Diabetes Mellitus and Self-Care Education

Introduction

Diabetes Mellitus (DM) is one of the chronic conditions that most worries the health professional. Referring in particular to DM type II, we see that it primarily affects those over 65 years of age (Kirkman et al., 2012). According to several of research already carried out in this regard, this relationship is based on the congruence of factors such as age, and the physiological deterioration seen with the age, and the prevalence of physical limitations that in turn lead to a lifestyle with certain deficiencies.

As it is already known, older adults who suffer from DM have a greater predisposition to suffer cardiovascular, visual, and renal complications, and therefore they are exposed to an increased risk of death (Kirkman et al., 2012). This condition is linked to a high health cost, that is why, it should be a priority for our health system, the promotion of an adequate educational program that leads to improve self-care behavior in patients with DM and thus, to achieve positive changes in their lifestyle (Jalilian, Motlagh, Solhi, & Gharibnavaz, 2014).

The Spirit of Inquiry Ignited

When we speak of DM, we are referring to a set of metabolic disorders, whose main characteristic is hyperglycemia, either due to defects in the production of insulin or its mechanisms of action. In its physiopathology, different processes are involved that eventually lead to a marked increase in insulin resistance (McCance & Huether, 2015). On the other hand, insulin plays an important role, since it is the main hormone involved in the transport of glucose to tissues.

Therefore, the high figures of glycemia manifested by the diabetic patient, is nothing else than the manifestation of the deficit of said hormone or an anomaly in the action of this hormone on the tissues, leading to the appearance of this syndrome (McCance & Huether, 2015). DM is initially treated with measures aimed at producing lifestyle changes, which if not provide the expected result, then continue with the introduction of insulin or other treatment.

The DM presents a prevalence rate that varies according to the results provided by different studies that have used different methodologies and criteria according to the population they have studied. In the US, it oscillates around 9.4% of the total population, which represents about 30.3 million people. This figure can vary with a difference of around 7.2 million, to include diabetic patients not known and if the population to be studied is limited to patients over 65 years, could exceed 12 million (ADA, 2017). Approximately 1.5 million cases of DM are diagnosed each year, this condition was listed as the seventh cause of death in the United States in 2015 (ADA, 2017).

According to the results of different studies, statistics have been obtained that indicate that males have a predominant number concerning women. On the other hand, it has been found that the increase in fasting blood glucose is more common in men than in women, as well as, conversely, glucose intolerance is less common in men than in women. It has also been proven that female patients with DM have a higher risk of mortality from cardiovascular causes and stroke than males (Kautzky-Willer, Jürgen, & Giovanni, 2016). It is also known that ethnic origin is closely related to the diagnosis of DM, so for example, Native Americans, African Americans, Hispanics, and Asian Americans have a greater predisposition and between them, Native Americans represent the highest rate with 15.1% (ADA, 2017).

The PICOT Question Formulated

Picot question: In the study of type 2 diabetic patients (P), how could the education provided about self-care (I), reduce the rate of complications (O), compared to those patients who have not received any self-care education (C), after a year (T)?

Search Strategy Conducted

The data was collected from CINAHL, PubMed, Cochrane Library National Guidelines Clearinghouse, and TRIP Database sources. The keywords were as follows: diabetes mellitus, type 2 diabetes, diabetes care, diabetes management, diabetes patient, type 2 diabetes self-management, and diabetes self-care. Level I, II, III, IV, and V evidence was gathered.

