Digital Repository Masters Projects Spring 2024 Nurse-Led Diabetic Clinics in Primary Care Christine Nundra Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Nundra, C. 2024. Nurse-Led Diabetic Clinics in Primary Care 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 Nurse-Led Diabetic Clinics in Primary Care Project Title by Christine Nundra 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 April 26, 2024 Ogden, UT Date Christine Nundra, BSN, RN, MSN Student April 26, 2024 Student Name, Credentials (electronic signature) Date Anne Kendrick, DNP, 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 Nurse-Led Diabetic Clinics in Primary Care Christine Nundra, BSN, RN, MSN Student Annie Taylor Dee School of Nursing Weber State University MSN Project 2 Abstract Purposes/Aims: Diabetes in America is increasing as one of the leading causes of death. Self-management of this disease is crucial, and regular follow-ups with a healthcare provider are vital in averting long-term effects. This project aims to create a nurse-led diabetic clinic to improve veteran knowledge, access, and treatment adherence with diabetes mellitus. Rationale/Background: Diabetes care has traditionally involved provider-led clinics; however, with the increasing chronic disease implications, nurses can help manage diabetic care. Having nurse-led diabetic clinics can allow for the overall coordination, management, and continuity of care. Methods: In the outpatient primary care clinic of the Department of Veteran Affairs, veteran access is limited due to high turnover rates with primary care providers. After the initial diagnosis of type 2 diabetes for the veteran, a pre-survey will be given. A post-survey will be provided quarterly while enrolled in the nurse-led diabetic clinic. Results: The results of the implementation of a nurse-led diabetic clinic in the outpatient primary care clinic of the Department of Veteran Affairs can improve patient satisfaction and increase adherence to self-management of type 2 diabetes for newly diagnosed veterans. Conclusions: Implementing a nurse-led diabetic clinic for newly diagnosed type 2 diabetic veterans can significantly reduce the progression of the disease process. Increasing access to a nurse-led diabetic clinic allows for improved patient outcomes, enhanced patient education, increased patient satisfaction, and decreased healthcare costs. Keywords: nurse-led diabetic clinic, type 2 diabetes, patient outcomes with a nurse-led clinic 3 Nurse-Led Diabetic Clinics in Primary Care Newly diagnosed type 2 diabetes is prevalent in the United States. An estimated 1.4 million adults are newly diagnosed with diabetes every year (Laiteerapong et al., 2019). Beginning intensive self-management patient education and increasing patient satisfaction can decrease the severe complications of uncontrolled diabetes. Diabetes causes various complications and a high rate of disability and mortality. It is a severe public health problem that affects the sustainability of the economy and society. Implementing a nurse-led diabetic clinic in primary care can increase access to healthcare professionals explicitly trained to monitor newly diagnosed type 2 diabetics in the veteran population (Levengood et al., 2019). The nurse-led diabetic clinic can ensure patients receive appropriate tests and examinations and manage patients' risk factors through diet, exercise, and medications. The clinic will educate and assist patients with self-management and adherence to treatment regimens, promote healthy behaviors and lifestyle choices to improve overall quality of life, and prevent the progression of diabetes-related complications (Levengood et al., 2019). These nurses can implement a wide range of interventions aimed at improving the care of people with diabetes, achieving better metabolic control, and improving patient satisfaction. Evidence shows that telephone-based support of self-management or coaching interventions delivered by a registered nurse effectively reduces the treatment gap and improves glycemic control, blood pressure, lipid, and psychosocial outcomes in type 2 diabetes (Blackberry et al., 2013). Statement of Problem Adults with diabetes have an increased risk of heart attacks and strokes (MedlinePlus, n.d.). In addition, they also have reduced blood flow from neuropathy in their feet, which 4 increases the chance of foot ulcers, infection, and possible need for limb amputation (Cho & Kim, 2021). Self-management of diabetes is essential, and the consequences of uncontrolled blood glucose levels are severe. Diabetes can be managed, and implications of the disease can be avoided or delayed with continuous adaptation, including diet control, physical