Digital Repository Doctoral Projects Fall 2021 Improving the Confidence and Competence of the Bedside Nurse in Providing Inpatient Diabetes Education Jesica Jensen Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Jensen, J. (2021) Improving the Confidence and Competence of the Bedside Nurse in Providing Inpatient Diabetes. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/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 archives@weber.edu. Improving the Competence and the Confidence of the Bedside Nurse in Providing Inpatient Diabetes Education. by Jesica Jensen A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Jessica Bartlett, DNP, CNM, RN, IBCLC__(signature) Faculty Advisor/Committee Chair (Jessica Bartlett, DNP, CNM, RN, IBCLC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running head: IMPROVING DIABETES EDUCATION 1 Improving the Confidence and Competence of the Bedside Nurse in Providing Inpatient Diabetes Education Jesica Jensen Annie Taylor Dee School of Nursing Doctorate of Nursing Practice Program Weber State University December 10, 2021 IMPROVING DIABETES EDUCATION 2 Dedication I want to dedicate this DNP project to my husband and three children, who bolstered, supported, and inspired me to reach my educational goals. IMPROVING DIABETES EDUCATION 3 Acknowledgments I would like to acknowledge Intermountain Healthcare for allowing me to complete this DNP quality improvement project in their continued strive for excellence in patient care. I would like to recognize the Inpatient Diabetes Education team at Intermountain Medical Center for serving as excellent resources for content and materials for diabetes education. A special thanks to Maryanne Palmer, RN-CDE, who served as a content expert and project champion for this quality improvement project. I want to acknowledge Lisa Stevens, MSN-RN/Unit Manager, for her support of this DNP project. I would like to thank Dr. Jessica Bartlett, who served as project chair. I would also like to thank all of the nurses at Alta View Hospital for their help and support in making this DNP project a success. IMPROVING DIABETES EDUCATION 4 Abstract PURPOSE: In the United States, one in ten individuals has diabetes. Diabetes is a significant cause of hospitalization, disabling morbidity, and increased mortality. Nurses must be knowledgeable with diabetes survival skills education (DSSE) to teach patients to safely self-manage their diabetes after discharge. Bedside nurses are often responsible for providing Inpatient diabetes education. However, bedside nurses often lack the knowledge, time, and comfort to provide the essential DSSE. The purpose of this Doctor of Nursing Practice (DNP) project was to increase the competence and confidence of the bedside nurse in providing diabetic education to patients using the DSSE model. METHODOLOGY: The DSSE educational toolkit was developed with the aid of organizational stakeholders and content experts. The diabetes toolkit included a DSSE training session, an education module, a resource binder, and a standardized skills checklist to be used for documentation. RESULTS: Twenty-three nurses (7 charge/16 bedside) participated in DSSE education implementation, representing 69% of unit nurses. Post project implementation, charge nurses reported a 43% increase in their comfort and confidence in delivering DSSE and a 57% increase in comfort answering patients' questions. Of the bedside nurses, 81% reported feeling comfortable and confident providing diabetes education and answering patients' questions. IMPLICATIONS FOR PRACTICE: Small hospitals often do not have inpatient diabetic educators resulting in diabetes education falling to the bedside nurse. This QI project shows that providing bedside and charge nurses with an evidence-based DSSE model is one way to help them feel more comfortable and confident in providing diabetes education to their patients. Keywords: Diabetes, education, quality improvement, confidence, competence, bedside nurses, and inpatient education. IMPROVING DIABETES EDUCATION 5 Inpatient Diabetes Education: Improving the Confidence and Competence of the Bedside Nurse. The prevalence of diabetes in the United States is estimated at 34.2 million (Centers for Disease Control and Prevention (CDC), 2020). The incidence of diabetes is growing at an alarming rate, with 26.9 million Americans diagnosed last year (CDC, 2020). Diabetes is associated with significant morbidity and mortality, ranked as the 7th leading cause of death in 2016, according to the World Health Organization (WHO, 2020). The diabetes epidemic's economic burden was 327 billion dollars in 2018 (American Diabetes Association (ADA), 2018). Diabetes is a life-altering diagnosis requiring life-long medication management and lifestyle modifications (Luan et al., 2016). Individuals must learn to effectively manage their diabetes to prevent acute and chronic complications associated with disease mismanagement. Diabetes education is crucial to increasing compliance with medication management and prescribed lifestyle changes (Deakin, 2011). Education is a large piece of the puzzle for patients to manage their diabetes successfully. Hospitalization provides a unique opportunity to assess patients' educational needs to self-manage their diabetes (Nettles, 2005). Often the responsibility of diabetes education falls to the bedside nurse. However, according to Krall, Donihi, Hatam, Koshinsky, & Siminerio (2016), bedside nurses lack the time and preparation to provide the necessary survival skills required for inpatient diabetes education. The purpose of this Doctor of Nursing Practice (DNP) paper is to provide context, support, and describe an evidence-based quality improvement project implemented to improve the competence