AADE7 TM (self care behavior) thd DSCA (diabetic self care activity).

Running head: IMPROVING DIABETES SELF-CARE ACTIVITIES 1
IMPROVING DIABETES SELF-CARE ACTIVITIES USING EDUCATIONAL SESSIONS IN
A PRIMARY CARE SETTING
by
Carolina de Varona
Capstone Paper submitted in partial fulfillment of the

requirements for the degree of
Doctor of Nursing Practice
Chatham University
4/14/2018
Signature Faculty Reader Date
Signature Program Director Date

IMPROVING DIABETES SELF-CARE ACTIVITIES 2
Acknowledgments
Firstly, I would like to thank all the wonderful professors at Chatham University,
especially Dr. Meigan Robb for all your encouragements and wonderful edits on this paper. I
would also like to thank my family and Andres for the support and for excusing me from
weekend activities so that I could focus on my school work. Lastly, to my greatest friend, Greta,
we have completed our bachelors, masters, and now finally completed our doctorate degrees
together, congratulations!
Abstract
Purpose: The purpose of this project was to evaluate how group educational classes in a
primary care setting lead by a nurse practitioner effects self-care activities.
Methods: A diabetes education course was implemented in a primary care office in Hollywood,
Florida. Education was based on core self-care activities information such as diet, exercise, and
blood glucose monitoring. Information from the American Diabetes Association was utilized.
Adults from the ages of 18-70 with type II diabetes were invited to participate. Pre-and post-
intervention outcomes were assessed using the Summary of Diabetes Self-Care Activities
measure. Mean scores, from 3 subsets of the questionnaire (diet, exercise, blood glucose
monitoring) were measured. Percent of blood glucose monitoring at the recommended times per
day 7 days a week, following a healthy eating plan at least 6 days a week, and having at least 30
minutes of physical exercise at least 6 days a week was also assessed.
Results: Mean scores improved post-intervention, when assessing all 3 subsets of the
questionnaire: diet, exercise, and blood glucose monitoring. There was also an improvement in
percent of participants who monitored their blood glucose at the recommended times per day 7
days a week (63% post-intervention), followed a healthy eating plan at least 6 days a week
(100% post-intervention), and had at least 30 minutes of physical exercise at least 6 days a week
(18% post-intervention)
Conclusions: The diabetes self-management education classes provided were effective in
improving participant’s self-care activities. Implementing diabetes education classes in a primary
care setting can improve patient self-care activity.
Key words: Type II diabetes, group classes, diabetes self-management education, primary care
Table of Contents
Acknowledgments..................................................................................................................2
Abstract ..................................................................................................................................3
Chapter One: Overview of the Problem of Interest ..............................................................8
Background Information ............................................................................................8
Significance of the Problem .......................................................................................9
Question Guiding Inquiry (PICO) .............................................................................10
Variables of the PICO question .....................................................................11
Summary ....................................................................................................................12
Chapter Two: Review of the Literature/Evidence ................................................................13
Methodology ..............................................................................................................13
Sampling strategies ........................................................................................13
Inclusion/Exclusion criteria ...........................................................................14
Literature Review Findings........................................................................................14
Discussion ..................................................................................................................18
Limitation of literature review. ......................................................................18
Conclusions of findings .................................................................................18
Potential practice change ...............................................................................19
Summary ....................................................................................................................19
Chapter Three: Theory and Model for Evidence-based Practice ..........................................21
Theory ........................................................................................................................21
Application to practice change.......................................................................22
Model for Evidence-Based Practice ..........................................................................22

Application to practice change.......................................................................23
Summary ....................................................................................................................24
Chapter Four: Pre-implementation Plan ...............................................................................26
Project Purpose ..........................................................................................................26
Project Management ..................................................................................................27
Organizational readiness for change ..............................................................27
Inter-professional collaboration .....................................................................27
Risk management assessment ........................................................................28
Organizational approval process ....................................................................29
Use of information technology ......................................................................30
Materials Needed for Project .....................................................................................30
Plans for Institutional Review Board Approval .........................................................31
Plan for Project Evaluation ........................................................................................31
Plan for demographic data collection ............................................................31
Plan for outcome data collection and measurement ......................................31
Plan for evaluation tool ........................................................................32
Plan for data analysis ...........................................................................32
Plan for data management ..............................................................................34
Summary ....................................................................................................................34
Chapter Five: Implementation Process .................................................................................35
Setting ........................................................................................................................35
Participants .................................................................................................................35
Recruitment ................................................................................................................35
Implementation Process .............................................................................................36
Plan Variation ............................................................................................................36
Summary ....................................................................................................................37
Chapter Six: Evaluation and Outcomes of the Practice Change ...........................................38
Participant Demographics ..........................................................................................38
Figure 1: Gender demographics .....................................................................38
Figure 2: Ethnicity demographics ..................................................................39
Outcome Findings ......................................................................................................39
Outcome One .................................................................................................39
Outcome Two.................................................................................................40
Outcome Three...............................................................................................40
Outcome Four ................................................................................................40
Figure 3: Self-care activity outcomes ............................................................41
Figure 4: Class attendance .............................................................................41
Summary ....................................................................................................................42
Chapter Seven: Discussion ...................................................................................................43
Recommendations for Site .........................................................................................43
Plans to sustain change ..................................................................................44
Implications for Policy..............................................................................................44
Links to Health Promotion .......................................................................................45
Role of DNP-prepared nurse ..........................................................................46
Next Steps for Evidence-based Practice ..................................................................46
Plans for Dissemination ...........................................................................................47

Summary ..................................................................................................................47
Chapter Eight: Final Conclusion ...........................................................................................49
Clinical Problem ........................................................................................................49
Evidence Base ............................................................................................................49
Theory and Model for Evidence-based Practice ........................................................50
Project Management ..................................................................................................51
Project Implementation ..............................................................................................51
Outcome Findings ......................................................................................................52
Discussion Summary .................................................................................................52
Final Conclusions...................................................................................................................53
References ..............................................................................................................................54
Appendix A: Cover Letter ....................................................................................................59
Appendix B: Flyer.................................................................................................................60
Appendix C: Informed Consent ............................................................................................61

Chapter One: Overview of the Problem of Interest
Diabetes is a major health concern and continues to cause devastating outcomes when
uncontrolled. Diabetes can lead to cardiovascular disease, blindness, renal failure, amputations,
and strokes, among other complications. It is estimated that 68% of people with diabetes die
from cardiovascular disease, which is the leading cause of death in the United States (American
Diabetes Association, 2016). Education is critical to social and economic development and has a
profound impact on population health” (Zimmerman, Woolf, & Haley, 2015, p.347). Research
suggests that chronic disease outcomes have been improved due to education and educational
programs (Brady et al., 2013; Tan et al., 2012; Wu et al., 2009).
It was observed at a clinical site located in Hollywood, Florida, that several patients with
type II diabetes were unaware of how to properly follow a diabetes diet or other self-care
activities. It was also observed that very few patients attended diabetes education classes as
recommended by the providers. Thus, the clinical problem of diabetes and the lack of education
of type II diabetes was identified, and the need to implement an evidence-based practice (EBP
change project was established. This chapter will present the significance of diabetes and the
questions guiding inquiry (PICO).
Background Information
In 2012, there were 29.1 million Americans with type II diabetes (American Diabetes
Association [ADA], 2016). Diabetes was also “the seventh leading cause of death in the United
States in 2010” (ADA, 2016). Healthy People 2020 reviewed objectives that required change,
two of which are improving glycemic control in patients with diabetes and increasing the amount
of patients who receive formal diabetes education (Office of Disease Prevention and Health
Promotion [ODPHP], n.d.). There were only 6.8% of newly diagnosed adults who received
formal diabetes education during their first year after diagnosis in 2011-2012 (ODPHP, n.d.). As
per the National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK] (n.d), “health
care reform calls for new approaches to diabetes care delivery and greater emphasis on
preventing diabetes and its complications” (para. 1).
There were a total of 529 type II diabetic patients in the primary care site in which the
EBP project took place. Out of those 529 patients, 27% (n = 148) had a hemoglobin A1C of
more than or equal to seven, 11% (n = 62) had a hemoglobin A1C of more than or equal to eight,
and 5% (n = 30) with a hemoglobin A1C above nine. It was observed in the clinical setting that
most type II diabetic patients would not follow through with diabetes education referrals, which
lead to poor self-care behaviors and lack of basic diabetes knowledge among patients. As per
McCulloch (2017), more than 90% of patients with type II diabetes receive their care from
primary care providers. This finding illuminates the need for primary care providers to expand
access to diabetes education.
Significance of Clinical Problem
Diabetes is a major health concern, which can cause other serious health conditions if left
uncontrolled. Complications associated with diabetes are hypoglycemia, hypertension,
dyslipidemia, heart attacks, stroke, blindness, kidney disease and amputations (ADA, 2016).
There are 1.4 million new cases of diabetes every year in America (ADA, 2016). The total cost
of diabetes in the United States was $245 billion in 2012 (ADA, 2016). One in 10 healthcare
dollars is spent treating diabetes and its complications and 1 in 5 health care dollars is spent
caring for people with diabetes (American Diabetes Association [ADA], 2015). “The prevalence
of diagnosed diabetes in the U.S. increased by 382% from 1988 to 2014” (ADA, 2015a). By
addressing this problem and improving self-care activities, it is expected that diabetes related
complications will decrease and therefore lower hospitalizations associated with diabetes.
Improving diabetes outcomes can reduce the risk of heart disease, which is the leading cause of
death in the United States. Since there is such a great expense associated with diabetes, as
explained above, improving diabetes self-care activities can also reduce financial costs.
A study conducted by Chavan et al. (2015) found type II diabetic patients lacked general
knowledge regarding type II diabetes and self-care activities. Furthermore, it was concluded that
“the compliance to the management of diabetes was better in patients with good knowledge”
(Chavan et al., 2015). As per Norris, Engelgau, and Narayan (2001), “there are significant
knowledge and skill deficits in 50–80% of individuals with diabetes (p.561). The prevalence of
diabetes is only increasing therefore, there is a need for increased diabetes support and outcome
improvement.
Question Guiding Inquiry (PICO)
EBP seeks to use relevant research and evidence to solve problems, providing high
quality healthcare to ensure best patient outcomes (Melnyk & Fineout-Overholt, 2015). As per
Melnyk and Fineout-Overholt (2015), steps of EBP include using a PICO format to ask clinical
questions. PICO is an acronym used to identify a problem, form an intervention, assess a
comparison intervention, and assess the outcome of a clinical question. The PICO question that
guided this clinical problem was: Can implementing a diabetes educational group class in a
primary care setting help improve patient’s self-care activities?