activity, medication, and regular screening and treatment for complications. This project aims to implement a nurse-led clinic to educate newly diagnosed type 2 diabetic veterans to improve patient management, satisfaction, and outcomes. The goal is to have nurse-led clinic visits in between provider visits. Using nurse-led weekly visits to manage and control blood glucose levels may significantly decrease frequent emergency room visits and readmissions to the hospital. These weekly nursing visits can improve glycemic control and provide adults with the knowledge and skills to better self-manage their type 2 diabetes, improving patient satisfaction and outcomes (Powers et al., 2016). Significance of the Project Studies have shown the positive outcomes of education on patient conditions and improved glycemic control when nurses are involved (Nikitara et al., 2019). Keeping veterans informed of the disease, possible complications, and test results can improve adherence and decrease healthcare costs. Direct medical costs associated with diabetes include expenses for preventing and treating diabetes and its complications and cover outpatient and emergency care, inpatient hospital care, and long-term care. Patient satisfaction can improve adherence and self-management of their disease (Świątoniowska-Lonc et al., 2022). Implementing a nurse-led diabetic clinic for newly diagnosed veterans can increase patient satisfaction, enhance self-management of their condition, and increase adherence to diet, exercise, weight management, and lipid control. Improved diabetic 5 self-management can give veterans better glycemic control, leading to better health outcomes (Levengood et al., 2019). Review of the Literature Diabetes impacts all social, economic, and ethnic backgrounds, with an estimated 37.3 million people in the United States (U.S.) having the disease (Shah et al., 2023). People with diabetes have an increased risk of developing several life-threatening severe health problems that could result in higher medical costs, lower quality of life, and increased mortality (Niu et al., 2021). Diabetes can cause serious complications, including heart disease, stroke, blindness, kidney failure, and amputation. More than ninety-five percent of people with diabetes have type 2 diabetes. Early diagnosis can be accomplished through inexpensive blood testing. The most important way to treat diabetes is to have a healthy lifestyle (World Health Organization, 2023). Managing diabetes can be complex, and type 2 diabetes management is a challenge for patients and their healthcare providers (Laurant et al., 2018). Current recommendations include health education, glucose management, lifestyle management, and drug therapy. The effects of nurse-led interventions are statistically significant, with improved patient outcomes in glucose levels and patient satisfaction and reduced systolic blood pressure and lipids. Study findings suggested that care delivered by nurses, compared to care provided by doctors, may generate similar or better health outcomes for a broad range of patient conditions. Nurse-led type 2 diabetic clinics can improve patient outcomes and increase patient satisfaction. Framework Kurt Lewin identified the change theory model for successful change implementation. The model involves three steps: unfreezing, moving, and refreezing (Crosby, 2020). Lewin believed that change was not easy, and to change old habits, an individual would need to 6 unfreeze to discard old behaviors before learning new ones (Burnes, 2004). In addition, Lewin thought individuals should consider all the behaviors on a trial-and-error basis and all available options to consider change. Lastly, refreezing stabilizes an individual's thinking and ensures new behaviors are safe from regression. Lewin believed his theory would bring the practice of change management. Kurt Lewin was seen as one of the foremost psychologists of his day. He is known for the three-step model of change. Lewin states, “A successful change includes three aspects: unfreezing the present level, moving to the new level, and freezing group life on the new level.” Lewin initially developed this model as helping resolve social conflicts such as racism. Lewin's theory is an adaptive system that brings to the forefront of organizations the need to adapt to the ever-changing environment to survive (Burnes, 2020). Strengths and Limitations A strength to using Lewin's theory of change model for a nurse-led diabetic clinic is the positive influence for the individual nurses and the organization to maintain the status quo for change. The three-step process can help the organization implement planned activities for quality improvement (Aguirre, 2022). Lewin's change model theory incorporates unfreezing, changing, and refreezing. Unfreezing allows people to let go of old ways or patterns. Changing seeks alternatives and demonstrates the benefits of change. Refreezing integrates and stabilizes a new equilibrium into the system, becoming a habit and resisting further change (Wojciechowski et al., 2016). A limitation of Lewin's three-step theory for change model is that it does not account for the dynamic healthcare environment in which nurses' function today. This change theory model may not allow for organizations to adapt to the needs of newly diagnosed type 2 diabetic 7 veterans. Healthcare organizations are complex adaptive systems where change is a process with varying degrees of complexity and agreement among disciplines. Analysis of Literature The prevalence of type 2 diabetes is growing in the U.S., and population health goals have emphasized nurses' role in patient self-management education and advocacy (Powers et al., 2020). The use of specialist nurse-led care in primary care clinics has been shown to decrease costs for diabetic patients and increase clinical effectiveness. This literature aims to explore how nurse-led clinics can improve type 2 diabetes patient health outcomes and improve patient satisfaction. The PICOT question for this project is: For veterans newly diagnosed with type 2 diabetes mellitus (P), how does a weekly nurse-led telephone call or clinic visit following the health care provider visit (I) improve patient reports of satisfaction, self-management, and timely return clinic visits (O) compared to the current standard (no follow-up) (C) over twelve-months (T)? Search Strategies A literature search was conducted to identify current evidence using Google Scholar and Weber State University's Stewart Library's OneSearch, accessing the databases of the Cochrane Library and CINAHL. The search included keywords such as: "nurse-led diabetic clinics," “diabetes education,” “long-term effects of type 2 diabetes,” “nurse-led versus physician-led clinics,” “patient satisfaction with nurse-led clinics,” “open access in healthcare for primary care,” “improved patient outcomes with specialty nurse clinics,” and “self-management of diabetes with diabetic nurse-led clinics.” In addition, various Boolean combinations were used with the keywords mentioned above to start a broad search. Synthesis of the Literature 8 Three themes were identified in the literature review: 1) nurse-led diabetic clinics can improve patient outcomes, 2) availability and trust in nurse-led clinics, and 3) the effects of nurse-led care on diabetes. The three themes are further discussed in the following section. Nurse-led Diabetic Clinics Can Improve Patient Outcomes Nurse-led integrated clinics can achieve measurable positive clinical outcomes such as lowering cholesterol and glucose levels. In addition, patients can gain confidence in selfmanaging their diabetes. In a study on patient satisfaction outcomes, ninety-eight percent of responders answered they were very satisfied or quite satisfied with the education and care they received by nurse-led diabetes self-management education (Hicks et al., 2012). A clinic incorporating nurse-led care with weekly telephone calls can improve patients’ satisfaction and health outcomes. A study reported that telenursing can improve metabolic parameters in type 2 diabetic patients (Shahsavari et al., 2020). Telephone follow-up and patient education effectively supported and enhanced outpatient and chronic patients. Nurse-led clinics can assist patients with self-care training and help improve the self-care process. The positive patient outcomes are related to the close relationships between patients and nurses and the active participation of the patients in diabetic treatment plans. In a qualitative study using constant comparison methods and semi-structured questions over one year, nurses provided insight into four areas of patient-centered care in type 2 diabetes management (Frost et al., 2014). The four areas identified were empowering collaboration, flexibility, approach, and practice (Frost, 2014). This study reflected that diabetic control with care cooperation promoted patient satisfaction and improved their quality of life. Collaboration decreased depression among low-income individuals with diabetes. A significant improvement in patient health outcomes was attributed to nurse-led diabetic clinics. 