groups have shown even more significant benefits when combined with peer interaction (Litchman et al., 2019). These findings highlight the need for virtual support groups that offer continued quality education and support services for T1D patients. Implementing the MSN project of a virtual support group aims to address the practice gap related to support for T1D pediatric patients and their families by reducing stress and anxiety related to diabetes management. The continued support through virtual group meetings will ease the transition into diabetic self-care and self-management practices. 5 Significance of the Project It is alarming that the educational needs of T1D patients and their families are not met sufficiently due to the potential dangers associated with the improper management of the disease, coupled with the limited support for patients and their families in coping with this intricate and persistent condition (LaManna et al., 2019). T1D is a lifelong illness that requires continual education and support (LaManna et al., 2019). For example, a T1D patient with good disease management may flounder when dealing with a life event such as puberty, marriage, menopause, psychological challenges, and more (Warshaw et al., 2019), negatively impacting their treatment understanding and compliance. However, with continued support and education during these transitional times, T1D patients can navigate these changes with minimal complications (Warshaw et al., 2019). New evidence on virtual education and support groups is strongly linked to greater patient access and better patient outcomes in T1D patients (Litchman et al., 2019). Virtual peer educational groups and programs can help patients and their families understand the importance of self-care and how to implement it in their daily routines (LaManna et al., 2019). This MSN project implements a virtual support group for T1D patients and their families, offering ongoing education and support facilitated by a nurse educator. Peer support reduces stress and anxiety in T1D patients and their families and is beneficial in developing self-care techniques (Edraki et al., 2020). By reducing stress and anxiety and promoting self-care techniques, patients can lead a more fulfilling life despite their condition. Review of the Literature Being diagnosed with T1D can be life-changing (Thoft et al., 2022). Treatment for T1D can be overwhelming and stressful for patients who are expected to quickly grasp the complexities of this chronic illness and learn about all the treatments necessary to manage it 6 (Ouzouni et al., 2019). Unfortunately, these expectations are often unrealistic, leading to poor outcomes and noncompliance with treatment plans (Prahalad et al., 2020). Even medical professionals can have difficulty understanding the complexities of T1D (Holt et al., 2021). These findings prompt the PICOT clinical question: In pediatric patients with newly diagnosed T1D and their families, does the use of a nurse-led virtual support group, as opposed to no virtual support group, reduce stress and anxiety associated with diabetic self-care management over the first six months post-diagnosis? This literature review aims to investigate current evidence regarding the educational and support needs of T1D patients and interventions to reduce stress and anxiety. The Johns Hopkins Nursing Model provides the framework to research the literature and plan evidence-based change for this MSN project (Dang et al., 2022). Framework The Johns Hopkins Nursing Model is ideal for evaluating a known problem or practice question (Speroni et al., 2020) and using a problem-solving approach through a three-phase process. These phases include the development of a practice question, then gathering evidence, followed by translation or implementation of the practice change (Dang et al., 2022). The model’s phases will help ensure that the project is structured correctly and that the evaluation is comprehensive (Speroni et al., 2020). The development of the clinical question of whether virtual support groups may decrease stress and anxiety occurs in the first phase. The second phase examines the current research and evidence related to the clinical question. The evidence suggests that T1D education is done too quickly with little to no follow-up, creating severe stress and anxiety (Thoft et al., 2022). Virtual support groups may help reduce these effects (Edraki et al., 2020) and fill a clinical practice gap. The final phase of the Johns Hopkins Nursing Model, implementing the plan, occurs through 7 translating the evidence, planning the change, implementing the program, evaluating the outcome, and communicating the results (Dang et al., 2022; Speroni et al., 2020). By creating nurse-led virtual support groups, T1D patients and their families will experience prolonged educational support to decrease the patient’s and family's stress and anxiety while promoting self-confidence and diabetic self-care practices. The Johns Hopkins Nursing Model’s outline is designed to facilitate repetition, if needed, by developing alternative implementation strategies based on the best evidence-based information found. This technique can be used until the intended outcome is achieved based on available best practice evidence (Dang et al., 2022) and provides a clear roadmap for professionals to follow (Speroni et al., 2020). Strengths and Limitations There are several strengths and limitations to the Johns Hopkins Nursing Model. This model offers a highly effective framework for solving problems and integrating best practices into healthcare (Speroni et al., 2020) and helps to ensure a thorough and systematic approach to improving practice and outcomes. Additionally, this model emphasizes the importance of reflection during project development, leading to better outcomes and improved implementation success (Dang et al., 2022). However, a limitation of the model is that it may be less productive when used in larger groups or corporate settings than in individual or small-group use (Speroni et al., 2020). As part of the MSN project, this model will guide the project in examining relevant literature and implementing evidence-based best practices. Reflection will generate alternative solutions to fill further practice gaps. Since this project takes place