and confidence of the bedside nurse in providing inpatient diabetes survival skills education (DSSE). Problem Description As with many small community hospitals, Alta View Hospital lacks a specially trained inpatient diabetes educator. Instead, the bedside nurses fulfill the role of the diabetes educator. IMPROVING DIABETES EDUCATION 6 Previously, there was no standardized process for inpatient diabetes education, which led to a fragmentation of diabetes education. Inpatient diabetes education aims to ensure that patients and their families gain the skills necessary to manage their diabetes, mitigate disease-related complications, and prevent hospital readmission. Expert consensus regarding necessary inpatient diabetes education focuses on providing survival skills, the essential foundational knowledge required to safely self-manage their diabetes at home. There was a need for a standardized tool and increased nursing education regarding diabetes care management. A diabetes education toolkit was devised to meet this practice gap, which combines additional nursing education via live training and a computer-based education module, and a standardized tool to communicate patient educational resources, needs, and education completion. Literature Review A systematic review of the available literature was completed to determine evidence-based educational requirements for diabetic patients. The search terms utilized included a variable combination of the following: nurses, teaching, diabetes, diabetic, education, knowledge, self-management, barriers, learning, memory, forgetting curve, remembering curve, obesity, sedentary lifestyle, diet, nutrition, dietary guidelines, physical exercise, type 1 diabetics, type 2 diabetics, inpatient, diabetes management, complications associated with diabetes, and education guidelines. The databases searched include Google Scholar, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Medline, EBSCO Host, and the Cochrane Collaboration. The inclusion criteria were limited to full-text journal articles produced in English within the last ten years. IMPROVING DIABETES EDUCATION 7 Diabetes Diabetes mellitus is defined as a metabolic disorder that is characterized by hyperglycemia. Hyperglycemia results from the individuals' inability to make insulin, utilize insulin, or decreased cellular sensitivity to circulating insulin in the bloodstream. Thus resulting in the body's inability to use the circulating glucose for cellular function (Chawla, Chawal, & Jaggi, 2016). Type 1 diabetes results from the failure to produce insulin due to the autoimmune destruction of pancreatic islet cells. These individuals require insulin medication management to survive (National Institute of Diabetes and Digestive and Kidney Disease (NIDDK), 2017). In type 2 diabetes, the individual reserves the ability to make insulin; however, body cells develop diminished insulin sensitivity, requiring more significant insulin quantities to transport glucose into the body cells (NIDDK, 2017). Individuals with type 2 diabetes can produce insulin, so management is aimed to decrease blood glucose levels and increase the affinity of body cells for insulin. Gestational diabetes is a type of diabetes that occurs in pregnancy; due to its transient nature, it is not discussed further within this paper. Type 1 diabetes risk. The development of type 1 diabetes is caused by autoimmune destruction of islet cells within the pancreas responsible for insulin production (CDC, 2020). Thus, the hallmark of type 1 diabetes is the absence of insulin production. Type 1 diabetes can occur at any age; however, it is more likely to develop in children, teens, and young adults (CDC, 2020). Type 1 diabetes, also commonly called insulin-dependent diabetes mellitus (IDDM), accounts for approximately 10% of diabetes diagnoses (NIDDK, 2017). Type 2 diabetes risk. The contributing factors for developing Type 2 diabetes are genetic and environmental factors such as obesity, aging, diet, and physical activity (Hu & Jia, 2018). Type 2 diabetes accounts for approximately 90% of diabetes diagnoses (Olfert & Wattick, IMPROVING DIABETES EDUCATION 8 2018). Diabetes can occur in any age, race, gender, or socioeconomic class; however, diet and activity level are considered the most modifiable risk factors associated with the development of type 2 diabetes (Olfert & Wattick, 2018). Diagnosis. The classic initial clinical presentation of patients with diabetes is polydipsia, polyuria, and polyphagia. However, the onset and rate of disease progression account for the variation of initial disease presentation, ranging from asymptomatic to life-threatening diabetic ketoacidosis (ADA, 2019). The diagnosis of diabetes is a result of laboratory testing, revealing a hyperglycemic state. The tests used to screen and diagnose diabetes include fasting blood glucose, a glucose tolerance test, and glycated hemoglobin (A1C) (ADA, 2019). Treatment. The diabetes treatment varies depending on the type, duration, and comorbidities, requiring a variable combination of glucose monitoring, diet, exercise, medication, and lifestyle modifications. For patients with type 1 diabetes, the mainstay therapy is insulin medication management to utilize blood glucose. Short-acting insulin is calculated and administered based on carbohydrate intake, premeal blood glucose levels, and anticipated physical activity to ensure optimal glucose control (American Diabetes Association, 2017). The treatment for type 2 diabetes patients is diet, exercise, weight loss, and glycemic control (Inzucchi, 2017; NIDDK, 2017). Oral glycemic lowering medications are often added when diet and exercise are not enough to normalize hyperglycemia. In addition, insulin can be added to a