9 In another study, information was collected to discuss the factors that patients felt threatened patient-centered care with type 2 diabetes patients (Foluke Bosun-Arije et al., 2021). The factors included unrealistic collaboration, rigid flexibility, uncomfortable approach, and unsteady practice with health care providers. Blood glucose monitoring diaries were distributed to patients at each follow-up visit to remind patients to monitor their fasting blood sugars at their convenience so that nurses could check and record results. Compared with the control group, the mean score for the diabetes self-management group demonstrated a better improvement over time than the control group after intervention. Availability and Trust in Nurse-Led Clinics A nurse-led clinic can incorporate trust and allow for more availability with healthcare providers in primary care clinics. Patients indicated that during appointments with their providers, they felt rushed and unable to disclose all the problems affecting them (Kieft, 2014). When patients do not experience time pressure, they are more able to participate actively in their diabetic care. Patients with type 2 diabetes receiving regular primary care have more opportunities to visit with their nurses (Pon et al., 2019). Actively participating patients can manage their diabetes better and improve clinical outcomes and quality of life. Nurses may give the patient more time to discuss information than with the provider, where the patient can ask questions and not feel rushed. Nurses can verify patient understanding, and patients can ask additional questions for clarification. A trusting relationship with the nurse encourages patients to express their emotions or concerns (Kourkouta & Papathanasiou, 2014). These trusting relationships can improve self-management behaviors. Patients indicated active participation is stimulated when they do not experience time pressure (Du Pon et al., 2019). Patients may feel more welcome to raise new topics without time constraints. Patients also stated 10 that personal preparation is beneficial for actively participating with their nurses. Most patients say communication between nurses and themselves is a balanced interaction, and having a trusting relationship with their nurses encourages patients to express common emotions and concerns. Effects of Nurse-Led Care on Diabetes Evidence suggests that diabetic specialist nurses are able to educate patients and deliver direct care (Lawler et al., 2019). The primary interventions in nurse-led diabetic clinics can improve glycemic control, diabetic symptoms, cost-effectiveness, and decrease the length of hospital stay or readmission rates. A study revealed that four factors were found to help patients actively participate in their disease process: developing trusting relationships with their nurses, having enough time in the appointment, preparing for their appointment, and allowing for the presence of a spouse (Du Pon et al., 2019). There is a considerable burden of type 2 diabetes on the healthcare system (Sapkota et al., 2015). Using a nurse-led clinic to treat type 2 diabetic patients can support and guide patients in diabetes management. Lack of knowledge of disease, financial burden, and family support are barriers. In nurse-led diabetic clinics, these issues can be addressed weekly with telephone calls or face to face nurse visits between provider-driven care. Complex diabetes management can improve patient outcomes by changing diet patterns, adhering to medications, and encouraging physical activity. Regular lifestyle training and treatment by a trained nurse can help maintain the glycemic level of diabetic patients. Summary of Literature Review Findings and Application to the Project The number of people with type 2 diabetes has doubled worldwide in the past twenty years (CDC, 2024). Patients with type 2 diabetes have an increased risk of developing heart 11 disease, stroke, foot problems, eye and kidney disease. This literature review reflected that it is possible to improve diabetic patients’ outcomes with improved glucose control, diet, physical activity, and increased patient satisfaction. The most significant challenge today is limited healthcare resources. Nurses can play a role in helping patient manage their type 2 diabetes and improve patient outcomes through a nurse-led clinic. The primary function of a nurse-led diabetic clinic is to set behavioral goals, establish individualized care plans, and provide relevant diabetes knowledge (Carey & Courtenay, 2007). By doing so, patient outcomes can improve, and patient satisfaction can increase. Nurse-led diabetic clinics are crucial for improving patient care outcomes and satisfaction for type 2 diabetes. Allowing open-access appointments to nurse-led clinics can decrease readmission rates and shorten hospital stays, allowing more room for patients needing care to be treated. Patients perceived a trusting relationship with their