in a small individual or group 8 setting, the limitations of this model will not be a factor of concern, allowing the project to take advantage of the model's strengths. Analysis of Literature A clinical practice gap resides in the current educational and support services for T1D patients’ and their families. Psychological stress and anxiety related to T1D management and care inhibited T1D patient and their families' success post-diagnosis (Ouzouni et al., 2019). There is evidence regarding diabetic management, associated stress and anxiety, educational needs, and educational techniques in the chronically ill. Additionally, the literature provides factors contributing to T1D stress and anxiety, and evidence exists for the education and support of these patients. Search Strategies The following databases were used when searching for evidence from the current literature review: PubMed, Google Scholar, Weber State University’s Stewart Library’s One Search and Advanced Search (which span multiple databases), Cochrane Library, and CINAHL. Restrictions on article dates were set from 2018 to 2023 to keep all evidence current and ensure accuracy. When searching the above databases, the keywords type 1 diabetes, diabetic, pediatric, juvenile, family, diagnosis, mental, support, stress, anxiety, education, non-traditional, virtual, support group, long-term, treatment, symptoms, management, caregiver, qualitative, quantitative, systematic review, self-care, compliance, complications, patient perception, and psychosocial were used. Various combinations of the above keywords and terms were used to develop the search for relevant data. 9 Synthesis of the Literature Three themes developed in the analysis of the literature related to the PICOT question. First, T1D patients and their families experience increased stress and anxiety related to diagnosis, primarily due to inadequate education (Ouzouni et al., 2019). Second, virtual support groups and educational programs improve successful disease understanding and effective selfcare practices (Edraki et al., 2020). Third, initial T1D education should include prolonged support and educational services to achieve lifetime understanding and treatment compliance (Thoft et al., 2022). Post-Diagnosis Stress and Anxiety The diagnosis of T1D is sudden and unexpected, affecting, in many cases, otherwise healthy individuals. The literature indicates that the shock associated with the development of T1D makes the reception of education difficult for patients and their families, with many reporting increased levels of stress and anxiety (Cho & Kim, 2023; Holt et al., 2021; Ouzouni et al., 2019; Thoft et al., 2022; Warshaw et al., 2019). The emotional distress caused by diagnosis initiates a grief process in response to the loss of the person's health and lifestyle, as well as fear of the unknown and how T1D will impact the person socially (Thoft et al., 2022). The grief process can include anxiety, sadness (which can develop into depression), anger, and other natural symptoms of grief (Ouzouni et al., 2019). Diabetes prejudice has been reported as a significant factor that enhances these symptoms for extended periods post-diagnosis, lasting a few months to even years later (Cho & Kim, 2023). T1D patients are three times more likely to develop a chronic mental disorder in the firstdecade post-diagnosis, the most prevalent being anxiety (15.5%) and mood disorders (3.9%) (Ouzouni et al., 2019). In a systematic review, Ouzouni et al. (2019) found 14 studies suggesting 10 that 32% of T1D patients feel anxiety and stress about their diabetes care and management and also indicated a high risk of depression with poor T1D self-care practices. T1D family members also experience elevated anxiety and stress levels (Thoft et al., 2022). Cho and Kim (2023) found clinically significant findings indicating elevated psychological symptoms in parents of T1D patients (p=0.001) when compared to their T1D child’s levels. While it is necessary to provide immediate and extensive education following the diagnosis of T1D (Thoft et al., 2022). However, the retention and understanding of the material will vary as each person attempts to process and work through the psychological aspect of this disease (Cho & Kim, 2023; Holt et al., 2021). Understanding the barriers to T1D education and providing psychological support is critical to achieving quality disease management and understanding (Warshaw et al., 2019). It can be challenging for T1D patients and their families to navigate through the learning process of this illness and try to manage the related anxiety and stress simultaneously (Ouzouni et al., 2019). Many behavioral problems and poor management techniques in T1D patients are due to under-education and limited available support (Cho & Kim, 2023). Virtual Support Groups Improve Self-Care Behaviors Multiple studies identified that educational virtual support groups improved self-care and better overall T1D control and management (Chopoghlo et al., 2021; Edraki et al., 2020; Garg et al., 2020; Litchman et al., 2018; Litchman et al., 2019; Rush et al., 2018; Wang et al., 2019; Warshaw et al., 2019). For example, T1D control and management are notoriously poor in adolescent-aged patients, particularly those ages 12-18 (Edraki et al., 2020). During this time, typical teenagers seek independence and are very socially driven. Further, biological changes in their bodies as they develop alter treatment protocols make managing T1D more complicated 11 and challenging (Edraki et al., 2020). The constraints and treatments needed to manage T1D frustrate this patient population, making behavioral problems common in T1D adolescents as they rebel against these restrictions (Warshaw et al., 2019). Additionally, the illness's complexity makes it difficult for pediatric patients to understand and accept (Litchman et al., 2019). These factors pushed researchers to find other methods to support and educate this population. The data shows that peer support and virtual educational opportunities are especially advantageous for pediatric patients (Chopoghlo et al., 2021). In multiple studies, virtual interventional services significantly improved outcomes in patients with chronic illnesses compared to the control groups (Rush et al., 2018; Litchman et al., 2019). These