patient's treatment regimen when the above-listed treatment options fail to normalize blood glucose (NIDDK, 2017). Diet. The goal of dietary recommendations for individuals with diabetes is to help the individual make healthier food choices. Nutritional guidelines that are too restrictive tend to lead to patient non-compliance. The NIDDK (2017) recommends increasing dietary intake of IMPROVING DIABETES EDUCATION 9 vegetables, fruits, whole grains, lean protein, and non-fat or low-fat dairy products while restricting simple carbohydrates, high-fat animal protein, and high glycemic foods. Although these recommendations sound simple enough, the western diet is often low in veggies, fruits, and whole grains; instead, it is high in animal protein, saturated fats, and refined carbohydrates (Olfert & Wattick, 2018). Restrictive diets that are extremely low in carbohydrates often yield the most significant glycemic control in diabetic patients (Lennerz et al., 2018). Making dietary changes can be difficult for many diabetic patients; it is often easier to make small changes at first and enlist help from their social support system to increase success (NIDDK, 2017). Activity. Exercise is one of the cornerstones for diabetes management (Jendle & Riddell, 2019). Physical exercise can increase glucose uptake into muscle by five times that of insulin alone (Colberg et al., 2016). To maintain health, the recommended level of physical activity is thirty to sixty minutes of moderate exercise a day, at least five days a week (NIDDK, 2017). Technology-based modern society promotes a sedentary lifestyle with reading, watching television, educational environments, and desk jobs. These inactive low energy expending activities adversely influence cardiometabolic health (Colberg et al., 2016). With lifestyle changes, regular physical activity can prevent or delay type 2 diabetes development and improve glycemic control for those with diabetes (Jendle & Riddell, 2019). Medication management. Patients with type 1 diabetes require treatment multiple times a day with insulin replacement. In contrast, the glucose-lowering medication selection for patients with type 2 diabetes varies for each patient based on treatment goals, medication compliance, the risk for hypoglycemia, level of insulin resistance, physical activity, and patient cost (Jendle & Riddell, 2019). Patients with type 2 diabetes often require oral glycemic lowering medication or IMPROVING DIABETES EDUCATION 10 a combination of insulin and oral medications to obtain euglycemia and decrease diabetes complications. Consequences. Diabetes is associated with grave health consequences if one does not learn to manage their diabetes (Johannsson, Osterberg, Leksell, & Berglund, 2016). Poorly controlled glucose can lead to acute and chronic long-term complications. Acute complications are often life-threatening and can occur quickly. These acute diabetes complications include hypoglycemia, hyperglycemia, non-ketotic hyperosmolar state, and diabetic ketoacidosis. The chronic complications of poorly controlled diabetes can result in microvascular and macrovascular complications. These diabetes complications are heart disease, stroke, nerve damage, kidney disease, delayed wound healing, and vision loss (Chawla et al., 2016). Afroz, Zhang, Wei Loh, Jie Lee, and Billah (2019) conducted a retrospective, cross-sectional study of 1253 participants, finding an increased prevalence of diabetes complications amongst type 2 diabetic patients in Bangladesh. The percentage of macrovascular complications determined in their study was 30.5% for coronary artery disease, 10% for stroke, and 12% had diabetic foot complications. While 34.2% of participants had microvascular complications, 25.1% experienced retinopathy, and 5.8% experienced neuropathy. Their study determined that prevention of complications should focus on physical activity, weight loss, smoking cessation, improvements in hypertension, and improved glycemic control (Afroz et al., 2019). Barriers. The barriers identified to diabetes management are medication cost, the cost of healthy foods, depression, lack of motivation, sedentary lifestyle, and knowledge deficits (Johansson et al., 2016). Randall et al. (2011), when studying 164 hospitalized minority patients admitted for recurrent diabetic ketoacidosis, found significant gaps in knowledge related to diabetes self-management. A considerable barrier to diabetes management is comorbid IMPROVING DIABETES EDUCATION 11 depression, hampering the patient's motivation for exercise and diabetes self-management (Kamrul-Hasan et al., 2019). Education. The foundation of diabetes self-management is education and success in enhancing self-care behaviors (Gucciardi, Chan, Manuel, & Sidani, 2013). The goal of diabetes education is to provide knowledge, skills, resources, and confidence to promote self-management. Adu, Malabu, Malau-Aduli, and Malau-Aduli (2019) conducted a mixed-methods cross-sectional survey of 31 participants to determine enablers and diabetes barriers to self-management. The study concluded that excellent knowledge regarding diabetes self-management and the risk of complications, coupled with problem-solving skills, could promote motivation to adhere to prescribed diabetes self-management (Adu et al., 2019). Gaps in Knowledge Diabetes education is vital to help patients learn to manage their diabetes and ensure compliance with the prescribed treatment plan. Effective diabetes education requires nurses to be knowledgeable, confident, and effective communicators (Nam et al., 2011). In addition, diabetes management requires a change in lifestyle, including diet, activity, daily management alterations, and medication management. Thus, education needs to be