Variables of the PICO question. The individual components of the PICO in relation to
this project are:
 Population (P). The population of interest was adults, regardless of gender
race/ethnicity, from the age of 18 to 70 with type II diabetes who were being
treated for diabetes in a primary care setting in Southern Florida.
 Intervention (I). The intervention was an implementation of a diabetes
educational course that incorporated the American Association of Diabetes
Educators (AADE) 7 self-care behavior guidelines that are used to develop
diabetes self-management education (DSME) programs. These 7 self-care
behavior guidelines include: Healthy eating, being active, monitoring blood
glucose, taking medications, problem solving, healthy coping, and reducing risks.
It has been concluded from previous research that DSME improves A1C levels,
lipids, self- care behavior, and weight loss (Chrvala, Sherr, & Lipman, 2016; Kim,
2016; Nicoll, et al., 2014; North & Palmer, 2015; Peros et al., 2016; Siminerio,
Ruppert, & Gabbay, 2013).
 Comparisons (C). No comparison groups were used for this EBP change project.
Project effectiveness was measured following a pre-posttest design.
 Outcome (O). The intended outcome was to increase patients’ self-care activities
such as following a healthy diet, engaging in an exercise routine, and checking
their blood sugars as recommended by their providers, in order to improve
diabetes outcomes.
Summary
This chapter discussed an overview of the problems of interest, which is diabetes and its
complications. Diabetes is a chronic illness, which can lead to poor patient outcomes, and is
associated with serious complications when left untreated. Complications include, but are not
limited to: renal damage, blindness, neuropathy, poor wound healing, amputations, myocardial
infarctions, and strokes. Due to the climbing numbers of patients who are diagnosed with
diabetes yearly, more primary care practitioners will be diagnosing and treating these conditions.
A gap in diabetes education was detected at a clinical setting located in Hollywood, Florida.
After the clinical problem was identified, a PICO question was developed to search the
literature. The next chapter will discuss the processes followed to conduct a literature search to
find an evidence-based intervention to address the clinical problem.

