Redesigning Hospital Diabetes Education: A Qualitative Evaluation With Nursing Teams

Education of adult type 1 diabetes patients in a diabetes ward setting: a best practice implementation project

INTRODUCTION AND OBJECTIVES

Type 1 diabetes is an autoimmune disease that destroys insulin-producing cells in the pancreas. Education is the cornerstone of effective diabetes care. In this implementation project, we aimed to improve compliance with best practices regarding type 1 diabetes educational interventions for adult hospitalized patients.

METHODS

This project was guided by the JBI Evidence Implementation Framework. A baseline audit was conducted involving 20 nurses and 20 type 1 diabetes patients who received regular educational measures. Areas of non-compliance were identified and an improvement strategy was implemented. A follow-up audit was then conducted to evaluate the effectiveness of the improvement strategy. The project was conducted in Poland in 2021 in a tertiary referral unit that specializes in the diagnosis and treatment of diabetes.

RESULTS

Substantial improvements were noted for all audit criteria after the implementation of strategies to address areas of non-compliance. Use of the education program improved from 0% to 100%. Compliance regarding patients receiving handouts and personalization of the program increased to 100%. We observed a significant improvement from 0% to 80% in the structuring of the program content.

CONCLUSIONS

This project successfully improved the quality of education provided for type 1 diabetes patients in all relevant areas. We devised an education program, covering important aspects of diabetes education, with the patients reporting increased satisfaction with the personalized educational measures during their hospital stay.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A215.

Management of Hyperglycemia in Hospitalized Adult Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline

BACKGROUND

Adult patients with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. These patients are at increased risk for adverse clinical outcomes in the absence of defined approaches to glycemic management.

OBJECTIVE

To review and update the 2012 Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Settings: An Endocrine Society Clinical Practice Guideline and to address emerging areas specific to the target population of noncritically ill hospitalized patients with diabetes or newly recognized or stress-induced hyperglycemia.

METHODS

A multidisciplinary panel of clinician experts, together with a patient representative and experts in systematic reviews and guideline development, identified and prioritized 10 clinical questions related to inpatient management of patients with diabetes and/or hyperglycemia. The systematic reviews queried electronic databases for studies relevant to the selected questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.

RESULTS

The panel agreed on 10 frequently encountered areas specific to glycemic management in the hospital for which 15 recommendations were made. The guideline includes conditional recommendations for hospital use of emerging diabetes technologies including continuous glucose monitoring and insulin pump therapy; insulin regimens for prandial insulin dosing, glucocorticoid, and enteral nutrition-associated hyperglycemia; and use of noninsulin therapies. Recommendations were also made for issues relating to preoperative glycemic measures, appropriate use of correctional insulin, and diabetes self-management education in the hospital. A conditional recommendation was made against preoperative use of caloric beverages in patients with diabetes.

CONCLUSION

The recommendations are based on the consideration of important outcomes, practicality, feasibility, and patient values and preferences. These recommendations can be used to inform system improvement and clinical practice for this frequently encountered inpatient population.

The impact of nursing staff education on diabetes inpatient glucose management: a pilot cluster randomised controlled trial

BACKGROUND

An increasing number of patients in hospital have diabetes, with most of them cared for by non-specialist staff. The effect of diabetes education for staff on patient outcomes, as well as the most effective method of staff education is unclear. Therefore, the aim of this study was to compare diabetes outcomes in medical wards where nursing staff were offered one face-to-face (F2F) session followed by access to online education (online), F2F education only, or standard care (control).

METHODS

We conducted a pilot cluster randomised controlled trial involving 16-weeks baseline/rollout followed by a 28-week post-intervention period across three medical wards (clusters) in a Sydney Teaching Hospital. The online ward provided an online competency-based diabetes education program and 1-h F2F teaching from a diabetes nurse educator (DNE), the F2F ward provided four separate 1-h teaching sessions by a DNE, with no additional sessions in the control ward. The primary outcome was length of stay (LOS); secondary outcomes included good diabetes days (GDD), hypoglycaemia and medication errors. Poisson and binary logistic regression were used to compare clusters.