engaging, thorough, relevant, repetitive, and motivational to help patients understand the treatment, make goals, and ensure success (Department of Veterans Affairs & Department of Defense (VA/DOD), 2017). Unfortunately, according to Ugur et al. (2015), graduating from a nursing program does not necessarily mean nurses are prepared to provide comprehensive diabetes education. The bedside nurse has the most significant ability to influence hospitalized patients learning due to the extensive amount of time spent at the patient's bedside. However, research shows that bedside nurses have knowledge gaps in diabetes self-care management (Ugur, 2015; Young, IMPROVING DIABETES EDUCATION 12 2011). Bedside nurses' knowledge and expertise regarding diabetes management can influence the patient's diabetes self-care management success (Ugur et al., 2015). Thus, exemplifying the need for bedside nurses to receive additional education in diabetes care (Young, 2011). Educational Needs. There are several aspects to diabetic teaching that are essential for successful self-management and lifestyle modifications. A patient must first understand the pathophysiology of diabetes, why they need treatment, and how glucose affects their body. Education should include how diet, medications, and exercise affects blood glucose (Deakins, 2011). Patient teaching consists of how, when, and why associated with diabetic medicines (Adu et al., 2019). Also, it is crucial to recognize the symptoms of hypoglycemia and hyperglycemia. People with diabetes often do not realize that 'weakness' can be a symptom of hyperglycemia (Baptista et al., 2019). A patient must learn how to use a glucometer, the importance of monitoring their blood glucose, and how to treat abnormal values (Randall et al., 2011). Another educational component is how to manage sick days, especially in patients who are insulin-dependent diabetics. The patient should be taught what their hemoglobin A1C is, set realistic A1C goals, and be included in devising a plan to reach those goals (Randall et al., 2011). Patient diabetes education should also include available community resources to ensure successful diabetes self-management. Diabetes survival skills are the cornerstone of diabetes education. Thus, nurses must be knowledgeable in diabetes care to provide the essential diabetes survival skill education (Ugur, 2015). Excellent diabetes survival skills education in the inpatient setting can improve health outcomes and prevent rehospitalizations (Healey et al., 2013). Skills. Several essential skills must be mastered before the patient can leave the hospital. First, the patient must learn to use a glucometer to check blood glucose levels, treat blood glucose levels, and administer medications correctly (Hu & Jia, 2018). Second, a necessary skill IMPROVING DIABETES EDUCATION 13 for patients to learn is how to balance oral intake with medication administration to keep their blood glucose within the target range (Adu et al., 2019). Third, patients must gain the skills necessary to treat both hypo- and hyperglycemia appropriately to avoid a yo-yo effect of their blood glucose. Finally, the available research shows that patients hospitalized with diabetes-related issues should be educated on diabetes survival skills. The focus of survival skills is to answer what it is, how it is treated, why it matters, and what to watch for, which can motivate the patient to take an active role in diabetes self-care management (Mogre, Johnson, Tzelepis, & Paul, 2019). Clinical Problem Before implementing the Inpatient DSSE Toolkit, the education of diabetic patients admitted to Alta View Hospital lacked structure, clarity of necessary teaching, and communication of teaching received, resulting in diabetes education variability. It is clear from the research that patients hospitalized with diabetes must gain the essential DSSE required to self-manage their diabetes and prevent hospital readmissions. Since many inpatient nurses lack knowledge and expertise in diabetes care management, the toolkit focused on providing clear guidelines for diabetes education (Ahmed, Jabbar, Zuberi, Islam & Shamim, 2012). Ahmed et al. (2012) endorsed a need for additional education and training for nurses to improve diabetes self-care management and improve patient outcomes. According to Zimmet (2017), the diabetes epidemic is one of the largest in human history. Hospitals face challenges in meeting the educational demands of the ever-growing diabetic population, which is amplified in small community hospitals due to limitations in personnel (Nassar, Montero, Magee, 2019). Hospital admission presents the optimal opportunity to educate diabetic patients (Wexler et al., 2012). Since the bedside nurse is responsible for IMPROVING DIABETES EDUCATION 14 providing education regarding medication administration, diabetes self-care management, and lifestyle changes, they must gain the necessary knowledge and skills required to provide this education (Ugur, Demir, Akbal, 2015). The overall consensus of experts is inpatient diabetes education should focus on DSSE to ensure safe self-management after discharge (Nassar et al., 2019; Krall et al., 2016, Ugur et al., 2015). Solution The findings of this literature review established that bedside nurses often lack the time, knowledge, and skills necessary to provide inpatient diabetes education (Krall et al., 2016; Ugur et al., 2015). Hospitalization is a critical access point to provide much-needed diabetes education (Wexler et al., 2012; Nassar, Montero, Magge, 2019). However, research indicates that inpatient diabetes education should focus on DSSE to enable patients to safely manage their diabetes after discharge (Krall et al., 2016; Nassar et al., 2019). The