Chapter Two: Review of the Literature
Diabetes is a chronic disease which, when uncontrolled, can cause multiple complications
such as blindness, amputations, renal failure, heart disease, and strokes. There are 1.4 million
Americans diagnosed with diabetes every year (ADA, 2016), and in 2014 there were 422 million
people in the world with diabetes (World Health Organization [WHO], 2017). In Florida, there
are approximately 2,3521 people (13.1% of the population) who have diabetes and every year
approximately 129,000 people are diagnosed with diabetes (ADA, 2015a).
The problem of uncontrolled type II diabetes was identified in a primary care setting
located in Hollywood, Florida and a means to improve outcomes was examined. Diabetes
education is an important aspect of diabetes care and assists in increasing diabetes self-care
activities such as checking fasting blood sugars, dieting, and exercising. This chapter will
present a review of literature that supports diabetes self-management education (DSME).
Methodology
A comprehensive electronic literature search to identify an evidence-based intervention
was completed using the Jennie King Mellon Library at Chatham University. The following
databases were searched: Cumulative Index to Nursing and Allied Health Literature (CINAHL),
MEDLINE, and PsychINFO.
Sampling strategies. Key words used to search databases were: diabetes self-
management education; diabetes self-management education in primary care; diabetes outcomes;
and tools for diabetes education and evaluation. Boolean operators were used to include and
exclude specific key words from the search. An example of a search used is: Diabetes AND
education AND outcomes NOT type 1 NOT children. The search was limited to articles that
were published in the English language and published within the last 10 years (2007-2017) in
order to identify the most current data.
Inclusion/exclusion criteria. Data evaluation of the literature review focused on the
significance of the articles to patient education, specific DSME programs and interventions, and
articles that focused on self-care activities as outcomes. All studies evaluated the effectiveness
of diabetes patient education. Sample sizes, intervention specifics and outcomes of the studies
were evaluated. Articles that were excluded were those that showed no relevance to the clinical
problem, articles that included telehealth as an intervention, and articles that were focused on
juvenile or gestational diabetes. All articles were rated on a hierarchy of evidence system as per
Melnyk and Fineout-Overholt (2015), and all articles included were rated from level I to level VI
on the following scale. Level I: Evidence from a systematic review or meta-analysis of all
relevant randomized controlled trials (RCTs); Level II: Evidence obtained from well-designed
RCTs; Level III: Evidence obtained from well-designed controlled trials without randomization;
Level IV: Evidence from well-designed case-control and cohort studies; Level V: Evidence from
systematic reviews of descriptive and qualitative studies; Level VI: Evidence from single
descriptive or qualitative studies; Level VII: Evidence from the opinion of authorities and/or
reports of expert committees.
Literature Review Findings
The literature was searched to identify an evidence- based intervention that improved
diabetes self-care activities. New (2008) conducted a quasi-experimental pilot study to evaluate
the effectiveness of a DSME program. The study consisted of comparing a formal DSME class
to a co-created DSME intervention. A descriptive, qualitative design was used to investigate the
co-created DSME intervention. DSME education included content from the American Diabetes
Association (ADA) Core Curriculum for Diabetes Self- Management Education and from focus
group session data that was obtained through the study. The participant sample consisted of
adult persons over the age of 40, with type II diabetes for more than 1 year. There were four
DSME sessions and each lasted about 90 minutes, approximately 8 hours total. Education topics
included pathophysiology of diabetes, meal planning, exercise, prevention of complications,
psychological issues, foot care, and costs of care. The Diabetes Self-Care Activities (DSCA)
tool was used to measure diabetes self-care activity. Results indicate that ANCOVA with race,
previous formal classes, and pre-intervention scores as covariates discovered a statistically
significant difference (p = 0. 020), with the intervention group having the largest improvement in
scores. There was an improvement in DSCA mean scores in both groups: the comparison groups
DSCA mean scores were 59.50 pre-intervention and 62.19 post-intervention, and the intervention
groups DSCA mean score were 47.59 pre-intervention and 64.27 post-intervention. The findings
support DSME as an intervention to improve diabetes self-care activities.
Similarly, Pena-Purcell, Boggess, and Jimenez (2011) conducted a prospective quasi-
experimental study to measure the effectiveness of a DSME program. There were a total of 144
participants, 61 in the control group and 83 in the intervention group. Participants were mostly
female Hispanic/Latinos, low income, and older than 40 years old. The DSME program was
completed in 5 weeks, was based on the American Diabetes Association’s standards for DSME,
and was guided by the empowerment philosophy. Class sizes were between 10 and 20
participants. The DSME program consisted of 5 weekly sessions, each class about 2 hours long,
for a total of 10 hours. Pre and posttests evaluated self-care activities and were done one week
before the intervention and at week 5. Hemoglobin A1C was collected at the beginning and at 3
months. The diabetes self- care activities were measured by a 12 item scale and assessed
participants diet, exercise, blood sugar monitoring, foot care, and smoking habits. At week 5
(posttest), the intervention group had higher diabetes self-care scores (median increase 22%)
compared with controls (median increase 0%). Improvements in self-care were seen in blood
glucose monitoring at the recommended number of times per day (increased from a median of 2
to 7 days per week), 30 minutes of exercise daily (increased from 2 to 6 days), following healthy
diet (increased from 3 to 6 days per week). There was also a higher self-efficacy score at
posttest when compared to the control group. Hemoglobin A1C levels had improved at 3 months
post intervention, but were not shown to be statistically significant. This article suggests that a
2-hour weekly DSME program occurring over a 5-week period improves diabetes self care
activities.
Furthermore, Karakurt and Kasikci (2012) conducted a pretest – posttest experimental
study that sought to assess the effect of a Patient Education Booklet on diabetes self care using
the 35-item diabetes self-care scale (DSCS). Hemoglobin A1C, lipids, blood pressure, and waist
circumference were also measured. The DSCS was used to measure self-care activities. DSCS
was suggested to have high validity and reliability. Education was provided for 45-60 minutes.
Education was repeated once a month for a 3-month period; a total of 3 hours of education. One
hundred patients with type II diabetes participated. The education booklet had 2 main sections:
general information on diabetes (definition, pathophysiology, symptoms) and diabetes treatment
(general care and follow up glucose monitoring, protein and ketone in urine, healthy diet, regular
exercise, regular use of oral ant diabetic drugs, regular insulin application, early developing
problems in diabetes disease, long term health issues, individual monitoring and self care, dental
health, smoking, sexual intercourse, alcohol use). There was an increase in the average scores of
the post education DSCS scale (pretest 63.51; posttest 93.80; p < .001). The difference between
the patients’ pretest and posttest A1C, total cholesterol, LDL, and blood pressure was statistically
significant (p < 0.001). These findings suggest that a monthly DSME intervention, totaling 3
hours, improves self-care activities.
Moreover, Johnson, Richards, and Churilla (2015) conducted a meta-analysis cross
sectional study of randomized clinical trials to examine the differences in self-care activities of
participants who received DSME versus those who have not. The study used data from the 2008
Florida Behavioral Risk Factor Surveillance (BRFSS). The BRFSS is a telephone-based survey
of adults with diabetes, which is administered by state health departments. Fifty-two point one
percent received no DSME, 22% had <4 hours of DSME, 14.8% had 4-10 hours of DSME, and
11.6% had >10 hours of DSME. The percentage that engaged in the self-care activity of self-
monitoring of blood glucose (SMBG) varied by DSME duration (p<0.05). The percentage
engaging in SMBG was highest among those who received 4 or more hours of DSME. The
findings indicate that DSME of more than 4 hours can improve self-care activities.
Lastly, Gumbs (2012) conducted an exploratory study using data from the 2007
Behavioral Risk Factor Surveillance (BRFSS). The study sample included African American
women above the age of 18 who reported a diagnosis of type II diabetes. The mean age of the
participants was 59. The largest group of participants (48.2%) reported seeing their health care
provider four times in the last 12 months. Eighteen point eight percent reported seeing their
health care provider 3 times, 17.5% twice and 15.5% once, in the last 12 months. The majority
of the participants, 74.6%, checked their blood sugar levels once a day. Twenty percent of
participants exercised for more than 30 minutes a day for 5 or more days a week, which meets
ADA moderate activity requirements. Linear regression analysis was conducted to assess how
DSME affects self-care activities. Having had a class in diabetes self-management education
predicted how often blood glucose was checked, engagement in moderate physical activity, and
how often feet were checked for sores (p < .001). In a second model, DSME participation
predicted how often A1C levels and last dilated eye exam occurred (p = < .001). In both models,
having had DSME resulted in more self-care activities compared to those who did not have
DSME. Participants who engaged in DSME were 45% more likely to engage in self-care
activities compared to those who did not receive DSME. The study suggests that DSME can
improve diabetes self-care activities.
Discussion
The literature suggests that DSME can improve diabetes self-care activities. Although
there were many differences between each study, they all resulted in improved self-care
activities. Differences included: types of studies, educational tools used, delivery of educational
material, size and duration of educational groups, and persons leading the educational sessions.
The intervention that was selected for the EBP project was a diabetes self management education
group class that educates patients on diabetes disease process, daily blood glucose monitoring,
diet and exercise, diabetes medication adherence, and potential diabetes complications.
Limitations of the literature review. There were a few limitations to the literature
review process. None of the articles used the same scale to measure self-care activities, which
decreased similarity between studies. All studies were conducted in the United States except for
one (Karakurt & Kasikci, 2012), which was conducted in Turkey—as such, this can interfere
with the interpretation of findings. In one study, the participants were limited to only one
ethnicity, which reduces generalization of findings.
Conclusion of findings. A goal of Healthy People 2020 is to increase the amount of
persons who receive DSME. Diabetes is a chronic disease that can lead to many complications.
It has been found through this literature search that DSME sessions, which include educational
topics such as diet, exercise, and blood glucose monitoring can improve self-care activities.
Articles differed in length of education, size of educational groups, and DSME delivery. Length
of DSME ranged from weekly to monthly and averaged about 6 total hours. All articles resulted
in an increase of self-care activities in those participants who received DSME. Self-care
activities such as diet, exercise, and blood glucose monitoring have a positive effect on diabetes
outcomes and proper control of the disease.
Potential project. Group DSME classes of more than 4 hours can increase patient self-
care behaviors, which then result in improved diabetes outcomes. DSME that follows the ADA
guidelines can increase patient compliance in diet, exercise, blood glucose monitoring, and self-
monitoring for foot ulcers. It is possible to integrate a DSME program in a primary care setting
in hopes to improve self-care behaviors and overall A1C values. Therefore, a group DSME
intervention that follows the ADA guidelines for DSME will be implemented in this project in
order to improve patients’ self-care behaviors.
Summary
This chapter discussed the review of the literature that supports DSME. Diabetes can be
debilitating and have severe consequences if not managed correctly. Every year there are an
increasing amount of patients diagnosed with diabetes. A literature review was conducted in
order to identify an evidence-based intervention that can improve diabetes self-care activities.
The literature review revealed that group DSME programs, which follow ADA guidelines, are
effective in improving diabetes self-care activities such as blood glucose monitoring, appropriate
diet modifications, and maintaining physical activity. DSME programs varied in group size,
duration of total educational hours, and delivery of education. The next chapter will discuss the
processes followed to integrate a theory and model for EBP.