studies included virtual interventions using telehealth, online groups, video conferencing, and mobile-based contact (Garg et al., 2020; Rush et al., 2018; Litchman et al., 2019). Litchman et al. (2018) found significant evidence that T1D patients involved in an online diabetic community had lower mean glycosylated hemoglobin (HbA1c) numbers and reported better T1D self-care and a better quality of life. Wang et al. (2019) tracked the use of a mobile health intervention and learned that HbA1c levels were statistically lower (95%, CI: -0.41-.09; P = 0.003). Additionally, Chopoghlo et al. (2021) conducted research on a peer-led T1D education program that utilized mobile phone social networking. Compared to the control, the interventional group had significant levels of HbA1c improvement (P<0.0001) and improvement in other areas of selfcare, including diet control (P=0.011), medical care (P=0.016), and blood sugar control (P=0.003). Finally, Edraki et al. (2020) found significant findings in a double-blind study between an interventional group who received three months of formal peer-led educational services and a control group. The interventional group achieved higher scores in self-care practices (P<0.001) and lower levels of mean HbA1c (P<0.001) when compared to the control 12 (Edraki et al., 2020). Across these studies, virtual support and educational services had statistically significant findings in improvement in T1D self-care and management outcomes. Life-Long Education and Support Needs Traditionally, T1D education is initiated at diagnosis and completed within a few days to weeks (Cho & Kim, 2023). During this time, the patient and their families are expected to become diabetic experts and be able to manage all care independently at home with little assistance from medical professionals (Thoft et al., 2022). This expectation and lack of continued support leads to severe stress and anxiety in T1D patients and their families (Ouzouni et al., 2019). Continued life-long education is essential in providing the support needed for the T1D patient population (Cho & Kim, 2023; Hawkes et al., 2019; LaManna et al., 2019; Ouzouni et al., 2019; Prahalad et al., 2020; Thoft et al., 2022; Warshaw et al., 2019). Multiple studies have found that intensive and comprehensive education at diagnosis is necessary (Thoft et al., 2022), and evidence suggests education and foundational treatment practices will lead to long-term compliance (Prahalad et al., 2020; LaManna et al., 2019). Data has found that a T1D patient will settle into its long-term glycemic control around 5 to 6 years post-diagnosis. After this time, significant change only occurs if another health event takes place and pushes the change (Prahalad et al., 2020). It takes 5 to 6 years of learning and developing an understanding of T1D before educational support and interventions are no longer effective, indicating the need for prolonged educational services, at least through this time frame (Prahalad et al., 2020). Hawkes et al. (2019) found that HbA1c levels improved in T1D patients with more intensive and ongoing educational services. However, the HbA1c level variation was not statistically significant a year after educational services ended, indicating the need for continued lifelong education (Hawkes et al., 2019). 13 To achieve quality care that supports all aspects of the T1D patient, lifelong education must be initiated and continued throughout the person's life (Warshaw et al., 2019). LaManna et al. (2019) found a 50% reduction in adverse hypoglycemic events in patients with continued support and educational services compared to those who did not participate in continued educational services. Further, Ouzouni et al. (2019) suggest that T1D pediatric patients require updated treatment options as their bodies change and develop, making continued growth and learning necessary (Cho & Kim, 2023). The literature indicates a need for prolonged T1D support and educational services to achieve the best possible outcomes. By supporting these patients throughout their lives, greater self-care and treatment compliance will be achieved (Prahalad et al., 2020). Summary of Literature Review Findings and Application to the Project The literature reviewed for T1D educational needs identified that prolonged support services are needed (Thoft et al., 2022), and virtual support methods positively impact patient outcomes (Rush et al., 2018). Psychological support is highly significant in all studies and is overlooked in this patient population during and following diagnosis (Ouzouni et al., 2019). Continued lifelong education and support services also significantly affected patients’ long-term outcomes and compliance (LaManna et al., 2019). These findings outline gaps in current patient care and support the need for T1D educational reform. New and innovative methods, such as virtual support groups for T1D patients, have been found to align with the existing literature, explicitly supporting the proposed PICOT question and confirming the need to develop a T1D virtual support group to provide ongoing educational services. 14 Project Plan and Implementation Implementation of a virtual support group for newly diagnosed pediatric T1D patients and their families within the pediatric endocrinology clinic, designed to aid the patient population and their families as they transition from diagnosis to self-care, will offer access to a supportive diabetic community. Specialized endocrinology nurses and diabetic educators will provide the clinic's virtual support group services. Patients and their families will be invited to attend the virtual support group meeting in addition to their regularly scheduled office visits. This added support and form of patient contact would assist healthcare personnel in meeting the needs of pediatric T1D patients and their families. Utilizing educational topics during support group meetings can reach a larger patient population, resulting in a healthier and more compliant clinic T1D patient population (Rush et al., 2018). Participating patients and their families will have a stronger likelihood of successful transition post-diagnosis with reduced rates of T1Drelated stress and anxiety. Plan and Implementation Process This project is designed for patients of a pediatric endocrinology clinic, requiring buy-in from the endocrinologists within the office. Using the Johns Hopkins Nursing Framework, planning the change will begin with a meeting for all the stakeholders (Speroni et al., 2020). Before the meeting, stakeholders will be given the PICOT question that initially incited the need for change and the literature review on the topic with the projected evidence-based data to drive the change in the practice setting. Once the need for change has been established and the evidence reviewed, an in-person meeting will be held to go over the project plan and the proposed implementation (see Appendix A). 