Critical Appraisal of the Evidence Performed

Citation	Design	Sample size: Adequate?	Major Variables Independent Dependent	Study findings: strengths and weaknesses	Level of evidence	Evidence synthesis
Karlsen, B., Bruun, B., & Oftedal, B. (2018). New possibilities in life with type 2 diabetes: Experiences from participating in a guided self-determination program in general practice. Nursing Research and Practice, 2018, 1-9.	Qualitative study design.	Interviews with 9 adults with type 2 diabetes: not adequate. 16 adults recruited for nurse-led GSD program: not adequate.	Independent: age, gender, occupation, how long ago diabetes was diagnosed. Dependent: patients’ self-care practice, level of education on the chronic condition, collaboration with nurses.	Strengths: patients’ self-awareness and self-management increased as a result of the nurse-led GSD program. Weaknesses: researchers did not provide participants with an opportunity to clarify the interpretation of the findings. Also, the low number of participants is a threat to the research credibility.	Level II-1 evidence: researchers obtained evidence obtained from a controlled trial that did not include randomization.	Research provided substantiate support for the use of self-care programs targeted at the improvement of health outcomes of patients with type 2 diabetes. For the current PICOT question, the research will be especially important because it involved the sampling of real patients diagnosed with diabetes to complement the systematic review.
Coulter, A., Entwistle, V., Eccles, A., Ryan, S., Shepperd, S., & Perera, R. (2015). Personalized care planning for adults with chronic or long-term health conditions. Cochrane Database of Systematic Reviews, 3(3), 1-20.	A systematic review of the literature on personalized management of type 2 diabetes.	The inclusion of 19 studies that in total involved 10,856 participants: adequate.	Independent: adherence as a function of the month, random effects of previous interventions. Dependent: random physician effect on participants, changing outcomes after follow-up, adherence to a self-care program.	Strengths: personalized care for patients with such chronic conditions as diabetes showed to improve their overall wellbeing. Weaknesses: practical limitations of the intervention due to the variability of patients’ adherence to self-management programs.	Level II-3 evidence: researchers obtained information from already existing sources to conduct a systematic review; no new trials were implemented.	The review offered a critical look at the effectiveness of personalized care and education for addressing chronic conditions, including type 2 diabetes. As to the PICOT question, the review will be useful for identifying effective interventions for managing chronic conditions and developing an action plan that patients can use.
EBSCO Information Services. (2018). Diabetes mellitus type 2 self-management.	National guidelines for the self-management of diabetes mellitus type 2.	Sample population or studies are not included in the guidelines.	Independent: patients’ age, gender, the severity of chronic conditions, previous success in self-management interventions. Dependent: changes in patients’ wellness after a self-management program, adherence to self-management practices.	Strengths: attention to a wider audience of patients who are diagnosed with type 2 diabetes. E.g., the guidelines included recommendations for pregnant women and children. Weaknesses: lack of acknowledgment of the limitations of available research.	Level III evidence: information for the guidelines is collected from multiple sources such as respected authorities, past clinical experiences, as well as expert reports.	The guidelines can support the PICOT question by providing information on how to implement self-management successfully. Multiple evidence sources are the main advantage of the resource due to the variability of their application to the studied subject.
Powers, M., Bardsley, J., Cypress, M., Duker, P., Funnel, M., Fischl, H., … Vivian, R. (2015). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition of Dietetics. Diabetes Care, 38(7), 1372-1382.	Qualitative research for assessing the effectiveness of education and self-management.	Sample population or studies are not included in the guidelines.	Independent: patients’ age, gender, history of chronic conditions, past experiences with self-management. Dependent: changes in patients’ awareness of the condition, level of education, level of well-being linked to improved self-management.	Strengths: attention to the regular and continuous check-ups and follow-ups associated with type 2 diabetes. Weaknesses: lack of functional integration of research, at least 20 participants could have been included in the qualitative study.	Level III evidence: researchers collected relevant information without conducting an intervention but through analyzing perspectives of known institutions.	The study is relevant for the inclusion of several associations’ perspectives on how the issue of diabetes self-management can be addressed. For the PICOT question, the use of the research is important for its perspective of self-educational practices that target chronic conditions.
National Guideline Clearinghouse (2016). Gestational diabetes mellitus evidence-based nutrition practice guideline.	US guidelines summary for recommending appropriate evidence-based nutrition practices.	Sample size related to the guidelines’ summary was not provided.	Independent: patients’ age, gender, history of illness, and so on. Dependent: changes in awareness about the condition, improvement of self-management efforts, enhancement of dietary practices.	Strengths: considerations for a variety of dietary practices that limit patients’ wellbeing. Weaknesses: the lack of real-life examples; interviews with patients could have been included.	Level II-3 evidence: information collected from the available literature provided by authorities, clinicians’ experiences.	Guidelines provided an all-encompassing look at the management of type 2 diabetes through the integration of nutrition-based interventions and self-education. With regards to the PICOT question, the guidelines will be useful for identifying best practices recommended by specialists as to the management of type 2 diabetes.