nurses as facilitating active participation (Du Pon et al., 2019). Patients experienced their nurse’s effective communication as pleasant and warm, encouraging them to discuss their emotions and concerns. In these trusting relationships with their nurses, patients felt encouraged to discuss issues unrelated to their type 2 diabetes, such as personal issues. Patients also preferred to visit their nurses with their spouses and felt supported by their spouses. Some patients reported that their spouses were more accurate in asking specific questions about their disease process. Project Plan and Implementation Providing sustainability in veteran healthcare is possible with a nurse-led diabetic clinic implemented in a primary care outpatient setting. Implementing a nurse-led diabetic clinic can lead to improvement of the disease progression and can allow veterans to have support during the fragile initial stages of type 2 diabetes. Patients with type 2 diabetes receiving primary care 12 regularly and actively participating during medical consultations can better manage their disease and improve clinical outcomes and quality of life (Du Pon et al., 2019). It is imperative to implement a strong plan of care for the veteran to follow closely with the interdisciplinary team to provide positive patient outcomes. The plan and implementation process, interdisciplinary team, description and development of project deliverables, and timeline are discussed in this section. Plan and Implementation Process The purpose of implementing a nurse-led diabetic clinic in the primary care clinic is to keep newly diagnosed type 2 diabetics under control by slowing the disease progression. The clinic will manage the patients' needs by allowing the nurse to educate and facilitate weekly phone calls to instill confidence in them in managing their new diagnosis. The continued communication with the nurse will allow for questions to be answered frequently and for any changes in symptoms of diabetes to be monitored. The registered nurse will initially contact the newly diagnosed veteran once a week to monitor the veteran with their new diagnosis and set them up with available resources. The process will promote self-management of the patient’s new diagnosis and promote patient satisfaction through frequent interactions with the nurse. The specialty nurse will undergo a training program that consists of twenty hours of practical training with endocrinology and individual self-study. Registered nurses will be trained over six weeks, with weekly competency checkoffs every two weeks. Interdisciplinary Team A study revealed that a nurse-led multidisciplinary team can lead to significantly improved effects on glucose control, decreased hospitalizations due to complications of diabetes, 13 and help-seeking behavior changes (Ni et al., 2019). Having a nurse-led diabetic clinic for newly diagnosed type 2 diabetics can expand the role of nurses in helping achieve glucose control. The multidisciplinary team for this project will be comprised of endocrinologists, dieticians, psychologists, cardiologists, nephrologists, and diabetic specialty nurses. The endocrinologist will follow the veteran's care after the initial diagnosis of type 2 diabetes. The endocrinologist will order the veteran's labs and medications after the initial diagnosis. The dietician will help compile an evidence-based diet and provide counseling on how dietary and lifestyle changes impact the veteran's blood sugar control. The psychologist will help support the newly diagnosed veteran and play an important role in improving attitudes towards treatments to allow for better adherence to strict regimens. The cardiologist will monitor the newly diagnosed diabetic for any increased risks of cardiovascular disease and the nephrologist will monitor the kidney function of the newly diagnosed diabetic to keep them informed of any progression of their kidney function. The diabetic registered nurse will follow the newly diagnosed veteran and educate them on diet, exercise, and lifestyle changes needed to continue controlling glucose levels. The diabetic nurse will also monitor lab values, report any new side effects from medications, and provide any medication management required. Description and Development of Project Deliverables Three deliverables will be utilized for this MSN project. This section will go through all three deliverables in detail and explain their role and importance in ensuring this project is successful and efficient. They will be presented in the next section in the same order they would be utilized in the project’s implementation. Nurse-Led Diabetic Clinic PowerPoint. The first deliverable is a PowerPoint presentation (see Appendix A). This presentation aims to educate staff and veterans to prepare 14 them for the new nurse-led diabetic clinic in the outpatient primary care clinic. The PowerPoint presentation includes information on type 2 diabetes and how to manage newly diagnosed veterans. The presentation lets staff know that there are no additional out-of-pocket costs, and that the clinic can slow the progression of the disease process. The material spotlights the operational side of the clinic and educate the staff on improving patient satisfaction, increasing open access for veterans, and bringing positive patient outcomes. Outpatient Primary Care Nurse-Led Diabetic Clinic Handout. The second deliverable created for this project is a patient handout (see Appendix B) given at the end of every appointment when the veteran is initially diagnosed with type 2 diabetes or any newly transferred veterans to the clinic. This handout provides valuable resources and vital information about a nurse-led diabetic clinic to assist veterans in managing their diabetes, helping instill confidence in them. Informational Piktochart for Organizational Stakeholders. The third deliverable developed for this project is an informational Piktochart (see Appendix C) for the organizational stakeholders during workgroups, meetings, and focus groups. The purpose of the Piktochart is to inform stakeholders of the importance of the nurse-led diabetic clinic and ensure the quality of healthcare given to each newly diagnosed veteran. This chart includes the breakdown of type 2 diabetes and how to help veterans self-manage the disease process. This informational chart provides essential information on the process of the nurse-led diabetic clinic and includes how the registered nurse specializing in diabetes will create a program to assist the veteran through the initial stages of being diagnosed. Pre- and Post-Surveys. The pre- and post-surveys will be given to newly diagnosed diabetic veterans established in the primary care outpatient clinic. These surveys will be provided 15 to the veteran on an electronic device, like an iPad. As they update any information in their medical history, they can also fill out the survey. The pre-survey (see Appendix D) collects data on accessibility, patient satisfaction, and the veteran's feelings about time with the provider. The post-survey (see Appendix E) will be given to veterans newly diagnosed with type 2 diabetes and will inquire about the wait time to schedule an appointment, the wait time in the lobby, the time with the provider, the time with the nurse, and the availability to schedule a follow-up appointment quickly. The data will be compiled into a report shared with the nurse manager, chief of primary care, executive leadership, and primary care providers. Timeline To help implement this project, a timeline (see Appendix F) was created to reflect the details of this nurse-led diabetic clinic. For this project to be implemented, it will take collaboration between executive leadership, the Chief of Primary Care, primary care providers, and the registered nurse care managers. First, a meeting will be scheduled with the primary care providers to provide project details. The PowerPoint presentation will be provided, and any questions will be answered at the end of the meeting. Second, a workgroup with the chief of primary care and executive leadership will be started to review patient data in the organization of newly diagnosed type 2 veterans. Once the project details are agreed upon and a rollout date is decided, the Piktochart and PowerPoint presentation will be provided to all staff in primary care. After completing the training for registered nurse care managers in primary care and competency checkoffs, a selected start date will be given. The primary care providers will begin to educate newly diagnosed veterans with the patient handout and start to schedule them in the nurse-led diabetic clinic. 16 Project Evaluation To evaluate the effectiveness of this project, pre- and post-surveys will be given to the veterans receiving care in the clinic. The pre-survey will be administered to the veteran on their first visit to the nurse-led diabetic clinic. A post-survey will then be administered to the veteran quarterly after receiving care in the nurse-led diabetic clinic. The surveys aim to gather information from veterans on their knowledge and ability to care for their newly diagnosed diabetes. Ethical Considerations The ethical considerations are confidentiality, maintaining patient relationships, and cultural competence. The survey information will be anonymous and kept confidential on a password-protected computer. Maintaining confidentiality