15 Upon approval of the plan, a training period will begin for the office staff, including endocrinology registered nurses, diabetic educators, and clinic secretaries. Nurse and diabetic educators will be trained during a staff meeting on the use of the virtual support group platform (see Appendix A) as well as on virtual educational topics (see Appendix B). Office secretaries will receive training on the initial T1D questionnaire (see Appendix C), follow-up questionnaire (see Appendix D), and the virtual group patient handout (see Appendix E) during a special office secretaries staff meeting. The clinic’s secretaries will provide newly diagnosed T1D patients and their families with the virtual group patient handout at their first office visit post-diagnosis, inviting them to attend a virtual support group. The clinic’s secretaries will also provide the initial T1D questionnaire to patients/families at their first visit post-diagnosis and the follow-up questionnaire at three- and six-months post-diagnosis. For organizational purposes, clinic secretaries will utilize the virtual support group checklist (see Appendix F). After the initial training, close on-site support will be offered during the first month of implementation, followed by virtual and distance support as needed. Virtual group meetings will occur during the first six months post-diagnosis in the following structure: once a week for the first month, then every other week for the next two months, and finally, once a month for the last three months. Patients and their families will be closely followed during virtual support groups and in-office visits. An endocrinology nurse or diabetic educator will hold virtual support group meetings during the first month of training. Close supervision and aid will be given in person, followed by distance support as needed. During meetings, the endocrinology nurse or diabetic educator will address any questions the patient or family may have and provide education on T1D topics. The goal is to provide support with T1D management to assist in developing self-care practices 16 without overwhelming the patient and their family with a large amount of information at once (Thoft et al., 2022). By having a discussion on care needs during support meetings, the patient and family's understanding of T1D treatment will increase, which will increase compliance and decrease related stress and anxiety as these practices become familiar (Ouzouni et al., 2019). Patients and families will also benefit from the peer support within the virtual support group, which will further assist in their transition to diabetic self-care management. During the initial endocrinologic visit, at three months and six months post-diagnosis, patients and their families will complete questionnaires to assess their stress and anxiety levels and assess their educational needs met and unmet. The results will provide information on whether virtual support group attendance helps reduce stress and anxiety. This project plan will provide newly diagnosed T1D pediatric patients and their families with additional education and support. The endocrinology nurse and diabetic educators will better understand their patient's and families' T1D understanding, mental well-being, and support needs. The questionnaire will help guide future improvements to the project. This clearer picture will provide the information needed to catch and implement additional support needs quicker, creating better quality care and avoiding adverse outcomes or behaviors. Interdisciplinary Team The following healthcare personnel will comprise the interdisciplinary team required to implement this project plan. By utilizing all members of the T1D patient care team, a wellrounded approach can be taken. Team members must collaborate and work cohesively to provide quality patient care (Wei et al., 2019). This approach will positively impact patient outcomes and the success of this project plan. 17 Endocrinologists. The buy-in of endocrinologists is vital to the success of this project plan. Implementing the project plan cannot begin without the clinic partners' support. These individuals must approve the project plan and provide the necessary time and funds to train their staff to implement the change. Hiring additional staff to fulfill the virtual support need may also be required. Additionally, the endocrinologist is the patient population physician who needs to be fully on board to encourage patient participation and take full advantage of this project plan and the patient care information it provides. Clinic Endocrinology Nurses and Diabetic Educators. Nurse and diabetic educators are the main driving force behind this project plan. These individuals will need to be trained and supported in this new role. Nurse and diabetic educators are experienced in T1D care and management, enabling them to answer patients' questions and provide quality education. It is vital that the educational staff provide a good patient experience in the virtual support group for this project plan to be successful. This includes a welcoming and safe environment for patients and their families to ask questions. The nurse and diabetic educators communicate using terms that patients and their families can understand. These individuals recognize signs of additional support needs and may reach out and assist those individuals as needed. Due to the close patient interaction required of this position with potentially life-threatening T1D treatment measures, the nurse and diabetic educators are licensed and qualified individuals to recognize patient safety concerns and respond appropriately. Clinic Unit Secretary. The clinic unit secretaries