identified solution is a quality improvement project designed to bridge the chasm that was inpatient diabetes education. The quality improvement project design is multifaceted to meet the three identified needs; additional nurse education, lack of educational framework, and ineffective communication. The recognized approach was to develop an inpatient DSSE toolkit. The DSSE toolkit created combines a diabetes academic learning module and in-person diabetes training session for bedside nurses to increase their knowledge and comfort in providing inpatient diabetes care management and education. A survival skills checklist was created based on the recommendations provided by Krall et al. (2016). The survival skills checklist clarified what diabetes education needs to be provided before discharge. This tool also provides a mode of communication regarding received and required diabetes education. The survival skills checklist also offers explicit instructions on finding the educational resources to educate patients IMPROVING DIABETES EDUCATION 15 with page numbers. In addition to the education and framework, a resource book was compiled that provides educational tools and handouts and available outpatient resources. Theoretical Framework. The theoretical framework used to guide the implementation of this evidence-based project was Lewin's Force Field Theory of Change. Lewin's theory approaches change as a three-step process; unfreeze, move, and refreeze (Finkelman, 2018). The initial step is unfreezing; this occurred in Fall 2019 when the gap in diabetes educational practices was identified. Next, a survey of the medical-surgical unit charge nurses was conducted to explore how frontline staff views the current state of diabetes education. The survey allowed the team to determine the problem's breadth, explore solutions, and bolster stakeholders' support (Finkelman, 2018). In this stage, the project was designed, potential barriers and solutions were identified, and the action plan was prepared for implementation. The second step in Lewin's theory is move; this is the phase where change occurs (Finkelman, 2018). The diabetes educational toolkit was implemented in February 2021. As indicated by Lewin's Change Theory, this is the stage where the most resistance is met; change can be difficult; it is easy to become complacent, preferring our comfort zone (Finkelman, 2018). This resistance was evident with nursing staff being slow to signup and attend in-person training sessions. Two different avenues were employed to educate point-of-care staff. First, a self-paced learning module was added to their required quarterly computer-based education in January 2021. Second, the in-person instruction was provided via Teams meet due to COVID-19 restrictions on large groups congregating; it was delivered on three different dates at variable times. Nurses were encouraged to sign up for 1 of the training sessions. The nurses were educated regarding the educational toolkit and survival skills during these training sessions. IMPROVING DIABETES EDUCATION 16 During this phase, continued data was obtained to determine if alterations needed to be made to any aspect of the implemented educational workflow. The final step in Lewin's theory is refreezing, which occurs when the practice change has become the norm and is well integrated into daily workflow. Keeping the project at the forefront of nurses' minds; otherwise, there is a risk of returning to old ways. The medical-surgical nurse educator has told this DNP leader that she plans to add the Diabetes 101 module annually to the nurse's required quarterly computer-based education. The diabetes educational toolkit use has continued past the initial pilot program. To ensure the toolkit gains permanency in the daily workflow, it is essential to educate new staff and remind current staff of the toolkit use (Finkelman, 2019). Expected Outcomes & Goals The expected outcome of this quality improvement project for diabetes education at Alta View was to increase the nurses' self-reported confidence in providing diabetes education by 60%. This DNP project aimed to improve the confidence and competence of bedside nurses in providing diabetes education, improve diabetes education consistency by delivering a diabetes educational toolkit, and improve diabetes education communication. The overarching goal of these aims was to enhance the knowledge of diabetic patients discharged from Alta View Hospital. This DNP project's objectives align well with the mission of Intermountain Healthcare in helping people live their healthiest lives possible (Intermountain Healthcare, 2020). The aims of this quality improvement project are threefold. 1) Improve nurse comfort in providing diabetes education. 2) Improve consistency of diabetes education amongst staff members. 3) Improve communication of patient educational needs. The overarching goal of IMPROVING DIABETES EDUCATION 17 these three aims is to improve the knowledge, skills, and abilities of diabetic patients to enable diabetes self-management and improve health outcomes. Target Population This quality improvement project's targeted population was bedside nurses responsible for delivering inpatient diabetes education at Alta View Hospital. The population consists of 33 medical/surgical registered nurses (RN) and 16 intensive care RNs. The RNs have various levels of experience and education, ranging from new grads to nurses with 20+ years of experience. The majority of the RNs are bachelor's prepared, with a minority that holds associate degrees. Setting The diabetic toolkit implementation was conducted at Alta View Hospital, a small community hospital in Sandy, Utah, nestled in the southeast corner of the Salt Lake Valley. Alta View