Chapter Three: Theory and Model for Evidence-based Practice
Evidence based practice change initiatives involve complex processes that integrate
theory and models that serve as a framework for change. “There is increasing recognition that
efforts to change practice should be guided by conceptual models or frameworks” Melnyk and
Fineout-Overholt, 2015, p. 245). Theories are used to explain phenomena and in particular
explain the reason for why an intervention may induce change (Sales, Smith, Curran, &
Kochevar, 2006). An evidence based diabetes educational course in order to improve
participants’ self care activities was introduced in a primary care clinic in Hollywood, Florida.
The theory chosen to support the evidence-based practice (EBP) change project was the
“Information Processing Theory” (David, 2015). The model used to guide this project was
Rosswurn and Larrabee’s (1999) Model for Evidence-Based Practice Change. The purpose of
this chapter is to introduce the theory and model that served as the framework for the EBP
project.
Theory
The theory that was identified to best reflect the concepts associated with the project was
the “Information Processing Theory” which originates from cognitive psychology. This theory
emerged from the field of psychology and is contributed to the works of numerous authors. The
theory is based on the idea that humans do not just respond to stimuli but also process the
information they receive (David, 2015). The information process model consists of stages:
Input, Storage, and Output (McLeod, 2008). The input is the information or stimuli, storage is
the process in which the stimuli is internalized and manipulated, and output is responsible for
preparing a response to the stimuli (McLeod, 2008). The concepts of sensory memory,
working/short-term memory, and long-term memory are defined under the information
processing theory. Sensory memory becomes short-term memory only if the person sees the
information as relevant (David, 2015). Sensory memory usually lasts seconds due to the
constant bombardment of our senses. Therefore, only when information is noted to be relevant,
the sensory memory transitions into working memory. Working memory includes auditory and
visual processes. Information is stored in working memory through repetition and organization.
It is said that long-term memory has unlimited capacity and most important component is how
the information is organized (David, 2015). Once information is obtained, it can be stored and
retrieved and these results may lead to behavioral changes.
Application to practice change. The project manager used this theory as a framework to
guide the development and implementation of the diabetes self-management education
intervention. The theory guided how education was organized and provided to participants.
Furthermore, the project manager used this theory to understand the various ways in which
patients can process education. With the guidance of the Information Processing Theory, the
project manager created a 90-minute weekly education program occurring over a 5-week period
for adults ages 18-70 with type II diabetes. One central concept of the theory was to repeat
important points in order to improve long-term retention of information. Another concept was to
organize information in a way that can be easily understood and stored for future retrieval.
These concepts were used when planning educational topics and carrying out educational
sessions in the EBP change project. Learners were able to process information in different ways
and ultimately change their behavior based on the teachings.
Evidence-Based Practice Change Model
Rosswurn and Larrabee’s (1999) Model for Evidence-Based Practice Change is a model
that was used to guide the project manager’s evidence-based practice change. This theory
integrates various steps in order to integrate EBP ideas into practice change initiatives as
presented by Melnyk and Fineout-Overholt (2015). The Model for Evidence-Based Practice
Change includes six steps. Step 1 is to assess the need for change. Step 2 and 3 is to locate the
best evidence by conducting evidence based literature search, and to critically analyze the
evidence, respectively. Step 4 is to design practice change, step 5 is to implement and evaluate
practice change and step 6 is to integrate and maintain change in practice.
Application to practice change. The six steps of this change theory were used as a guide
in the development, implementation, and evaluation of the EBP change project.
 Step 1: At the practice site the need for change was assessed. The identified
clinical problem was uncontrolled type II diabetes.
 Step 2: A literature search was conducted to identify an evidence-based
intervention to improve diabetes self-care activities. This search was conducted
by using Cumulative Index to Nursing and Allied Health Literature (CINAHL),
MEDLINE, and PsychINFO databases in Chatham University’s Jennie King
Mellon Library. Key words used to search databases were: diabetes self-
management education; diabetes self-management education in primary care;
diabetes outcomes; and tools for diabetes education and evaluation.
 Step 3: To identify the best evidence, the retrieved literature was critically
appraised and analyzed. All articles were rated on a hierarchy of evidence system
as per Melnyk and Fineout-Overholt (2015), from level I including evidence from
systematic reviews or randomized controlled trials to level VII including evidence
from the opinion of authorities and/or experts. The main intervention observed
was the integration of diabetes self-management education group classes.