will provide the virtual support group information and materials. The unit secretary will assist the patient with access to the virtual support group at their first office visit. They ensure the patient and family can access the virtual support group independently. Provide all patients and families with the instructional handout and 18 answer any questions. These individuals will also provide each patient and their families with the questionnaires at the initial, three-month, and six-month check-in points. The clinic unit secretaries will maintain organization, ensuring that each patient and their family have access to the virtual support group and that the accompanying questionnaires are completed at the correct intervals. Pediatric T1D Patients. The age of the pediatric T1D patient will directly impact the input the patient has in their care. If the patient is very young, the family/caregiver may take full responsibility for the patient’s T1D care until they are old enough to understand and gain independence in their self-care. If the pediatric patient is an older adolescent or a teen, they will have greater independence and can actively participate in the interdisciplinary team. In either scenario, the patient is the primary recipient of the project. The patient's needs will drive the virtual support meetings and provide the subject of discussion and education. The patient/family will attend the virtual support group and complete the questionnaires. T1D Patient’s Family/Caregiver. The T1D family or caregiver is an important contributor to pediatric patient care. These individuals are the number one support structure provided to the patient and can directly impact the patient’s care compliance. Due to this clear support need, including the T1D family/caregiver in the virtual support groups is important, as it will provide greater support within the patient’s home. This is especially important in the pediatric patient population as they mature and develop into their independence. The family and caregivers also may require additional support for themselves as they work through the stress and anxiety related to caring for a T1D child. Encouragement of participation in the virtual support group should be prioritized for this interdisciplinary team member for their benefit and the benefit of the patient they are caring for. These individuals will also directly impact the 19 participation of the patient in the virtual support group meetings, which will aid the patient in T1D understanding and self-care behaviors. MSN Project Planner. The MSN project planner is a registered nurse and MSN student who directly impacts the development and implementation of the project plan. This individual provides a clear outline of the plan with evidence-based research and practices to support the proposed change. Presentation of the plan and all the associated materials for implementation is also required. Once buy-in has been achieved, education on the project plan and how to implement it within the clinic will be initiated. The MSN project planner will be available for questions and directly assist in the plan's implementation. This individual should also check in and verify the proposed plan is being utilized correctly and address any concerns that may arise. Description and Development of Project Deliverables This project's deliverables will aid in stakeholder buy-in, staff training, project implementation, patient participation, and staff support. The developed deliverables will support each of these areas. Project Presentation PowerPoint. The Project Presentation PowerPoint (see Appendix A) introduces the project plan to stakeholders and staff, providing a clear overview of why the project is needed, the benefits, the implementation process, and the methods used to evaluate the effectiveness of the Virtual Support Group. Once buy-in and approval are achieved, this presentation serves as an educational tool for the staff to understand the project, its reasoning, and the implementation process. Additionally, this presentation can be used as an excellent resource to refer to as needed with any misunderstanding or questions during the implementation process. 20 Virtual Support Group Educational Topics. The Virtual Support Group Educational Topics (see Appendix B) suggest type 1 diabetic education topics to address during the Virtual Support Group meetings. These topics are outlined in a progressive order, from what is critical for the patient to know at diagnosis to other important topics that can be taught after the initial concepts have been understood (Cho & Kim, 2023). Endocrinology nurses and diabetic educators will be the instructors for the virtual support groups and can adjust topics as they feel necessary to meet the needs of their patient groups. Each weekly outline includes a questionanswer section to create a supportive environment by answering patient questions and encouraging group interactions throughout the meeting. This deliverable is only a reference for educational topics, as endocrinology nurses and diabetic educators are qualified individuals to provide type 1 diabetic education. Initial Diagnosis - Type 1 Diabetes Questionnaire. The Initial Diagnosis – Type 1 Diabetes Questionnaire (see Appendix C) is given at diagnosis during the patient’s first office visit. This questionnaire obtains a baseline from the patient and family on stress and anxiety associated with diabetic self-care management. General demographics are obtained to be used to assess the data after the completion of the project. Additional questions are asked to evaluate the patient and their family's current knowledge, understanding, and stress at diagnosis (Henry & Crawford, 2011; Litchman et al., 2018; Szabo & Lovibond, 2022). These results will be compared to the follow-up questionnaires. Type 1 Diabetes Questionnaire – 3 and 6 Months. Patients and families complete the Type 1 Diabetes Questionnaire – 3 and 6 Months (see Appendix D) at three and six months postdiagnosis. The questionnaire obtains general demographic information, followed by questions asking how attending the Virtual Support Group has helped the patient and their family since 21 their T1D diagnosis (Henry & Crawford, 2011; Litchman et al., 2018; Szabo & Lovibond, 2022). These questions address The perception