Hospital is a member of Intermountain Healthcare, a leader in healthcare delivery, and is known for excellence. Despite the small community hospital status, 6.3% of patients served at Alta View Hospital have diabetes, ranking eleventh within the Intermountain Region (Intermountain Alta View Hospital, 2013). The quality improvement project was piloted on the 28-30 bed adult Medical-Surgical Unit and 6-8 bed Adult Intensive Care Unit. Implementation Research and development for this quality improvement project were conducted from Fall 2019-Fall 2020. The development and implementation of this quality improvement project were made possible through the consultation of content experts, faculty advisors, and facility stakeholders. The quality improvement project was presented and accepted by Weber State University for the Internal Review Board (IRB) for approval in 2020. The project was submitted to Intermountain Healthcare IRB for approval in December 2020 and gained acceptance in IMPROVING DIABETES EDUCATION 18 January 2020. Utilizing non-probability, convenience sampling, a pre-implementation survey was conducted in October of 2020 of charge nurses. The survey was conducted anonymously to determine the pre-implementation perception of nurses regarding inpatient diabetes education and their self-reported comfort and confidence in providing diabetes education. Once project approval was obtained, this QI project implementation began with live web-based nurse training due to large group restrictions established due to the COVID-19 pandemic. Live web-based training began in February of 2021. Three separate training sessions were scheduled, nurses were asked to attend one of the three sessions. The agenda for the live training included survival skills education, diabetes medication management, orientation to the standardized survival skills checklist, and exposure to the diabetes toolkit with education materials. During the live training, nurses were oriented to educational requirements and allowed questions and answers from the DNP student and content expert. In addition, computer-based diabetes 101 training module was added to the bedside nurses' yearly required education which covers key knowledge concepts with quiz questions to test competency in January 2021. This QI project implementation go-live occurred in mid-February 2021. Evaluation and Data Analysis Data collection for this quality improvement project utilized self-report anonymous surveys employing a Likert scale to quantify qualitative data. Convenience sampling of medical-surgical charge nurses was used pre-implementation to assess the perceived environment surrounding inpatient diabetes education before the diabetes toolkit implementation. Approximately 70% (7/9) of charge nurses completed the pre-implementation survey. A post-implementation survey was conducted of charge nurses with a completion rate of 67% (6/9) and bedside nurses with a completion rate of 70% (16/23). Post-implementation surveys were IMPROVING DIABETES EDUCATION 19 conducted in the same manner as the pre-implementation survey, utilizing the majority of the same questions in two separate surveys; one included only charge nurses while the other included all bedside nurses. The two post-implementation surveys were designed first to assess like-groups while also assessing the collective views of nurses regarding inpatient diabetes education. One question in the post-implementation survey deviated from the original survey. In the pre-implementation survey for charge nurses, the question read 'I feel that the current process for diabetes education could be improved' to this question, 85.71% responded with agreeing or strongly agree. Post-implementation, this question was slightly changed to read 'I feel the process for diabetes education has been improved.' To this question, 100% of charge nurses responded with agreed or strongly agreed. When questioned regarding comfort and confidence in providing inpatient diabetes education pre-implementation, 57.14% of charge nurses reportedly agreed or strongly agreed with feeling confident and comfortable in providing diabetes education. Post-implementation, 100% of nurses endorsed that they agreed or strongly agreed with feeling comfortable and confident in providing diabetes education, increasing by 42.86%. When questioned regarding perceived comfort, charge nurses answered patients' questions regarding diabetes self-care management pre-implementation. Only 42.86% of charge nurses agreed or strongly agreed, while post-implementation 100% agreed or strongly agreed, representing an increase of 57.14% in comfort with answering patients' questions regarding diabetes self-care management. Charge nurses, when questioned whether they felt prepared to deliver diabetes education, only 42.86% said that they agreed or strongly agreed on pre-implementation. In comparison, post-implementation, 100% stated that they agreed or strongly agreed to this question, an increase of 57.14%. IMPROVING DIABETES EDUCATION 20 The data represented in Table 1 - Appendix B shows the survey questions pre-and post-implementation responses collected from charge nurses with the variance. Table 1- Appendix B also provides the collected post-implementation data reported by bedside nurses regarding self-reported perceptions of diabetes education and self-report comfort. No pre-implementation data was collected from the bedside nurses resulting in a lack of comparative data. Table2- histogram provides a visual representation of the marked improvement in charge nurse reported comfort and confidence in delivering inpatient diabetes education post-quality improvement project implementation of the diabetes educational toolkit. Several variables account for the outliers and discrepancies seen between charge nurses' and floor nurses' comfort and confidence. The diabetes live training sessions were provided on three separate occasions at variable times to ensure maximum nurse availability for attendance. 