 Step 4: The project manager designed a practice change group diabetes
educational course. The course included topics such as: diet, exercise, medication
management/adherence, blood glucose monitoring, and potential diabetes
complications.
 Step 5: The EBP intervention was implemented and evaluated. The project
manager implemented the group diabetes course in a primary care organization in
South Florida. The educational courses were 90 minutes each, occurred weekly,
and were continued for a total of 5 weeks.
 Step 6: After findings were disseminated, diabetes classes were integrated in the
primary care clinic in which the EBP change project took place. Instead of
weekly classes as in the EBP change project, two monthly 90-minute group
diabetes educational classes were made available at the primary care clinic for all
type II diabetic patients.
Summary
This chapter introduced the theory and model that served as the framework for the EBP
project. The theory and evidence based practice change model presented above were useful in
guiding the development and implementation of the evidence based intervention. It is necessary
for doctorate prepared nurse practitioners to integrate theory and a practice change model when
exploring ways to implement and evidence based change concept. When referencing to the EBP
change project, Rosswurn and Larrabee’s (1999) Model for Evidence-Based Practice Change
was used in order to translate evidence into practice. This model incorporated all the steps
needed to implement the EBP change project. The project manager was able to follow through
with all 6 stages and successfully implement, evaluate and disseminate a group diabetes self-
management education course in a primary care office. The theory chosen to support the EBP
change project was the “Information Processing Theory” (David, 2015). This theory allowed for
the project manager to understand how the intervention may encourage change. The next
chapter will discuss the processes for planning for implementation by assessing organizational
readiness for change, conducting a risk management analysis, obtaining organizational approval,
plans for Institutional Review Board approval, and plan for project evaluation and data analysis.
Chapter Four: Pre-implementation Planning
Diabetes prevalence is continuing to increase in numbers and techniques to improve
outcomes must be examined. Patients are generally referred to diabetes educators for diabetes
education at time of diagnosis. Patients at a primary care clinic in Hollywood, Florida were
underutilizing these educational classes, and a means to bridge the gap was explored. Taking
diabetes education into the primary care practice area is not common, however, this evidence-
based practice (EBP) seeks to implement diabetes self-management education (DSME) in a
primary care setting in order to improve patient self-care activities. The purpose of this chapter
is to discuss the planning considerations related to project management and project evaluation of
a EBP diabetes self management educational program in a primary care setting which aimed to
improve self –care activities in type II diabetic patients.
Project Purpose
This Evidence based change project aimed to improve diabetes education and self care
activities through incorporating diabetes self -management education (DSME) in a primary care
setting. It was due to the poor diabetes outcomes and lack of formal diabetes education seen in
the project manager’s primary care setting that the need for change was expressed. The
collaborating physician at the project manager’s clinical site expressed concern about the
increasing amount of office patients with uncontrolled diabetes. After an extensive literature
search, group diabetes self-management educational classes were identified as the intervention
best supported by the evidence. The proposed outcome was an improvement in diabetes self-
care activities.
Project Management
The organization in which this EBP was implemented was a primary care office that
contains three providers: one physician and two nurse practitioners. The facility provides care to
adults ages 18 and older and focuses in internal medicine. Prior to implementation, numerous
areas related to project management were assessed in relationship to planning considerations.
Organizational readiness for change. Plans for this EBP change project was addressed
with the project manager’s collaborating physician, the office manager, office secretaries and one
medical assistant. Within the organization, the collaborating physician and nurse
practitioner/project manager observed that many of the type II diabetic patients in their office
had uncontrolled diabetes and had little knowledge about diabetes management, diet, and lacked
medication compliance. This observation was made during quarterly office visits. The providers
understood the risk of uncontrolled diabetes and were eager to improve self-care activities
through an evidence-based intervention. Many methods to improve patient access to diabetes
education were discussed among the providers. The providers enthusiastically supported the use
of the proposed intervention.
Inter-professional collaboration. “The inter-professional team is essential for the
cohesiveness and success of a project and requires excellent communication skills to function
optimally” (Harris, Roussel, Thomas, & Dearman, 2016, p. 126). This EBP change intervention
intended to include an inter-professional team that consisted of a project manager who is the
nurse practitioner at the site, the office manager, the collaborating physician, and one medical
assistant. The office manager was responsible for mailing letters for recruitment and organizing
the room in which the intervention took place. The project manager provided education,
conducted follow up telephone calls, and collected and analyzed data. The collaborating
physician was involved in deciding which educational tools to use and which measures and data
points to explore. One medical assistant scheduled patients and helped with setting up group
sessions and handling patient surveys. The team maintained communication through 30-minute
weekly meetings. These meetings were designed to take place in order to update all involved on
the progress of the educational sessions and review participant feedback. This meeting was also
arranged for all involved to offer suggestions and brainstorm possible changes in educational
material, in order to improve the effectiveness of the project.
Risk management assessment. A SWOT analysis was necessary to be conducted at the
organization for risk management assessment in order to assess internal and external factors that
may affect the project. SWOT stands for “strengths, weaknesses, opportunities, and threats”
(Harris et al., 2016, p. 126).
Strengths. Several strengths, weaknesses, opportunities, and threats were identified.
Strengths identified include motivation from the collaborating physician, and participants’
familiarity with location. Participants were familiar with the office and most already had an
established rapport with the project manager, which was expected to ease participant’s stress and
anxiety. Another strength was the availability of the classes. Classes were available Monday,
Tuesdays, and Wednesdays to reduce scheduling conflicts.
Weakness. A weakness identified was the organization’s small size when compared to a
large organization such as large hospital. Smaller organizations have limited resources and
staff. Another weakness was the participants’ willingness to participate. It was unknown how
many patients would want to participate, given that many patients were known to be non-
compliant.
Opportunities. One opportunity that was vital was the acceptance from the facility for a
practice change project to take place. Another opportunity identified was the availability of
supplies and access to a space in which education can take place. Furthermore, the opportunity
to revisit current practices at the site regarding patient education was appreciated.
Threats. Threats identified during the SWOT analysis were time constraints and
participant adherence with group sessions. It was anticipated that patients could drop out during
the group sessions and not follow through with all 5 classes, which could be a potential threat to
data collection and outcome assessment. Time constraints and scheduling was also a threat
because it could be difficult to provide education at a time that is convenient and accessible to all
patients. Due to the identified barriers, education was divided into three different groups and the
five-week educational intervention was conducted twice, at week 2-6 and week 7-11, in order to
allow for added scheduling options and potentially attract more participants. Snacks, water, and
coffee were provided during sessions in order to make participants more comfortable and
potentially increase participant retention.
Organizational approval process. Organizational approval was to be obtained during a
meeting between the project manager, the office manager, and the collaborating physician. At
this time the project manager introduced the vision for EBP change and steps that will be
necessary in order to reach final project implementation. Topics included in the meeting were
the overall project plan, group session design, potential materials that will be needed, an
overview of the timeline, and outcomes that will be measured after implementation. The office
manager and the collaborating physician quickly agreed and the staff was then presented with the
plan so that all employees in the primary care setting are aware of the upcoming project
intervention.
Use of information technology. The use of information technology is an integral part of
project planning and management and is “a valuable tool in today’s evolving technological
healthcare environment” (Harris et al., 2011, p. 174). The project manager used information
obtained from the American Diabetes Association (ADA) as educational materials. PDF
documents of the ADA material were to be projected on a large TV screen so that participants
could follow along with the teachings. It was also intended that the project manager would use
excel spreadsheets to organize data and statistics. Follow up telephone encounters were also to
be logged in excel.
Materials Needed for Project
The participant’s teaching materials were obtained through the American Diabetes
Association website. The Summary of Diabetes Self-Care Activities (SDSCA) measure was
provided along with pencils to complete the survey. A cover letter was attached to the survey,
which reviewed and explained the EBP project, process, and time line (see Appendix A). The
survey was a total of five pages and the cover page was one page. The total number of pages
was three because the survey will be printed front and back. Two copies of the three-page
survey was needed for each patient to be used for the pre and post-test. There were 11
participants and 77 sheets of paper, each 8 ½ x 11 inches, were needed for the survey and cover
sheet. The PDF handouts from the ADA educational materials were an additional 30 pages per
person, totaling 330 pages for educational materials. Each participant was also supplied with a
clipboard at each session to improve ease of writing notes.
The educational presentation was delivered via a laptop computer that was connected and
projected on a television screen in order to project the information in a larger display. The
participants were able to follow along with their individual PDF printouts. Chairs were needed
and were obtained from the waiting room of the primary care office. The intervention was
conducted after office hours. Excel software was used for data collection and analysis.
Plans for Institutional Review Board Approval
The Institutional Review Board (IRB) approval was sought through Chatham University.
The IRB approval was submitted as an exempt review. The project manager submitted the
application and all requirements to the IRB. IRB approval was submitted on December 11th
2017, and was approved January 3rd 2018.
Plan for Project Evaluation
Evaluation of the project is essential for proper understanding of results and
determination of permanent practice change interventions. During project design, it is crucial to
plan for evaluation of the project. During this planning phase, it must be determined how the
project will be evaluated for generating the desired outcome. Evaluation of project effectiveness
would be based on data collected from the pre and post intervention questionnaire.
Plan for demographic data collection. It was planned that demographic information
needed to include participants’ age, gender, and ethnicity. This information was to be collected
at the beginning of the first educational session. Gender and ethnicity was to be reported as a
percentage and age as a range and mean. Pie charts were to be used to display gender and
ethnicity percentages. Participants were made aware that demographic information was to be
used and presented in chart format.
Plan for outcome data collection and measurement. The EBP change project intended
to measure self- care activities. The Summary of Diabetes Self-Care Activities (SDSCA)
questionnaire was used to measure self-care activities before and after education implementation.
Subsets of general diet, exercise, and blood glucose monitoring were measured. It was
considered that demographic information was to be evaluated and percent of attendance for at
least 3 classes and all 5 classes would also be assessed in order to evaluate for any participant
dropout and to assess how likely it was for those participating to complete the entire course.
Plan for evaluation tool. The SDSCA questionnaire was used to measure self-care
activities before and after education implementation. This questionnaire is available through
Oregon Research Institute and was available to be purchased at a charge of $25.00. Permission
to use the SDSCA questionnaire was obtained. The SDSCA questionnaire was developed by
scientists Deborah Toobert, Sarah Hampson, and Russell E. Glasgow from the University of
Colorado School of Medicine. The SDSCA measure is a brief questionnaire of diabetes self-
management that includes topics such as: general diet, specific diet, exercise, blood glucose
monitoring, foot care, and smoking status. Toobert, Hampson, and Glasgow (2000) reviewed 7
studies that used the SDSCA in order to revise the scale to include two additional components:
foot care and smoking status. “The internal consistency of the scales, assessed by average inter-
item correlations were acceptable” with exception of specific diet category (Toobert et al., 2000,
p. 944). The test-retest correlations were moderate (r = 0.40, r = -0.05 [for medications] to 0.78
[glucose testing]). Evaluation of validity for diet and exercise were based on methods of self-
report. Toobert et al. (2000) reviewed the SDSCA questionnaire in 7 previous studies that also
provided valuable information on reliability and validity not mentioned above.
Plan for data analysis. Self-care activity outcomes were measured using simple
descriptive statistics. Percent of pre and post intervention data was assessed for specific subsets:
diet, exercise, and blood glucose monitoring. Demographic information was evaluated and
percent of attendance for at least 3 classes and all 5 classes was also assessed. Research shows
varying results of mean percent change after diabetes educational interventions (Karakurt &
Kasikci, 2012; Surucu, Kizilci, & Ergor, 2017). Subsets were analyzed for any changes and
improvements in percent and mean. Pre and post intervention data for each subset was presented
in a bar graph.
The percent of participants who completed at least 3 classes, and the percent that
completed all 5 classes were measured. The benchmark being used for these data points is based
on the results from the study conducted by Pena-Purcell et al. (2011), in which 35% of
participants completed all 5 classes and 72% attended at least 3 classes.
In addition, changes in blood glucose monitoring at the recommended times per day,
changes in following a healthy eating plan, and changes in having at least 30 minutes of physical
exercise each day post intervention will also be measured. Furthermore, a benchmark for these
data points will be based on the study conducted by Pena-Purcell et al. (2011), where there was
an improvement of blood glucose monitoring at the recommended times per day from a mean of
2 to 7 days a week, an improvement of participants who followed a healthy eating plan post
intervention from 3 to 6 days a week, and an improvement in mean of participants having at least
30 minutes of physical exercise each day from 2 to 6 days a week. The project manager aims to
find that at least 80% of participants post intervention check their blood glucose as recommended
7 days a week, and 80% of participants follow a healthy eating plan 6 days a week, and 80% of
participants participated in at least 30 minutes of physical exercise at least 6 days a week.
Collected data will suggest if the DSME classes that were provided were effective in improving
self-care activities. Data will also provide an idea as to how many participants were actually in
attendance. The project manager used excel to document pre and posttest scores, participant
attendance, and demographic data.

Plan for data management. All paper documents were kept secured in a locked filling
cabinet in the PM’s locked office. All data collected via the questionnaire was entered into a
password protected Microsoft Excel spreadsheet file for analysis and stored on the PM’s
password protected computer. All data will be retained for at least three years in compliance
with federal regulations. The PM was the only person who had immediate access to the data.
The assigned faculty advisor had access to the data upon request.
Summary
This chapter discussed plans for implementation and evaluation of the evidence-based
change project. In order to implement this EBP change project, organizational discussion and
approval was necessary. Organizational approval was achieved prior to implementation. Risk
management assessment as well as use of information technology was also evaluated. The plan
for the EBP practice change was to implement a diabetes self-management education group class
in a primary care setting in order to assess self-care activities pre and post intervention. Data
would be measured using the SDSCA questionnaire. The next chapter will discuss the processes
for the implementation of the EBP project.

Chapter Five: Implementation Process
The purpose of this evidence-based practice (EBP) change project was to implement a
group diabetes education program targeting type II diabetic patients in a primary care setting.
The planning and implementation of the EBP project was a collaborative effort between the
project manager, office manager, collaborating physician and a medical assistant. This chapter
includes a description of the processes followed to implement the EBP change project.
Setting
The setting for this EBP change project was a private primary care practice in South
Florida. This practice offers care to any person above the age of 18. There was a total of 529
type II diabetic patients identified in the primary care setting. Patients were identified through a
search on the organization’s computer system.
Participants
Participants for this project were patients of the practice site. All type II diabetic patients
between the ages of 18 to 70 were invited to participate.
Recruitment
Participants were recruited for 6 weeks through mailed flyers (see Appendix B). All
participants who wanted to participate were instructed to contact the project manager by cell
phone or email in order to discuss expected requirements. The project manager explained to all
participants that confidentiality would be maintained during and after the project and that they
could withdraw from the project at any time without penalty. The informed consent form was
collected from all participants at the first educational session class (see Appendix C). A total of
11 participants took part in the diabetes educational sessions.