of education, understanding, support, and stress (Litchman et al., 2018). The questionnaires are spaced evenly throughout the project to indicate over time if attending the Virtual Support Group helped to reduce stress and anxiety after diagnosis of T1D. This clear data can track patient outcomes and overall improvement throughout the project. Patient Education Handout. The Patient Education Handout (see Appendix E) introduces the patient to the Virtual Support Group. At the first office visit post-diagnosis, the patient and their family are invited to attend the Virtual Support Group and provided with this handout to help them understand what it offers and how it will benefit them. It serves as a reminder of the date and time of their first meeting. Virtual Support Group Checklist. The clinic secretaries utilize the Virtual Support Group Checklist (see Appendix F) for organization throughout implementation. This checklist allows patients and families to receive meeting reminders and questionnaires at the correct times. The checklist allows the project's implementation to run smoothly and serves as a reminder for each step that should be taken. Timeline Initially, stakeholder buy-in and approval are required to initiate the project. This process is projected to take 1-2 months. After approval and buy-in is achieved, implementation of the project at the clinic can begin. The MSN project planner educates the clinic’s staff over an estimated 1-2 months. The MSN project planner offers continued support, both onsite and virtual, throughout the first few months of implementation. Once staff are fully trained, the project can begin implementation with all newly diagnosed T1D patients, starting with their first 22 office visit. Patients and families will be invited to the Virtual Support Group during their first office visit and over the next six months as outlined within the project. The total timeframe of the project, from initial contact and buy-in of the stakeholders to implementation of the project to the first patients completing the program, is 8-10 months. Re-evaluation and any improvements to the project occur after the initial group of patients and families complete the Virtual Support Group after six months, and questionnaire data can be compiled (Dang et al., 2022). Once the implementation of the project begins, each patient and family Virtual Support Group will run for a total of six months. During implementation, the Virtual Support Group will meet every week for the first month, then every other week for months two and three postdiagnosis. During months four, five, and six of the project, the virtual support group will meet monthly. Patients and families complete questionnaires at diagnosis, three months postdiagnosis, and at completion of this program at six months. Project Evaluation Project evaluations determine the effectiveness of the project change. A benchmark level of the patient’s or family’s perception of stress, anxiety, knowledge, and confidence related to diabetes is obtained post-diagnosis at the initial office visit using the Initial Diagnosis – Type 1 Diabetes Questionnaire. Direct patient comparisons are drawn from this benchmark using the follow-up questionnaire at three and six-month check-in points to evaluate the summative outcome of the virtual support group. All questionnaires are helpful in the clinic as the interdisciplinary team evaluates the overall effectiveness of the project and individual trends. Formative evaluation is ongoing and occurs at each virtual support group meeting, as the endocrinology nurse or diabetic educator assesses patient understanding of questions being asked and listens to patient dialog during meetings. These regular formative assessments help providers 23 recognize subject areas needing additional support or training throughout the program. Both evaluation methods enhance this project to improve the quality of care for patients and families. Ethical Considerations The nurse educator or diabetic educator ensures that all personal information during the virtual support group meetings is confidential and secure. All program documentation, including patient and family questionnaires, will be treated as medical documents utilizing all patient privacy rights. Overall project evaluation outcomes are generalized data absent of patient and family identifiers. Meetings will be conducted with enforced non-discriminatory behaviors, making the virtual support group a safe place to ask questions and ensuring participants do not feel inadequate or judged. Patients not wishing to be on camera at the group meeting can elect to have their camera device turned off and still participate in the meeting. Patients and families may want to remain anonymous during meetings, which will be respected, with no personal information given during group meetings. The endocrinology nurse and diabetic educators will refer all care concerns to the patient’s healthcare provider. Patients and families who do not wish to participate in the virtual group meetings will receive treatment without discrimination. Additionally, the endocrinology nurse and diabetic educators provide quality educational and emotional support services for those individuals outside of the virtual support group as they desire. If patients and their families stop attending virtual support group meetings during the project, the project team will respect their choice without affecting patient care. Any patient or family refusing to complete questionnaires will still be allowed to attend the Virtual Support Group meetings respectfully. 