RESULTS

Staff attendance/completion of ≥ 2 topics was greater with online than F2F education [39/48 (81%) vs 10/33 (30%); p < 0.001]. Among the 827/881 patients, there was no difference in LOS change between online [Median(IQR) 5(2-8) to 4(2-7) days], F2F [7(4-14) to 5(3-13) days] or control wards [5(3-9) to 5(3-7) days]. GDD improved only in the online ward 4.7(2.7-7.0) to 6.0(2.3-7.0) days; p = 0.038. Total patients with hypoglycaemia and appropriately treated hypoglycaemia increased in the online ward.

CONCLUSIONS

The inclusion of online education increased diabetes training uptake among nursing staff. GDD and appropriate hypoglycaemia management increased in the online education wards.

TRIAL REGISTRATION

Prospectively registered on the Australia New Zealand Clinical Trials Registry (ANZCTR) on 24/05/2017: ACTRN12617000762358 .

A New Learning Approach to Improve Nurses' Knowledge of and Skills in Diabetes Care

BACKGROUND

Patients' knowledge of how to care for their diabetes mellitus (DM) is critically influenced by health education, which is mostly provided by nurses. Therefore, effectively increasing nurses' knowledge of and skills in diabetes care is crucial. The aim of this study was to explore the effectiveness of the Diabetes Conversation Map™ Program (DCMP) in improving nurses' knowledge of DM care and skills in insulin injection.

METHOD

A quasi-experimental design was adopted that used a pre-test and a posttest. A total of 18 nurses were included in the intervention group, while 19 nurses were in the control group receiving conventional teaching. A structured questionnaire regarding knowledge of and skills in DM care was administered before the program and then one month after.

RESULTS

Knowledge of DM and skills in insulin injection improved significantly in the intervention group compared to the control group (p < .001 vs. p < .01).

CONCLUSION

The DCMP can be used to increase nurses' knowledge of DM and their skills in caring for DM. It leads to more effective learning than conventional teaching. [J Contin Educ Nurs. 2022;53(2):90-96.].

Diabetes to Go-Inpatient: Pragmatic Lessons Learned from Implementation of Technology-Enabled Diabetes Survival Skills Education Within Nursing Unit Workflow in an Urban, Tertiary Care Hospital

BACKGROUND

Diabetes survival skills education (DSSE) focuses on core knowledge and skills necessary for safe, effective, short-term diabetes self-care. Inpatient DSSE delivery approaches are needed. Diabetes to Go (D2Go) is an evidence-based DSSE program originally designed for outpatients.

METHODS

Implementation science principles were used to redesign D2Go for delivery by staff on medicine and surgery units in a tertiary care hospital to adults with type 2 diabetes (T2DM) using a tablet-based e-learning platform. Implementation efficacy was evaluated from staff and patient engagement perspectives. The Practical, Robust Implementation and Sustainability Model (PRISM) guided redesign. The team conducted qualitative evaluation (implementation barriers and facilitators); program redesign (via stakeholder feedback and education and human factors principles); implementation design for tablet delivery and patient engagement by unit staff; and a prospective implementation feasibility study.

RESULTS

Among 596 T2DM patients identified on three medical/surgical units, 415 (69.6%) were program eligible. Of those eligible, 59 (14.2%) received, accessed, and engaged with the platform; and among those, 43 (72.9%) completed the intervention, representing just 10.4% of those eligible. Multilevel implementation barriers were encountered: staff (receptivity, time, production pressures, culture); process (electronic health record [EHR] integration, patient identification, data tracking, bedside delivery); and patient (receptivity, acuity, availability, accessibility). Most completers required technology support.

CONCLUSION

Time constraints, limited EHR integration, and patient barriers markedly impeded implementation of the delivery of diabetes education at the bedside, despite stated staff interest. As a result, uptake and adoption of a tablet-based DSSE e-learning program in a high-acuity care setting was limited.