Implementation Process
The EBP change project diabetes educational courses were offered from January 8th until
March 14th, total of 10 weeks. Educational classes were held after office hours in the waiting
room of the clinical site. Classes took place from 5:30-6:30 pm every Monday, Tuesday, and
Wednesday of each week.
Participants were divided into two groups. Group 1 received educational sessions from
week 2 to week 6; and group 2 received educational sessions from week 7 to week 11. Each
group participated in the diabetes education sessions once a week over a total of 5 weeks. Three
educational sessions covering the same topic was available three times a week, in order to avoid
scheduling conflicts. Each class lasted 90 minutes.
At the beginning of the first educational session, participants were asked to complete The
Summary of Diabetes Self-Care Activities (SDSCA) questionnaire (Toobert et al., 2000). After
the pre-test, the first session of the diabetes education course was initiated which included an
overview of diabetes, progression of diabetes, and an introduction to diet using American
Diabetes Association PDF educational materials. Session 2 reviewed diet and exercise, session 3
medications and adherence, session 4 blood glucose monitoring, session 5 included
complications associated with uncontrolled diabetes and post-tests.
Plan Variation
The main modification the project manager experienced with implementation was the
teaching material for group 2. Week 3 and 4, medication and glucose monitoring respectively,
were switched to allow for improved continuity of information. In both groups combined, an
additional 6 participants signed up but never showed up for classes. Furthermore, the class on
February 14th was canceled due to lack of participant sign up, presumably due to the Valentines
Day holiday.
Summary
The diabetes educational sessions took place over a 10-week period. A total of eleven
individuals participated in classes. Pre- and post-intervention questionnaires were completed
using The Summary of Diabetes Self-Care Activities (SDSCA) questionnaire (Toobert et al.,
2000). A small change in the schedule of educational materials was made for group 2 in order to
improve the continuity of the classes. Otherwise, the implementation process went as planned.
The next chapter presents project evaluation and outcomes.

Chapter Six: Evaluation and Outcomes of the Practice Change
Complications associated with uncontrolled diabetes include hypertension, dyslipidemia,
heart attacks, stroke, blindness, kidney disease and amputations (ADA, 2016). As per the Office
of Disease Prevention and Health Promotion (n.d), there were only 6.8% of newly diagnosed
adults who received formal diabetes education during their first year after diagnosis in 2011-
2012. An improvement in self-care activities after the implementation of an evidence-based
diabetes education program is anticipated. Evaluation of an evidence-based practice (EBP)
project is necessary in order to analyze data and understand how the intervention affected the
outcomes being assessed. Project evaluation was based on data collected from the pre post
intervention scores of The Summary of Diabetes Self-Care Activities (SDSCA) questionnaire.
Demographic data was also collected and analyzed. The purpose of this chapter is to introduce
project evaluation and outcomes of the EBP change project.
Participant Demographics
The project included 11 participants with type II diabetes between the ages of 18 and 70.
The majority of participants were female (64% female). Eighteen percent of participants were
Hispanic/Latino (n=2), 73% were Caucasian (n=8), and 9% were African American (n=1). The
average age of the participants was 59 (range: 49-70). (See Figure 1 and 2).
Male
36%
Female
64%
Figure 1. Gender. Percent of participant gender demographic