57.14% 42.86% 85.72% 57.15% 14.29% 42.85% 100% 81.25% 62.50% 75% 81% I FEEL CONFIDENT IN PROVIDING DIABETES EDUCATION. I KNOW WHAT NEEDS TO BE TAUGHT I BELIEVE DIABETES EDUCATION IS MY RESPONSIBILITY I FEEL COMFORTABLE IN ANSWERING PATIENTS QUESTIONS REGARDING DIABETES SELF -MANAGEMENT I FEEL THERE IS AN ORGAINZED TOOL FOR DIABETES EDUCATION I FEEL PREPARED TO DELIVER DIABETES EDUCATION Self -reported Confidence of Nurses in Providing Inpatient Diabetes Education Preimplementation Charge Nurse Survey Responses Post-Implementation Charge Nurse Responses Post-Implementation Bedside Nurse ReponsesIMPROVING DIABETES EDUCATION 21 Despite this, only approximately 69% of the floor nurses attended the live diabetes survival skills education and training sessions, while 78% of the charge nurses attended these live sessions. All nurses received the Diabetes 101 module in their required computer-based quarterly education in January 2021. In addition, all of the nurses were provided a copy of the narrated power-point presentation highlighting the information contained in the live diabetes survival skills education and training sessions. However, there was no requirement to ensure that all nurses completed the diabetes survival skills education. Discussion This DNP quality improvement project was conducted on the medical-surgical and intensive care units at Alta View Hospital, a small community hospital nestled in a suburb in the Salt Lake Valley. The focus of this quality improvement project was on nursing staff who are responsible for providing inpatient diabetes education. As with many small community hospitals, bedside nurses are responsible for providing inpatient diabetes education. So bedside nurses must be afforded the additional knowledge, skills, tools, and resources to provide inpatient diabetes education (Krall, Donihi, Hatam, Koshinsky, & Siminerio, 2016). In addition, according to research, inpatient diabetes education should focus on diabetes survival skills (Ugur, Demir, & Akbal, 2015; Krall et al., 2016). The goal of this DNP quality improvement project was to improve the competence and confidence of the bedside nurse in providing inpatient diabetes education. An education curriculum was created, including in-person survival skills diabetes educational training sessions with the bedside nurses. An evidence-based survival skills checklist was developed and utilized to communicate educational needs and resources to use and share the completed education. A yearly Diabetes 101 education module was provided, allowing nurses to brush up on their IMPROVING DIABETES EDUCATION 22 knowledge of diabetes care management. Implementing these quality improvement measures has marked improvement in nurses' self-reported confidence and competence in providing diabetes survival skills education. Since this project focuses on the nursing staff, no data was collected regarding patient-reported outcomes. However, one nurse reported that her patient was a new-onset diabetic '…loved the education provided…feeling that the survival skills checklist structure built upon previous education.' Communication of diabetes education is essential since nurses have limited time for diabetes education. As reported by nurse surveys, the diabetes educational toolkit with the survival skill checklist has substantially increased nursing communication by approximately 68.25%-100%. The diabetes educational toolkit also provides clear guidelines and structure to inpatient diabetes education as evidenced by nurse self-reported surveys. Strengths and Limitations The project design allowed for the standardization of DSSE. Organizational and managerial support allowed for greater nurse project participation. However, since the project implementation occurred at a small community hospital, it may be difficult to generalize findings in non-similar facilities. Another perceived limitation is the use of internet-based anonymous surveys as a means of project evaluation. It is difficult with surveys to validate results and avoid non-response. It could be argued that a convenience sampling of charge nurses, who represent between a quarter to a third of bedside nurses, may not be generalized through inferential statistical analysis to all bedside nurses. Arguably charge nurses often have added nursing experience, which may lend to their comfort and confidence in DSSE. To offset this limitation, a post-implementation survey of bedside nurses was conducted to corroborate findings. Another perceived limitation is the focus of this DNP project was on nursing staff, so there is no data IMPROVING DIABETES EDUCATION 23 collected regarding the effect of DSSE on patient outcomes. Of interest for future studies would be data collection regarding the patient level of understanding and patient outcomes. Recommendations The first recommendation is to standardize diabetes education with an emphasis on diabetes survival skills. Knowledge of what to teach is half of the battle. A standardized survival skills checklist provides an essential outline of what needs to be taught. The DSSE checklist created for this quality improvement project established where to locate the educational materials for each topic, taking the guesswork out of DSSE. The DSSE checklist saves time in trying to determine what education the patient needed and received. The second recommendation is providing additional education and training for bedside nurses regarding inpatient DSSE. In healthcare, we use the adage learn one, do one, teach