24 Discussion Type 1 diabetic patients and their families feel overwhelming stress and anxiety related to the complexity of T1D treatment measures combined with inadequate education (Thoft et al., 2022). A lack of patient support for these individuals leads to poor treatment compliance and outcomes (Warshaw et al., 2019). The lack of educational protocols for this demographic compounds this problem, resulting in high levels of patient misunderstanding, increasing stress, and decreased support services (Cho & Kim, 2023). This MSN project aims to provide ongoing support to T1D patients and their families, especially immediately post-diagnosis, to decrease stress and anxiety and increase diabetic self-care behaviors and treatment compliance. This section will address the project’s strengths and limitations, nursing significance, implications, recommendations, and dissemination of the results. Evidence-based Solutions for Dissemination Dissemination of the project occurs in multiple ways. The stakeholders will receive a compiled report from the patient and family questionnaires and will discuss program strengths, limitations, and potential improvements. Additionally, a presentation of project outcomes will occur during a meeting with endocrinology nurses, diabetic educators, dietitians, and other healthcare providers to share how a virtual support group can augment diabetes education. Finally, the MSN project planner will also give a project poster presentation to faculty and peers at Weber State University. Significance to Advance Nursing Practice This project provides endocrinology nurses and nurse educators with a virtual option to meet with patients in a group setting, specifically within this project, and offers structured support with optional educational topics for newly diagnosed T1D patients and their families 25 over the first six months. The virtual support group format facilitates an additional option for endocrinology nurses and diabetic educators to deliver higher-quality patient care and reduce nurse uncertainty about the correct procedural process (Cho & Kim, 2023). The stress and anxiety of T1D patients and families will decrease as they better understand their treatment regimen and feel supported, reducing nurse-patient strain and improving patients' self-care practices and outcomes (Hawkes et al., 2019; Ouzouni et al., 2019). This education and support program will lead to patient and family acceptance, life-long treatment, and care compliance (Hawkes et al., 2019). Implications This project features many strengths, including a virtual avenue for T1D patient and family support and tools tailored to facilitate group discussion. It is based on evidence-based practices and is readily applicable to other healthcare areas and clinics. The project design follows the Johns Hopkins Model (Dang et al., 2022), using evidence-based information to support the plan. The deliverables included with the project include an educational PowerPoint for stakeholders and staff, educational topics for patient and family support, questionnaires for evaluation, patient and family handouts, and organizational tools for staff. These tools align with the project implementation and goal of answering the PICOT question. Implementation of the project uses endocrinology nurses ' and diabetic educators' knowledge and enhances T1D patient and family reception of provided teaching and support throughout the project. Evaluation of the project uses qualitative data from patients and families to assess their perceptions and experiences with the Virtual Support Group. By following this model, this MSN project will implement a change based on evidence and provide a clear way to assess and improve the implementation process. 26 Several project limitations have been identified, including possible pushback from staff, broad age groups, sample size, and patient buy-in. This project requires extensive staff support and can be an inhibiting factor with poor staff reception. Clear and thorough staff education emphasizing this program's impact and expected outcomes would help reduce this barrier. Broad age groups with all pediatric ages included could skew the results. This limitation could be reduced by dividing adolescent and teen groups to focus education on specific patient needs as reflected by age and life events immediately following diagnosis. Depending on the clinic's patient population and the number of newly diagnosed T1D patients, these groups can be further divided among educators to better tailor the Virtual Support Group's educational content. This approach would enhance the Virtual Support Group topics to be relevant to the group dynamic. Further, the teenage patient’s parents may also need to be divided into groups away from their children to encourage open discussion from the T1D teens without feeling inhibited by their parents. Further, the patient population of the clinic, coupled with a potential lack of buy-in, could lead to a small sample size. If patients and families are given the option to participate in the TID virtual support group but opt not to, this would critically limit the project implementation. Staff encouragement of T1D patients and families to participate in the Virtual Support Group would aid in reducing this limitation by offering clear invitations, providing reminders, and creating a supportive environment. Recommendations This MSN project's primary focus is adequate T1D support post-diagnosis to improve stress, reduce anxiety, and promote self-care practices. Factors found in the literature review suggested support groups to improve successful education and lifelong support and educational 27 services to achieve treatment compliance (Edraki et al., 2020; Ouzouni et al., 2019; Thoft et al., 2022). Additional research on the proper education of non-medical personnel on complex medical issues, the effects of peer support and education, the age at which the transition of care goes from parent to T1D pediatric patient, effects of stress, anxiety, and depression in T1D patients, and life-long educational support for T1D patients would enhance this project, to improve care. Finally, this MSN project could be further enhanced by including other persons involved in the T1D support group, including the endocrinologist, dietician, pharmacist, and any other team members involved in the T1D patient's care. Conclusions The development of T1D in pediatric patients is overwhelming, resulting in increased levels of stress and anxiety (Ouzouni et al., 2019). Patients and families must receive diabetic education at diagnosis to avoid life-threatening complications; however, due to the complexity of the illness, education is met with frustration (Thoft et al., 2022). Without adequate diabetic education, post-diagnosis diabetic self-care practices are not developed, leading to poor treatment compliance and outcomes (Cho & Kim, 2023). This MSN project aims to provide enhanced T1D patient and family support to reduce stress and anxiety and improve diabetic selfcare practices and outcomes. 