Evidence Integrated with Clinical Expertise and Patient Preferences to Implement the Best Practice

Purpose

Diabetes education is an active process aimed at maintaining self-management skills and providing the opportunity to make decisions about improving diabetes supervision by the changing circumstances of nowadays’ life (Powers et al., 2015). The main purpose of designing the proposed evidence-based practice project is the necessity to improve the existing situation with self-care in patients with type 2 diabetes. Intending to determine the effectiveness of the intervention presented in the PICOT question earlier in this paper, it is critical to identify evaluation procedures.

The mentioned procedures aim to ensure that the collected data is relevant to the given topic and that stakeholders will receive the required information. A fundamentally new approach is required to promote effective management of this complex chronic disease by involving a patient in active participation in the medical process (Powers et al., 2015). More to the point, one may state that evaluation results may be used to disseminate them as the confirmation of the intervention reliability.

Clinical Question

In this project, the clinical question coincides with the PICOT question.

Time

The period specified in the PICOT question is one year. Considering that the participants of the study will be asked to visit educational sessions continuously, the mentioned time seems to be appropriate. The effectiveness of type 2 diabetes treatment directly depends not only on a care provider but also on a patient himself or herself. Doctors and nurses may be rather experienced, yet in case the recommended diet is not followed, and there is a lack of physical exercise and self-care, it will be extremely difficult to achieve sustainable management for diabetes. Patients spend one on one with his or her disease most of life, and they should learn how to handle their health conditions.

Stakeholders

In this project, there are two key groups of stakeholders such as nurses and patients. The former is expected to provide self-care education, including the following vital elements: basic knowledge of the correction of nutrition and lifestyle in general as well as indications for changing the dose of insulin. Nurses will also collect information about any changes in the patients participating in the study. Not only medical records but also patients’ perceptions about the intervention will be collected and analyzed. The second group of stakeholders will be composed of patients diagnosed with type 2 diabetes, who will be asked to participate in education and apply the obtained information and skills in practice. One should stress that nursing managers and the unit administration may be regarded as indirect stakeholders.

Methods

Theoretical Framework

The theoretical foundation of the proposed project is the combination of behavioral realism and social influence. Vorderstrasse, Shaw, Blascovich, and Johnson, (2014) state that the establishment of the virtual community for patient education may serve as an innovative solution to enhance their self-care. In particular, patients will be offered to receive education via the Internet with the use of modern technology.

A special community will be designed to include only the participants of the study. According to the identified theoretical framework, it will be possible to allow the participants to learn new information comfortably. They will be able to repeat information, discuss it with each other, and ask any related questions. In addition, it is expected that nurses will provide necessary assistance with assessing this virtual environment.

Design

Based on the specified theoretical framework, the design of the project may be defined as an experimental study. The provision of valuable skills and knowledge will be an independent variable. At the same time, the patients’ health outcomes and perception will compose dependent variables. One should state that the identified variables are measurable using analyzing medical records and initiating interviews with the mentioned stakeholders (Holloway & Galvin, 2016). In this regard, the mixed-method analysis will be used to interpret the collected data based on ANOVA statistical method or some other relevant tool.

Confidentiality

The ethical considerations will be implemented throughout the research to ensure confidentiality. The informed consent forms will be collected, and no deception of any kind will be used (LoBiondo-Wood & Haber, 2017). Each of the study participants will receive an ID number, while their names will not be disclosed. It is critical to stress the fact that the sensitive information and results will be encrypted and stored on the external device to prevent the possibility of hacking and other threats. The set of possible risks will be explained to the participants.

Sample/Setting/Procedure

The patients receiving outpatient care will be offered to take part in the study, while those having the basic skills working with a personal computer or any other device will be considered eligible. Among other criteria, there are ages between 21 to 55 years and the agreement to receive an education. As for the setting, it will be the online environment to ensure convenient education. The procedures will include the presentation of relevant data with their sources, interactive mini-tasks, and group discussions during one hour. Considering the attitudes of participants, the duration of educational sessions may be increased. The data about the results of the study progress will be collected every two months and then compared to the outcomes.