one; this applies to diabetes education. Without that foundational knowledge, it is challenging for nurses to provide diabetes survival skills education. The third recommendation is repetition; the more nurses provide diabetes education, the easier and quicker it will become. Repetition leads to proficiency, as seen with the standardization of heart failure teaching called MAWDS. Bedside nurses have often provided MAWDS teaching so repetitively that they have the fine details memorized. As nurses provide DSSE more frequently, they will have the fine critical details memorized and will find diabetes education to be second nature. Conclusion The diabetes epidemic has highlighted the need for improvements in inpatient diabetes education. The focus of inpatient diabetes resides with essential DSSE to mitigate life-threatening complications and prevent hospital readmission. Implementing an evidence-based IMPROVING DIABETES EDUCATION 24 standardized DSSE toolkit at Alta View Hospital has improved the confidence and competence of the bedside nurse in providing inpatient DSSE. IMPROVING DIABETES EDUCATION 25 References Adu, M. D., Malabu, U. 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Retrieved from Educating staff nurses on diabetes: knowledge enhancement. - Free Online Library (thefreelibrary.com) IMPROVING DIABETES EDUCATION 32 Appendices Appendix A: IRB approval letters: Weber State University Intermountain Healthcare IRB approval letter IMPROVING DIABETES EDUCATION 33 Appendix B: Table 1 Diabetes Survey Results: Survey Question Pre-implementation Survey of Charge Nurses Post-Implementation Survey of Charge Nurses A variance of those that agree or strongly agree Post-implementation of Bedside Nurses I feel comfortable and confident in providing diabetes education? 28.57% Strongly agree 28.57% Agree 28.57% Somewhat Agree 14.29% Disagreed 0% Strongly Disagree 60% Strongly agree 40% Agree 0% Somewhat agree 0% Disagree 0% Strongly disagree + 42.86% 31.25% Strongly Agree 50% Agree 6.25% Somewhat Agree 12.5% Disagree 0% Strongly Disagree I know what needs to be taught? 14.29% Strongly agree 28.57% Agree 28.57% Somewhat Agree 28.57% Disagree 0% Strongly Disagree 40% Strongly Agree 60% Agree 0% Somewhat Agree 0% Disagree 0% Strongly disagree + 57.14% 25% Strongly Agree 37% Agree 25% Somewhat Agree 6.25% Disagree 6.25% Strongly Disagree I believe diabetes education is my responsibility? 14.29% Strongly agree 71.43% Agree 14.29% Somewhat Agree 0% Disagree 0% Strongly Disagree 40% Strongly Agree 60% Agree 0% Somewhat Agree 0% Disagree 0% Strongly disagree + 14.28% 37.5% Strongly Agree 37.5% Agree 18.75% Somewhat Agree 0% Disagree 6.25% Strongly Disagree I feel comfortable answering patients' questions regarding diabetes self-management? 14.29% Strongly agree 28.57% Agree 28.57% Somewhat Agree 28.57% Disagree 0% Strongly Disagree 40% Strongly Agree 60% Agree 0 % Somewhat Agree 0% Disagree 0% Strongly disagree + 57.14% 31.2% 5rongly Agree 50% Agree 6.25% Somewhat Agree 12.5% Disagree 0% Strongly Disagree There is an organized, well-established, and consistent tool for delivering diabetes education. 14.29% Strongly agree 28.57% Agreed 28.57% Somewhat Agree 28.57% Disagree 0% Strongly Disagree 40% Strongly Agree 60% Agree 0 % Somewhat Agree 0% Disagree 0% Strongly disagree + 57.14% 31.25% Strongly Agree 50%Agree 6.25% Somewhat Agree 12.5% Disagree 0% Strongly Disagree I know exactly what resources are 0% Strongly agree 28.57% Agree 40% Strongly Agree 60% Agree + 71.43% 25% Strongly Agree 37.5% Agree IMPROVING DIABETES EDUCATION 34 available for diabetic education and who can help to educate? 28.57% Somewhat Agree 42.86% Disagree 0% Strongly Disagree 0 % Somewhat Agree 0% Disagree 0% Strongly Disagree 25% Somewhat Agree 6.25% Disagree 6.25% Strongly Disagree I know what diabetes education and skills have been provided to the patient by the previous nurse? 0% Strongly agree 0% Agree 28.57% Somewhat Agree 71.43% Disagree 0% Strongly Disagree 40% Strongly Agree 60% Agree 0 % Somewhat Agree 0% Disagree 0% Strongly Disagree + 100% 18.25% Strongly Agree 50%% Agree 18.75% Somewhat Agree 6.25% Disagree 6.25% Strongly Disagree I know exactly what skills are needed for patients to successfully manage their diabetes at home? 0% Strongly agree 50% Agree 16.67% Somewhat Agree 33.33% Disagree 0% Strongly Disagree 40% Strongly Agree 60% Agree 0 % Somewhat Agree 0% Disagree 0% Strongly disagree + 50% 35.5% Strongly Agree 50% Agree 6.25% Somewhat Agree 6.25% Disagree 0% Strongly Disagree I feel prepared to deliver diabetes education? 0% Strongly agree 42.86% Agree 28.57% Somewhat Agree 28.57% Disagree 0% Strongly Disagree 80% Strongly Agree 20% Agree 0% Somewhat Agree 0% Disagree 0% Strongly disagree + 57.14% 25% Strongly Agree 56.25% Agree 6.25% Somewhat Agree 6.25% Disagree 6.25% Strongly Disagree IMPROVING DIABETES EDUCATION 35 Appendix D: Evidence Tables Appendix E: Evidence-Based Practice Models/Theoretical Framework 57.14% 42.86% 85.72% 57.15% 14.29% 42.85% 100% 81.25% 62.50% 75% 81% I FEEL CONFIDENT IN PROVIDING DIABETES EDUCATION. I KNOW WHAT NEEDS TO BE TAUGHT I BELIEVE DIABETES EDUCATION IS MY RESPONSIBILITY I FEEL COMFORTABLE IN ANSWERING PATIENTS QUESTIONS REGARDING DIABETES SELF -MANAGEMENT I FEEL THERE IS AN ORGAINZED TOOL FOR DIABETES EDUCATION I FEEL PREPARED TO DELIVER DIABETES EDUCATION Self -reported Confidence of Nurses in Providing Inpatient Diabetes Education Preimplementation Charge Nurse Survey Responses Post-Implementation Charge Nurse Responses Post-Implementation Bedside Nurse ReponsesIMPROVING DIABETES EDUCATION 36 Appendix F: Data Collection Tools IMPROVING DIABETES EDUCATION 37 Appendix G: QI tools – Nurse education PowerPoint IMPROVING DIABETES EDUCATION 38 Survival skills checklist