A cross-sectional survey interconnecting health information seeking behavior with clinical data of type 2 diabetes mellitus patients

Purpose

The purpose of this paper is the investigation of type 2 diabetes patients' information seeking behavior in terms of their information needs, sources and barriers faced by patients when seeking information. The information seeking behavior is associated with clinical patient data.

Design/methodology/approach

The relevant literature is reviewed, and the results of a cross-sectional survey informed by Wilson's macro-model of information seeking behavior are reported. The survey includes 106 outpatients from the diabetes clinic of a Greek major university hospital and includes information seeking behaviors and patient's clinical evidence.

Findings

The most important health information needs are related to the complications, symptoms and causes of diabetes, to the proper diet for diabetics and the measures adopted to avoid foot complications. Furthermore, the most important information resources were physicians, ophthalmologists, books, broadcast media and family members. Obstacles encountered during information seeking include the complicated nature of health information, which involves scientific terms as well as psychological issues. The diabetes stage is correlated with information needs for diabetes medication, while the years from the first diagnosis are negatively correlated with the use of informal sources.

Research limitations/implications

The information needs and sources of diabetic patients, as well as the main obstacles to this pursuit, could potentially have important implications in designing a future information campaign and information services for diabetes patients.

Originality/value

The Wilson's macro-model of information seeking has been applied to the diabetic patients' information seeking behavior; while information needs, information sources and information obstacles are correlated with clinical evidence from patients’ hospital records.

Knowledge of peripheral artery disease: What do the public, healthcare practitioners, and trainees know?

This systematic review evaluated the knowledge and awareness of peripheral artery disease (PAD) within the general public (including patients with peripheral vascular disease), nonspecialist healthcare professionals (nsHCP), and trainees (medical students and trainee doctors). Relevant articles were identified from electronic databases using key search terms: ‘peripheral artery disease’; ‘limb ischaemia’; ‘intermittent claudication’; ‘knowledge’; ‘understanding’; ‘public’; ‘medical professional’. The heterogeneous results were described narratively. A lack of knowledge and understanding of PAD (disease awareness) were identified in all groups. Among nsHCPs, factors which affect knowledge include the level of training, early clinical exposure and the presence of family members with cardiovascular/vascular disease. Within the general public, knowledge and awareness was improved if a family member/friend had a diagnosis, or following a patient-centred consultation with any HCP. Public campaigns are proven effective in improving disease knowledge/awareness in conditions such as stroke alongside sustained patient education. These may provide future avenues to improve PAD knowledge and awareness, in order to effectively manage risk factors and minimise delayed or missed diagnosis of PAD. (PROSPERO registration number: CRD42018117304)

Diabetes Education for Behavioral Health Inpatients: Challenges and Opportunities

OBJECTIVE: To adapt a diabetes survival skills education (DSSE) program for delivery on inpatient behavioral health units (BHUs) and to evaluate implementation feasibility within nursing unit workflow. METHODS: We employed mixed methods to codesign, implement, and evaluate a DSSE program for inpatient BHUs. The Diabetes to Go core program incorporates linking knowledge deficits to video education content, a companion book on diabetes survival skills, and education for nurses on delivery processes and teaching content. The Diabetes to Go adaptation for BHUs was codesigned in partnership with BHU staff and patients. Implementation evaluation included patient surveys and nursing staff feedback obtained during field observations. RESULTS: A total of 89 patients participated in nine group education sessions among whom 17 (20%) had diabetes. Nursing unit staff and patients expressed willingness to engage in program design. Barriers to implementation were encountered in both groups including lack of standardization of education content by nurse facilitators and difficulty engaging patients for the time required for completion of surveys plus group education. Preferred education media for both nurses and patients was a book. Diabetes knowledge deficits were identified among over two thirds of participants with diabetes. CONCLUSIONS: Group class may not be the optimal delivery model for specialized DSSE on BHUs. It remains to be determined if individual diabetes education alone or a model which combines individual and group sessions is preferable. Translation of standardized approaches for diabetes education on inpatient BHUs will require further redesign to meet the unique needs of this population.