with veterans’ healthcare information is essential to gaining trust and building a rapport, which is vital to the success of the veterans' clinical outcomes. Building trusting relationships with veterans is imperative, and collaborating with multidisciplinary teams will help veterans achieve positive health outcomes and patient satisfaction. Discussion The success of treating type 2 diabetes depends on the patient’s ability and willingness to self-manage the disease and lifestyle changes. This MSN project aims to improve veterans' ability to self-manage this disease process and identify any possible barriers. A nurse-led diabetic clinic can be instrumental in bringing positive patient outcomes and increasing patient satisfaction. This section will discuss the dissemination of the project’s results, nursing significance, strengths, limitations, and additional recommendations. Evidence-based Solutions for Dissemination 17 The project’s results will be disseminated several ways after the implementation. First, data will be gathered and analyzed after the first quarter of implementation. A data report will be compiled from the pre- and post-surveys. This report will be submitted to executive leadership in the Department of Veteran Affairs for their evaluation and discussion of the project’s continuation. Second, a staff meeting will be held for the primary care unit stakeholders, and a PowerPoint presentation will be provided. The unit's stakeholders will include the Chief of Primary Care, Chief Nurse of Primary Care, nurse manager, unit educator, and registered nurses. The project outcomes will be presented in the PowerPoint presentations, and further evaluation of strengths, limitations, and recommended improvements will be identified. Finally, a poster presentation will be created and shared with peers and faculty at Weber State University. Significance to Advance Nursing Practice This project can benefit newly diagnosed diabetic veterans by providing information on type 2 diabetes and allowing veterans to comprehend the sustainability of managing the disease process. Patients with type 2 diabetes are expected to increase by thirty percent by 2030 (Du Pon et al., 2019). This project can, in turn, allow veterans to feel autonomy and confidence that type 2 diabetes is manageable. For cultural competence, the primary care nurse-led diabetic clinic will provide healthcare to patients with diverse values, beliefs, and behaviors and tailor care to meet the veterans' social, cultural, and linguistic needs (Castillo & Gui, 2011). With a nurse-led diabetic clinic, the registered nurse will provide accessible education to the veteran, abundant resources to manage lifestyle changes, and build significant trusting relationships with the veterans. The nurses who navigate the clinic will also have comprehensive and accessible education, to provide a higher confidence level and improve patient outcomes. 18 Implications Several strengths and limitations have been identified in this project. Strengths include the project’s various educational materials, interventions to assist veterans in the future, evaluation methods, and building a solid foundation to self-manage type 2 diabetes. The project deliverables include a pre- and post-survey for the veteran to complete quarterly during treatment in the nurse-led diabetic clinic. The surveys will collect data from the veterans to provide feedback before and after the treatment in the clinic. A PowerPoint presentation and informational Piktochart will be presented to stakeholders for buy-in, and a flyer will be handed to a newly diagnosed type 2 diabetic veteran. Limitations include stakeholder buy-in, implementation barriers, and adequate staffing of a nurse-led diabetic clinic. The improper implementation of the nurse-led diabetic clinic could impede access and decrease patient satisfaction. Effective communication between the nurse and the veteran during the nurse-led clinics will be instrumental in its success and getting stakeholder buy-in. Staffing the nurse-led diabetic clinic will need to be done initially with voluntary nurses. If staffing is short in the primary care clinic, then nurses will need to be utilized for the primary care appointments, and the nurse-led diabetic clinic will not be able to function appropriately. Recommendations The research on nurse-led diabetic clinics reviews the effects and outcomes of people with type 2 diabetes. Nurses who specialize in diabetes play an increasingly crucial role in educating patients (Lawler et al., 2019). Much of the education nurses give is to assist veterans in developing skills in self-managing their diabetes. This MSN project shows that having a nurseled diabetic clinic can allow nursing to intervene in medicine management. Nursing expertise is crucial in adjusting treatment and managing comorbidities. 