African Hispanic
American 18%
9%
Caucasian
73%
Figure 2. Ethnicity. Percent of participant ethnicity demographic
Outcome Findings
Project evaluation was based on data collected from the pre and post intervention
questionnaire. Self-care activity outcomes were measured using simple descriptive statistics.
Percent of pre and post intervention data was assessed for specific subsets. In addition, percent
of attendance for at least 3 classes and all 5 classes was also assessed. The questionnaire does not
offer a total score, therefore subsets were measured: changes in blood glucose monitoring as
recommended 7 days a week, changes in following a healthy eating plan at least 6 days a week,
and changes in having at least 30 minutes of physical exercise at least 6 days a week.
Changes in blood glucose monitoring at the recommended times per day. Sixty-three
percent (n=7) of participants post intervention checked their blood glucose as recommended 7
days a week, which was less than expected, though its was an improvement when compared to
pre-intervention percent. Pre-intervention 36% (n=4) of participants checked their blood glucose
as recommended 7 days a week (see figure 3). There was an improvement in blood glucose
monitoring as recommended from a mean of 4.2 days to a mean of 6.4 days a week. The
benchmark for this data point was based on the study conducted by Pena-Purcell et al. (2011),
where there was an improvement of blood glucose monitoring at the recommended times per day
from a mean of 2 to 7 days a week. The project manager aimed to find that at least 80% of
participants post intervention checked their blood glucose as recommended 7 days a week. The
given benchmark was not met.
Changes in following a healthy eating plan. Thirty-six percent (n=4) of participants’
pre intervention followed a healthy eating plan 6 days a week and 100% (n=11) followed a
healthy eating plan at least 6 days a week post intervention (see figure 3). There was an
improvement in participants who followed a healthy eating plan post diabetes education; mean
amount of days increased from 4.5 to 6.6 days a week. As per Pena-Purcell et al. (2011), an
improvement of participants who followed a healthy eating plan post diabetes education
intervention increased from 3 to 6 days a week. The project manager aimed to find that 80% of
participants followed a healthy eating plan 6 days a week post intervention. Both benchmarks
were met.
Changes in having at least 30 minutes of physical exercise each day. Nine percent
(n=1) of participants participated in at least 30 minutes of physical activity at least 6 days a week
pre intervention. Post intervention, only 18% (n=2) of participants participated in physical
exercise at least 6 days a week (see figure 3). An increase in exercise was seen from a mean of
2.5 day per week to a mean of 5.7 days per week. A benchmark used for this data point was
based on the study conducted by Pena-Purcell et al. (2011), where an improvement in mean of
participants having at least 30 minutes of physical exercise each day increased from 2 to 6 days a
week. The project manager aimed to find 80% of participants participated in at least 30 minutes
of physical exercise at least 6 days a week. Neither of the two benchmarks were met.
Participation. The percent of participants who completed at least 3 classes, and the
percent that completed all 5 classes were measured. The benchmark used for these data points
were based on the results from the study conducted by Pena-Purcell et al. (2011), in which 35%
of participants completed all 5 classes and 72% attended at least 3 classes. It was determined
that 100% of participants completed at least 3 classes and 64% attended all 5. Two participants
missed the first class, and one participant missed 2 classes (see Figure 4).
120%
Percent of participants
100%
80%
60%
Pre-intervention
40%
Post-Intervention
20%
0%
Blood glucose Healthy eating Physical
monitoring plan exercise
Self-care activity outcomes
Figure 3. Self-care activity outcomes. Differences in the percent of participants, pre and post
intervention, on self-care activities.
3 classes 5 classes
39%
61%
Figure 4. Class attendance. Percent of class attendance for at least 3 classes and all 5 classes.
Summary
The EBP project appears to have had a positive impact on self-care activities. One
hundred percent of participants followed a healthy eating plan at least 6 days a week post
intervention. There was also an improvement in the mean amount of days that participants
followed a healthy eating plan: from 4.5 to 6.6 days a week. These results exceeded
expectations. Sixty-three percent of participants checked their blood sugars as recommended 7
days a week and only 18 % of participants exercised at least 30 minutes 6 days per week.
Although there was an improvement in percentages and an improvement in the mean amount of
days participating in blood glucose monitoring and exercise, these activities did not meet the
benchmark goal. Participation was low, however 100% of participants completed at least 3
classes and 64% completes all 5, which did not meet the benchmark goals. The diabetes
educational program is helpful in improving glucose monitoring, maintaining a healthy diet, and
increasing amount of exercise activity. The next chapter presents the discussion of the EBP
change project.
Chapter Seven: Discussion
Diabetes is a major health concern and is linked to heart disease and stroke, among other
complications. It is estimated that 68% of people with diabetes die from cardiovascular disease,
which is the leading cause of death in the United States (American Diabetes Association, 2016).
As evidenced by the literature and results of this project, education is an important factor in
controlling type II diabetes. Data from the project demonstrated that the group diabetes
education classes were successful in improving self-care activities. These findings support that
implementing a diabetes self-care management education program in a primary care office lead
by a nurse practitioner can improve diet, exercise, and blood glucose monitoring. This chapter
presents the recommendations for project site implementation, indications for policy change, and
plans for dissemination.
Recommendations for Site
There were a total of 529 type II diabetic patients in the primary care site in which the
evidence-based practice (EBP) project took place. Out of those 529 patients, 27% (n = 148) had
a hemoglobin A1C of more than or equal to seven, 11% (n = 62) had a hemoglobin A1C of more
than or equal to eight, and 5% (n = 30) with a hemoglobin A1C above nine. It was observed in
the project managers’ clinical setting that most type II diabetic patients would not follow through
with diabetes education referrals, which lead to poor self-care behaviors and lack of basic
diabetes knowledge among patients. Since approximately 90% of patients with type II diabetes
receive their care from primary care providers (McCulloch, 2017), the need for primary care
providers to expand access to diabetes education was illuminated.
Due to positive results from the EBP change project, management from the EBP change
project site are in discussion regarding implementation of a group diabetes education program.
The education classes will be led by the nurse practitioner at the site. Instead of weekly classes
as carried out in this EBP project, the group classes will be planned to take place monthly for
returning participants, and twice a month for new participants. It was recognized that new
participants will need a separate introduction class and then can join the regular group classes
once a month. Classes will be held the second Tuesday of every month and will be 90 minutes in
duration. Furthermore, the educational material will cover an introduction to diabetes, blood
glucose monitoring, diet and carb counting, exercise, and potential complications associated with
diabetes. All type II diabetic patients will be notified of upcoming classes at each appointment,
and will be able to schedule their class at that time as well.
Plans to sustain change at site. At the conclusion of the EBP project, all data was
gathered and presented to the office manager and collaborating physician. A conference was
held in order to discuss results and plan for implementation of diabetes education classes at the
site. The discussion brought up many points. One was the amount of classes that will be offered
monthly and how to split material between the two classes. It was discussed that new
participants will receive a packet that includes specific topics (introduction, diet/carb counting,
exercise, glucose monitoring, and complications associated with diabetes) in order to read at
home and be prepared for the second monthly class. The ultimate goal and success will be a
group diabetes class that takes place twice a month and improved participants self-care activities,
and potentially improve A1C scores, which could be assessed at a later time.
Implications for Policy
DNP prepared nurse practitioners have the ability to implement change in their clinical
sites and influence policy change on a larger scale. There is a need for healthcare professionals
to provide legislators with evidence-based interventions and findings from research that
legislators can understand, in the hopes of influencing policy change (Melnyk & Fineout-
Overholt, 2015). The EBP project was able to improve diabetes self-care activities especially in
regards to blood glucose monitoring and sustaining a healthy diet plan. There is no policy in
place, in the EBP project site, that involves diabetes or diabetes education. It is anticipated that
the EBP project site will implement a diabetes education course and integrate this in their
forthcoming policy initiatives.
Potential outcomes from a type II diabetes education program can include reduction in
A1C scores, reduction of diabetes complications, and reduction in hospitalizations related to
diabetes. Although the EBP change project did not address these outcomes, it did improve self-
care activities. Since self-care activities are linked to patient care outcomes, it is reasonable to
presume that a diabetes program may improve population health and complications associated
with diabetes.
On a national level, the Medicare Diabetes Prevention Program (MDPP) expanded model
is a structured behavior change intervention that aims to prevent the onset of type 2 diabetes
among medicare beneficiaries diagnosed with pre-diabetes (Centers for Medicare & Medicaid
Services [CMS], n.d.). The goal is to administer group classes and educate patients who are pre-
diabetic in order to prevent diabetes. Although the target population differs from this EBP
change project, it is a good example of how policy can affect overall population health.
Links to Health Promotion.
The EBP change project outcome suggested that diabetes education improves self-care
activities such as blood glucose monitoring, diet, and exercise. These improvements in self-care
activities may improve diabetes outcomes and prevent complications associated with diabetes. It
is important for health care providers to identify the need for programs to address health
promotion practices. This group diabetes class can be implemented in any primary care practice,
and the providers can improve population health by doing so. The nation’s health can be
significantly improved by achieving improved control of diabetes and preventing complications,
such as heart disease. Improving self-care activities such as healthy diet and exercise can
promote healthy lifestyles and ultimately help people live healthier lives.
Role of DNP-prepared nurse. The American Association of Colleges of Nursing
(2016) examines 8 Essentials of Doctoral Education for Advanced Nursing Practice. The
Essentials include but are not limited to improving population health outcomes, clinical
prevention, and health care policy. While examining essential VIII, it was learned that to
advance the nursing practice, one must sustain therapeutic relationships with the collaborating
team and patients, continue to advance knowledge, and use evidence based information to
provide care in order to improve the health of the population. DNP prepared nurse practitioners
can advance knowledge and improve the health of the population by first identifying problems in
clinical settings. Once problems are identified, interventions that are based on evidence can be
implemented and therefore, improvements in health can be accomplished. DNP prepared nurse
practitioners are at the forefront of change and advances in healthcare. Efforts should be made to
identify problems in all clinical care settings and work along with organizations to improve the
community’s health.
Next Steps Related for Evidence-Based Practice
Due to time constraints, only self-care activity outcomes were assessed in this EBP
change project. Therefore, a logical next step would be to evaluate if A1C values would also
improve. A suggestion for future projects is to include A1C as an outcome. Some insurance
companies “grade” providers based on A1C scores, therefore, not only would lowering A1C
scores benefit patients and reduce risks associated with uncontrolled diabetes, but it would also
benefit clinical sites. Another suggestion would be to explore classes for diabetes prevention.
This can be done by either integrating pre-diabetes patients in the group classes with the current
curriculum, or create a separate class for pre-diabetic patients.
Plans for Dissemination
All findings will be presented to the collaborating physician and the office manager of the
primary care practice. Findings will be presented in a handout format and will be discussed
during an office meeting in April 2018. Findings will also be shared with the four other primary
care offices that the practice change site merged with. A manuscript will also be submitted to a
healthcare journal for publication in order to disseminate findings at a broader level.
Summary
Evidence from the project adds to the literature that diabetes self-management
educational classes are effective in improving self-care activities. The evidence-based group
diabetes educational classes improved all 3 self-care activities among participants: diet, exercise,
and blood glucose monitoring. Implementing a group diabetes program in the primary care site
can potentially lower diabetes complications and improve overall health outcomes. Plans for
implementation are currently underway. Further discussion is needed in the area of scheduling
the diabetes classes and finalization of all details. In addition, this EBP project can influence
health care policy on a institutional level and potentially have an effect on governmental actions
related to diabetes management and education. DNP prepared nurse practitioners have the
knowledge and experience to understand the needs of a practice site and understand how to bring
about change. The dissemination of findings is essential for furthering the nursing practice and
has potential for improving the nations health. The next chapter summarizes the final conclusions
and key points from all chapters.

Chapter Eight: Final Conclusions
The prevalence of diabetes increases each year, which in turn increases the amount of
complications associated with diabetes as well as health care costs. A diabetes education
program was implemented in order to assess changes in type II diabetes patients’ self-care
activities. DNP prepared nurse practitioners have the ability to bring about change, as observed
in this evidence-based practice (EBP) change project. Diabetes can lead to severe complications
if left untreated. Diabetes education can improve diet, exercise, and blood glucose monitoring.
Diabetes education should be a part of type II diabetes treatment and should be considered for
implementation in primary care offices. This chapter presents the summarization and conclusion
of the EBP change project.
Clinical Problem
Uncontrolled diabetes can cause heart disease, renal disease, strokes, and even blindness.
The ADA (2016) reports that there are 1.4 million new cases of diabetes every year and it was
the seventh leading cause of death in 2010. It was observed at a clinical site located in
Hollywood, Florida that several patients with type II diabetes were unaware of how to properly
follow a diabetes diet or other self-care activities. Since more than 90% of patients with type II
diabetes receive their care from primary care providers, the need for primary care providers to
expand access to diabetes education was explored (McCulloch, 2017).
Evidence Base
A comprehensive electronic literature search to identify an evidence-based intervention
was completed using the Jennie King Mellon Library at Chatham University. The Cumulative
Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, and PsychINFO
databases were used. The literature was searched to identify an evidence- based intervention that
improves diabetes self-care activities. Five research articles that focused on patient education as
the intervention and self-care activities as outcomes were included. Three studies measured the
effectiveness of Diabetes Self Management Education (DSME) and found an improvement of
self-care activities among type II diabetic patients after DSME (Karakurt & Kaşıkçı, 2012; New,
2010; Pena-Purcell et al., 2011). Topics of education included pathophysiology of diabetes, diet,
exercise, medication adherence, glucose monitoring, and potential health complications
associated with uncontrolled diabetes. The other two studies used data from the 2007 and 2008
Florida Behavioral Risk Factor Surveillance (BRFSS) to examine the differences in self-care
activities of participants who received DSME versus those who have not and it was found that
those who attended DSME had improved self-care activities (Gumbs, 2012; Johnson, Richards,
& Churilla, 2015).
The literature suggested that group diabetes self-management education (DSME) classes,
which include educational topics such as diet, exercise, and blood glucose monitoring, are
effective in improving self-care activities. Self-care activities such as diet, exercise, and blood
glucose monitoring have a positive effect on diabetes outcomes and proper control of the disease.
Theory and Model for Evidence-Based Practice
The theory that was identified to best reflect the concepts associated with the project was
the “Information Processing Theory” which originates from cognitive psychology (David, 2015).
This theory was used as a framework to guide the development and implementation of the
diabetes self-management education intervention. The three stages of the theory (input, storage,
and output) were used to guide the length of the educational classes, the structure and
organization of the educational material, and the requirement to repeat information in order to
maximize retention of information.