Understanding Nursing Workflow for Inpatient Education Delivery: Time and Motion Study

Background

Diabetes self-management education and support improves diabetes-related outcomes, but many persons living with diabetes do not receive this. Adults with diabetes have high hospitalization rates, so hospital stays may present an opportunity for diabetes education. Nurses, supported by patient care technicians, are typically responsible for delivering patient education but often do not have time. Using technology to support education delivery in the hospital is one potentially important solution.

Objective

The aim of this study was to evaluate nurse and patient care technician workflow to identify opportunities for providing education. The results informed implementation of a diabetes education program on a tablet computer in the hospital setting within existing nursing workflow with existing staff.

Methods

We conducted a time and motion study of nurses and patient care technicians on three medical-surgical units of a large urban tertiary care hospital. Five trained observers conducted observations in 2-hour blocks. During each observation, a single observer observed a single nurse or patient care technician and recorded the tasks, locations, and their durations using a Web-based time and motion data collection tool. Percentage of time spent on a task and in a location and mean duration of task and location sessions were calculated. In addition, the number of tasks and locations per hour, number of patient rooms visited per hour, and mean time between visits to a given patient room were determined.

Results

Nurses spent approximately one-third of their time in direct patient care and much of their time (60%) on the unit but not in a patient room. Compared with nurses, patient care technicians spent a significantly greater percentage of time in direct patient care (42%; P=.001). Nurses averaged 16.2 tasks per hour, while patient care technicians averaged 18.2. The mean length of a direct patient care session was 3:42 minutes for nurses and 3:02 minutes for patient care technicians. For nurses, 56% of task durations were 2 minutes or less, and 38% were one minute or less. For patient care technicians, 62% were 2 minutes or less, and 44% were 1 minute or less. Nurses visited 5.3 and patient care technicians 9.4 patient rooms per hour. The mean time between visits to a given room was 37:15 minutes for nurses and 33:28 minutes for patient care technicians.

Conclusions

The workflow of nurses and patient care technicians, constantly in and out of patient rooms, suggests an opportunity for delivering a tablet to the patient bedside. The average time between visits to a given room is consistent with bringing the tablet to a patient in one visit and retrieving it at the next. However, the relatively short duration of direct patient care sessions could potentially limit the ability of nurses and patient care technicians to spend much time with each patient on instruction in the technology platform or the content.

Inpatient Diabetes Education in the Real World: an Overview of Guidelines and Delivery Models

PURPOSE OF REVIEW

Diabetes self-management education and support improves diabetes-related outcomes, yet less than 50% of persons with diabetes in the USA receive this service. Hospital admissions present a critical opportunity for providing diabetes education. This article presents an overview of the current state of inpatient diabetes education. It incorporates a summary of existing guidance relative to content followed by an overarching discussion of existing inpatient diabetes education models and their reported outcomes, when available.

RECENT FINDINGS

As diabetes rates continue to soar and adults with diabetes continue to have high hospitalization and readmission rates, hospitals face challenges in assessing and meeting diabetes patients' educational needs. The consensus recommendation for inpatient diabetes teaching is to provide survival skills education to enable safe self-management following discharge until more comprehensive outpatient education can be provided. Established and emerging models for delivery of diabetes survival skills education in the hospital may be broadly grouped as diabetes-specialty care models, diabetes non-specialty care models, and technology-supported diabetes education. These models are often shaped by the availability of diabetes specialists, including endocrinologists and diabetes educators-or lack thereof, and staffing resources for provision of services. Recent studies suggest that all three approaches can be deployed successfully if well planned. This article presents an overview of the current state of inpatient diabetes education. It incorporates a summary of existing guidance relative to content followed by an overarching discussion of existing inpatient diabetes education models and their reported outcomes, when available. The authors seek to make the reader aware of the heterogeneous approaches that are being implemented nationwide for inpatient diabetes education delivery. Meeting inpatient diabetes educational needs will require a sustained effort, diverse strategies based on resources available, and additional research to explore the impact of these strategies on outcomes.