19 Rolling out this nurse-led diabetic clinic initially on the main hospital campus will allow for barriers to be identified and resolved, interventions to be evaluated and improved, and a review of veterans' ability to successfully self-manage their diabetes. Implementing this program and its success will allow the expansion of the nurse-led clinic to the surrounding communitybased outpatient clinics in the Department of Veteran Affairs. There would be ten additional clinics this project could expand to in surrounding areas to improve veteran healthcare access. Conclusions Addressing the needs of type 2 diabetic veterans can decrease the economic burden on people and communities and lower healthcare costs (Blackberry et al., 2013). Evidence shows that nursing support of self-management or coaching interventions delivered by a range of health professionals effectively reduces the treatment gap and improves glycemic control, blood pressure, lipid, and psychosocial outcomes in patients with type 2 diabetes. Nurse-led diabetic clinics can provide more accessible appointments for veterans, improve veteran satisfaction, and bring positive patient outcomes. 20 References Aguirre, R. C. (2022). Implementation of a self-care management program among adult patients with type 2 diabetes mellitus in a primary care clinic [Doctoral dissertation, Grand Canyon University]. ProQuest Dissertations Publishing. Bhattacharya, B., Pickering, S., McCulloch, A., Redhead, J., & Heald, A. (2007). The nurse-led diabetes clinic: A care satisfaction audit. 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Diabetes. https://www.who.int/news-room/factsheets/detail/diabetes#:~:text=Over%20time%2C%20diabetes%20can%20damage,blood %20vessels%20in%20the%20eye 26 Appendix A Nurse-Led Diabetic Clinic Nurse-Led Diabetic Clinic CHRISTINE NUNDRA BSN, RN, MSN STUDENT What is Type 2 Diabetes? • Most common type of diabetes (niddk.nih.gov, 2017) • Not enough insulin in the body • Insulin is a hormone made by the pancreas • Too much glucose stays in the blood • Millions of U.S. adults are at high risk for This Photo by Unknown Author is licensed under CC BY-NC-ND 27 What is a Nurse-led Diabetic Clinic? • Specifically targeted to newly diagnosed type 2 diabetic veterans • Led by registered nurses who specialize in diabetes and management of diabetes • Encourage veterans towards the movement of selfmanagement care • Conveniently located inside outpatient primary care clinic • Teaches patients lifestyle changes and techniques to improve outcomes This Photo by Unknown Author is licensed under CC BY What is the Cost? • Cost effective care (va.gov, 2023) • Veterans have no out-of-pocket expense • Specially trained registered nurses • The clinic will open inside of the outpatient primary care clinic and operate using their supplies and equipment This Photo by Unknown Author is licensed under CC BY-NC-ND 28 How will it help? Nurse-led diabetes self-management education plays an important role. Enhances diabetic self-care knowledge, practice and improves clinical and psychological outcomes and quality of life (Tamiru et al., 2023). Registered Nurses will meet with newly diagnosed type 2 diabetic veterans weekly by face-to-face appointments or weekly telephone appointments. Nurses will monitor labs, manage medications, educate on self-management, diet and physical activity. Suggestions…Questions? This Photo by Unknown Author is licensed under CC BY-NC-ND This Photo by Unknown Author is licensed under CC BY-ND 29 References • Morgan P, Smith V, Berkowitz T, Edelman D, Van Houtven C, Woolsen S, Hendrix C, Everett C, White B, and Jackson G. Impact of physicians, nurse practitioners, and physician assistants on utilization and costs for complex patients. Health Affairs. June 2019;38(6):10281036. 10.1377/hlthaff.2019.00014 • National Institute of Diabetes and Digestive and Kidney Diseases. (2017). Retrieved from U.S.Department of Health and Human Services: https://www.niddk.nih.gov/healthinformation/diabetes/overview/what-is-diabetes/type-2-diabetes • Tamiru, S., Dugassa, M., Amsalu, B., Bidira, K., Bacha, L., & Tsegaye, D. (2023). Effects of nurse-led diabetes self-management education on self-care knowledge and self-care behavior among adult patients with type 2 diabetes mellitus attending diabetes follow up clinic: A QuasiExperimental study design. International Journal of Africa Nursing Sciences, 18, 100548. https://doi.org/10.1016/j.ijans.2023.100548 30 Appendix B 31 Appendix C 32 33 34 35 Appendix D Pre-Survey 36 Appendix E Post-Survey 37 Appendix F Timeline