The model used to guide this project was Rosswurn and Larrabee’s (1999) Model for
Evidence-Based Practice Change. This theory integrates various steps in order to integrate EBP
ideas into practice change initiatives as presented by Melnyk and Fineout-Overholt (2015). All
six steps were used to successfully implement, evaluate, and disseminate a group diabetes self-
management education course in a primary care office.
Project Management
Plans for this EBP change project was addressed with the project managers’ collaborating
physician, the office manager, and one medical assistant. In order to implement this EBP change
project, organizational discussion and approval was necessary. Risk management assessment
was also a main component of pre-implementation procedures. The collaborating physician,
office manager, project manager, and medical assistant were all included in the implementation
of the project. All collaborated on different aspects of the EBP change project. The team
maintained communication through 30-minute weekly meetings.
Project Implementation
The EBP change project was conducted in a private primary care practice in South
Florida. All type II diabetic patients between the ages of 18 to 70 who were patients of the
primary care office met criteria for inclusion. Recruitment was completed week one on
implementation and group classes took place from week 2 to week 11; a total of 11 participants
took part in the EBP project. All participants were asked to complete a pre and post intervention
questionnaire. Diabetes classes took place Monday, Tuesday, and Wednesday of each week, and
each class lasted 90 minutes. Lastly, in order to expand educational material, poster boards were
made weekly to reflect educational material for that week and were displayed in the waiting rom
of the primary care office.

Outcome Findings
Self-care activity outcomes were measured using simple descriptive statistics. There was
an improvement in mean scores post intervention for blood glucose monitoring at the
recommended times per day, following a healthy eating plan, and having at least 30 minutes of
physical exercise each day. The project manager aimed to find at least 80% of participants post
intervention to check their blood glucose as recommended 7 days a week, however, only 63%
(n = 7) checked their blood glucose as recommended 7 days a week post intervention. It was
also expected for 80% of participants to exercise at least 30 minutes a day at least 6 days a week.
This goal was also not met; only 18% (n = 2) of participants participated in 30 minutes of
exercise at least 6 days a week. One subset did exceed expectations. It was anticipated that at
least 80% of participants would follow a healthy eating plan at least 6 days a week. It resulted
that 100% (n = 11) of participants participated in a healthy eating plan at least 6 days of the
week. Although not all expectations were met, there was an improvement in overall mean scores
for diet, exercise and blood glucose monitoring.
Discussion Summary
Healthy People 2020 reviewed objectives that required change, two of which are
improving glycemic control in patients with diabetes and increasing the amount of patients who
receive formal diabetes education (Office of Disease Prevention and Health Promotion
[ODPHP], n.d.). The Model for Evidence-Based Practice Change by Rosswurn and Larrabee
(1999) was used to guide this project. All steps were conducted and integrated in order to
implement and evaluate a group diabetes class. An extensive literature review was conducted
and it was discovered that group diabetes classes have the potential to improve self-care
activities. A project plan was created and ultimately implemented in a primary care office in
Hollywood, Florida. Eleven type II diabetic patients from the ages of 18-70 participated.
Results revealed an improvement in mean scores for the subsets of diet, exercise, and blood
glucose monitoring. Results suggests that implementing a group diabetes class in a primary care
setting can improve self-care activities and the dissemination of these findings is crucial in
improving diabetes outcomes.
Final Conclusions
Diabetes is a disease that has the potential to cause severe complications, particularly
when left uncontrolled. It is clear from the literature search and this EBP change project that
education can greatly improve self-care activities associated with diabetes. “The prevalence of
diagnosed diabetes in the U.S. increased by 382% from 1988 to 2014” (ADA, 2015a). Diabetes
is a growing concern and a rising threat to all Americans. It is possible, through education and
proper treatment, to achieve controlled blood glucose levels, which can then prevent significant
complications.
It was revealed, through the literature search, that group diabetes education classes that
follow ADA guideline are effective in improving diabetes self-care activities. Therefore, a 90-
minute diabetes educational session was conducted in a primary care setting in order to improve
self-care activities. Results from the EBP change project revealed an improvement in self-care
activities after diabetes education intervention in type II diabetic patients between the ages of 18
and 70. Improving self-care activities has the potential to improve diabetes outcomes and
prevent complications associated with diabetes.

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Appendix A
Cover Letter
Appendix B
Flyer
Appendix C
Informed Consent

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Running head: IMPROVING DIABETES SELF-CARE ACTIVITIES 1

IMPROVING DIABETES SELF-CARE ACTIVITIES USING EDUCATIONAL SESSIONS IN

A PRIMARY CARE SETTING

Capstone Paper submitted in partial fulfillment of the

Doctor of Nursing Practice

Signature Faculty Reader Date

Signature Program Director Date

primary care setting lead by a nurse practitioner effects self-care activities.

minutes of physical exercise at least 6 days a week was also assessed.

Conclusions: The diabetes self-management education classes provided were effective in

improving participant’s self-care activities. Implementing diabetes education classes in a primary

care setting can improve patient self-care activity.

Chapter One: Overview of the Problem of Interest ..............................................................8

Background Information ............................................................................................8

Significance of the Problem .......................................................................................9

Question Guiding Inquiry (PICO) .............................................................................10

Variables of the PICO question .....................................................................11

Chapter Two: Review of the Literature/Evidence ................................................................13

Sampling strategies ........................................................................................13

Inclusion/Exclusion criteria ...........................................................................14

Literature Review Findings........................................................................................14

Limitation of literature review. ......................................................................18

Conclusions of findings .................................................................................18

Potential practice change ...............................................................................19

Chapter Three: Theory and Model for Evidence-based Practice ..........................................21

Application to practice change.......................................................................22

Model for Evidence-Based Practice ..........................................................................22

Application to practice change.......................................................................23

Chapter Four: Pre-implementation Plan ...............................................................................26

Project Purpose ..........................................................................................................26

Project Management ..................................................................................................27

Organizational readiness for change ..............................................................27

Inter-professional collaboration .....................................................................27

Risk management assessment ........................................................................28

Organizational approval process ....................................................................29

Use of information technology ......................................................................30

Materials Needed for Project .....................................................................................30

Plans for Institutional Review Board Approval .........................................................31

Plan for Project Evaluation ........................................................................................31

Plan for demographic data collection ............................................................31

Plan for outcome data collection and measurement ......................................31

Plan for evaluation tool ........................................................................32

Plan for data analysis ...........................................................................32

Plan for data management ..............................................................................34

Chapter Five: Implementation Process .................................................................................35

Implementation Process .............................................................................................36

Plan Variation ............................................................................................................36

Chapter Six: Evaluation and Outcomes of the Practice Change ...........................................38

Participant Demographics ..........................................................................................38

Figure 1: Gender demographics .....................................................................38

Figure 2: Ethnicity demographics ..................................................................39

Outcome Findings ......................................................................................................39

Outcome One .................................................................................................39

Outcome Four ................................................................................................40

Figure 3: Self-care activity outcomes ............................................................41

Figure 4: Class attendance .............................................................................41

Chapter Seven: Discussion ...................................................................................................43

Recommendations for Site .........................................................................................43

Plans to sustain change ..................................................................................44

Implications for Policy..............................................................................................44

Links to Health Promotion .......................................................................................45

Role of DNP-prepared nurse ..........................................................................46

Next Steps for Evidence-based Practice ..................................................................46

Plans for Dissemination ...........................................................................................47