Instrument

It is suggested to use social media to create a special closed community that can be discussed with the participants in advance. Data collection and analysis will be based on both qualitative and quantitative methods, while their processing will target the use of statistical instruments such as SPSS or any other reliable tool (Palinkas et al., 2015).

The outcome of Practice Change Evaluated

The key metrics to be evaluated are the patients’ awareness and commitment to self-care about diabetes. The main stage of education will assess the effectiveness of patients’ skills of control and treatment activities in diabetes as well as the existence of permanent motivation for lifestyle changes and maintaining compensation for the disease. The ultimate stage should be the logical conclusion of the entire education cycle.

The patients’ realization of their physical condition and the quality of diabetes compensation will be evaluated. The implementation of an approximate set of physical exercises, nutrition recommendations, and drug therapy will also be targeted. Special attention should be paid to the ability to apply the knowledge gained in practice: to use blood sugar meters, calculate the necessary number of test strips, and so on.

The achievement of sustainable compensation is reduced to the following indicators: the adherence to the prescribed diet and control of body weight along with constant self-monitoring of blood glucose levels. For diabetes patients, the ability to properly inject insulin, recognize signs of impending hyperglycemia in time, et cetera are vital needs (Jalilian et al., 2014). If possible, stressful situations should be avoided, since physical and mental overstrain can nullify all the results achieved. Thus, the data regarding control and intervention groups will be compared, and results will be disseminated as appropriate.

Project Dissemination

The results of the project are to be disseminated to provide key insights and contribute to the practice of nursing. The nursing management will receive reports about the initiated procedures and the obtained findings. The nurses who participated in the study as well as those who relate to the outpatient care unit will be gathered to the meeting to discuss the results. At the same time, the patients will receive reports via email. It is also possible to consider the dissemination of the project on a larger scale such as the publication in a peer-reviewed journal, thus contributing to the theory of nursing in the field of diabetes management associated with patient self-care.

Conclusion

To conclude, the paramount aim of the proposed project is to examine the role of self-care in type 2 diabetes treatment. Since such patients need to control their nutrition and blood glucose level, the role of self-care cannot be overestimated. It was suggested to utilize a mixed-method design to ensure that both qualitative and quantitative data will be collected and processed. As a solution to the problem of managing care in people with diabetes, one-year education in an online environment seems to be a feasible and reliable way to improve their health outcomes.

References

American Diabetes Association (ADA). (2017). Statistics about diabetes.

Holloway, I., & Galvin, K. (2016). Qualitative research in nursing and healthcare (4th ed.). New York, NY: John Wiley & Sons.

Jalilian, F., Motlagh, F., Solhi, M., & Gharibnavaz, H. (2014). The effectiveness of self-management promotion educational program among diabetic patients based on health belief model. Journal of Education and Health Promotion, 3, 14-19.

Kautzky-Willer A., Jürgen, H., & Giovanni, P. (2016). Sex and gender differences in risk, pathophysiology, and complications of type 2 diabetes mellitus. Endocrine Reviews, 37(3), 278-316.

LoBiondo-Wood, G., & Haber, J. (2017). Nursing research-e-book: Methods and critical appraisal for evidence-based practice (9th ed.). St. Louis, MO: Elsevier Health Sciences.

McCance, K. L., & Huether, S. E. (2015). Study guide for pathophysiology: The biological basis for disease in adults and children (7th ed.). Web.

Palinkas, L. A., Horwitz, S. M., Green, C. A., Wisdom, J. P., Duan, N., & Hoagwood, K. (2015). Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Administration and Policy in Mental Health and Mental Health Services Research, 42(5), 533-544.

Vorderstrasse, A., Shaw, R. J., Blascovich, J., & Johnson, C. M. (2014). A theoretical framework for a virtual diabetes self-management community intervention. Western Journal of Nursing Research, 36(9), 1222-1237.