28 References Cho, M., & Kim, M. Y. (2023). Educational needs of people with type 1 diabetes mellitus and their parents: A cross‐sectional study. Nursing Open, 10(7), 4849–4858. https://doi.org/10.1002/nop2.1737 Chopoghlo, S. B., Hosseinkhani, A., Khedmat, L., Zaki-Nejad, M., & Puryaghoob, M. (2021). The self-efficacy improvement in adolescent girls with type 1 diabetes mellitus with selfcare education through mobile-based social networking. International Journal of Diabetes in Developing Countries, 41(4), 676–682. https://doi.org/10.1007/s13410-021-00929-5 Dang, D., Dearholt, S., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidencebased practice model. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/evidence-based-practice/model-tools Edraki, M., Zarei, A., Soltanian, M., & Moravej, H. (2020). The effect of peer education on selfcare behaviors and the mean of glycosylated hemoglobin in adolescents with type 1 diabetes: A randomized controlled clinical trial. International Journal of Community Based Nursing and Midwifery, 8(3), 209–219. https://pubmed.ncbi.nlm.nih.gov/32656273/ Garg, S. K., Rodbard, D., Hirsch, I. B., & Forlenza, G. P. (2020). Managing new-onset type 1 diabetes during the COVID-19 pandemic: Challenges and opportunities. Diabetes Technology & Therapeutics, 22(6), 431–439. https://doi.org/10.1089/dia.2020.0161 Hawkes, C. P., Willi, S. M., & Murphy, K. M. (2019). A structured 1‐year education program for children with newly diagnosed type 1 diabetes improves early glycemic control. Pediatric Diabetes, 20(4), 460–467. https://doi.org/10.1111/pedi.12849 Henry, J. D., & Crawford, J. R. (2011). The short‐form version of the Depression Anxiety Stress Scales (DASS‐21): Construct validity and normative data in a large non‐clinical sample. 29 British Journal of Clinical Psychology, 44(2), 227–239. https://doi.org/10.1348/014466505x29657 Holt, R. I. G., DeVries, J. H., Hess-Fischl, A., Hirsch, I. B., Kirkman, M. S., Klupa, T., Ludwig, B., Nørgaard, K., Pettus, J., Renard, E., Skyler, J. S., Snoek, F. J., Weinstock, R. S., & Peters, A. L. (2021). The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care, 44(11), 2589–2625. https://doi.org/10.2337/dci21-0043 LaManna, J., Litchman, M. L., Dickinson, J. K., Todd, A., Julius, M. M., Whitehouse, C. R., Hyer, S., & Kavookjian, J. (2019). Diabetes education impact on hypoglycemia outcomes: A systematic review of evidence and gaps in the literature. The Diabetes Educator, 45(4), 349–369. https://doi.org/10.1177/0145721719855931 Litchman, M. L., Edelman, L. S., & Donaldson, G. W. (2018). Effect of diabetes online community engagement on health indicators: Cross-sectional study. JMIR Diabetes, 3(2). https://doi.org/10.2196/diabetes.8603 Litchman, M. L., Walker, H. R., Ng, A. H., Wawrzynski, S. E., Oser, S. M., Greenwood, D. A., Gee, P. M., Lackey, M., & Oser, T. K. (2019). State of the science: A scoping review and gap analysis of diabetes online communities. Journal of Diabetes Science and Technology, 13(3), 466–492. https://doi.org/10.1177/1932296819831042 Ouzouni, A., Galli-Tsinopoulou, A., Kazakos, K., & Lavdaniti, M. (2019). Adolescents with diabetes type 1: Psychological and behavioral problems and compliance with treatment. International Journal of Caring Sciences, 12(2), 1298–1304. http://internationaljournalofcaringsciences.org/docs/84_.ouzouni_special_12_2.pdf 30 Prahalad, P., Zaharieva, D. P., Addala, A., New, C., Scheinker, D., Desai, M., Hood, K. K., & Maahs, D. M. (2020). Improving clinical outcomes in newly diagnosed pediatric type 1 diabetes: Teamwork, targets, technology, and tight control—the 4T study. Frontiers in Endocrinology, 11. https://doi.org/10.3389/fendo.2020.00360 Rush, K. L., Hatt, L., Janke, R., Burton, L., Ferrier, M., & Tetrault, M. (2018). The efficacy of telehealth delivered educational approaches for patients with chronic diseases: A systematic review. Patient Education and Counseling, 101(8), 1310–1321. https://doi.org/10.1016/j.pec.2018.02.006 Speroni, K. G., McLaughlin, M. K., & Friesen, M. A. (2020). Use of evidence‐based practice models and research findings in magnet‐designated hospitals across the United States: National survey results. Worldviews on Evidence-Based Nursing, 17(2), 98–107. https://doi.org/10.1111/wvn.12428 Szabo, M., & Lovibond, P. F. (2022). Development and psychometric properties of the dassyouth (dass-y): An extension of the Depression Anxiety Stress Scales (DASS) to adolescents and children. Frontiers in Psychology, 13. https://doi.org/10.3389/fpsyg.2022.766890 Thoft, D. S., Nielsen, B. K., & Enggaard, H. (2022). To become an expert within a week: Children’s and parents’ experiences of the child being diagnosed with type 1 diabetes and receiving diabetes education – a qualitative interview study. Journal of Pediatric Nursing, 67, e24–e30. https://doi.org/10.1016/j.pedn.2022.10.004 Wang, X., Shu, W., Du, J., Du, M., Wang, P., Xue, M., Zheng, H., Jiang, Y., Yin, S., Liang, D., Wang, R., & Hou, L. (2019). Mobile Health in the management of type 1 diabetes: A 31 systematic review and meta-analysis. BMC Endocrine Disorders, 19(1). https://doi.org/10.1186/s12902-019-0347-6 Warshaw, H., Hodgson, L., Heyman, M., Oser, T. K., Walker, H. R., Deroze, P., Rinker, J., & Litchman, M. L. (2019). The role and value of ongoing and peer support in diabetes care and education. The Diabetes Educator, 45(6), 569–579. https://doi.org/10.1177/0145721719882007 Wei, H., Corbett, R. W., Ray, J., & Wei, T. L. (2019). A culture of caring: The essence of healthcare interprofessional collaboration. Journal of Interprofessional Care, 34(3), 324– 331. https://doi.org/10.1080/13561820.2019.1641476 32 Appendix A Project Presentation PowerPoint https://1drv.ms/p/s!AkQbS6LTmwS4glLR4-drts7JMLm3 33 Appendix B Virtual Support Group Educational Topics https://1drv.ms/w/s!AkQbS6LTmwS4glTSs-k098-2c0u_ 34 Appendix C Initial Diagnosis - Type 1 Diabetes Questionnaire https://1drv.ms/w/s!AkQbS6LTmwS4glyp161qQyI2PJPr 35 Appendix D Type 1 Diabetes Questionnaire – 3 and 6 months https://docs.google.com/document/d/1zx7xEvEnFcxjCHs5eo15LCK9cYLJ5vJr893x2yp dg1Q/edit?usp=sharing 36 Appendix E Patient Educational Handout 37 Appendix F Virtual Support Group Checklist https://1drv.ms/w/s!AkQbS6LTmwS4gmZidLBWsnvarVyI 38 Appendix G Project Plan Timeline