The Ten Strategic Points
TOPIC: DPI Project: Outline of 10 Strategic Points Revision Review
Please use the Sample provided to draft the Outline of 10 Strategic Points based on the attached school’s Template of the Ten Strategic Points. Also, please take the topic from the attached CONHCP: Doctor Of Nursing Practice Final PICOT-D Approval Form.
Grand Canyon University
College of Doctoral Studies
Ten Strategic Points: QUANTITATIVE
Aligns with new v9.0 Template
Please find below an updated copy of the 10 strategic points that is focused on a quantitative study. This copy includes tips in the right-hand column to guide you as you develop your 10 strategic points. Delete the bulleted items in the right column as you add your own information there.
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QUANTITATIVE STUDY The ten strategic points emerge from researching literature on a topic, which is based on, or aligned with a defined need or problem space within the literature as well as the learner’s personal passion, future career purpose, and degree area. The Ten Strategic Points document includes the following key points that define the research focus and approach: |
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Strategic Points Descriptor |
Learner Strategic Points for Proposed Study |
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1. |
Dissertation Topic- Provides a broad research topic area/title. |
Topic comes out of problem space supported by the literature, not the learner’s head or personal agenda Aligned to the learners’ program of study, and ideally the emphasis area Researchable and feasible to complete within the learners’ doctoral program of study including extension courses as needed. Focused |
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Literature Review – Lists primary points for four sections in the Literature Review: (a) Background of the problem and the need for the study based on citations from the literature; (b) Theoretical foundations (theories ,models, and concepts) and if appropriate the conceptual framework to provide the foundation for study); (c) Review of literature topics with key themes for each one; (d) Summary. |
· Background to the problem · Literature is predominantly from past 5 years · Historical treatment of problem being studied · Clearly defines a stated need · Theoretical foundation · Theories, models, or concepts and if appropriate the conceptual framework are described to guide the research and the data collection · Review of literature topics · Relevant to the topic · Demonstrates breadth of knowledge |
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3. |
Problem Statement – Describes the problem to address through the study based on defined needs or problem space supported by the literature |
· Statement is structured appropriate for the design · Researchable · Quantitative: Researchable variables to be better understood |
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4. |
Sample and Location – Identifies sample, needed sample size, and location. |
· Size is appropriate for design · Likely to be able to access it/get permission · Identify alternative to their organization (associations, community orgs, research companies, snowball sampling, etc.) |
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5. |
Research Questions – Provides research questions to collect data to address the problem statement. |
· Appropriate for the design · Resulting data will address the problem statement · Minimum of 2 |
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6. |
Hypothesis/Variables – Data sources are valid; variables are clearly defined and measurable (quantitative) |
· Quantitative: Data sources are valid; variables are clearly defined and measurable · |
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7. |
Methodology and Design – Describes the selected methodology and specific research design to address the problem statement and research questions. |
· Methodology and design sections · Appropriate for problem statement · Justifies the methodology or design using problem statement and citations · Methodology does not discuss design, instrument, data collection Design does not discuss instrument, data collection, data analysis |
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8. |
Purpose Statement – Provides one sentence statement of purpose including the problem statement, methodology, design, target population, and location. |
· Purpose statement = Methodology + design + problem statement + sample + location · |
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9. |
Data Collection – Describes primary instruments and sources of data to answer research questions. |
· Quantitative: Validated/previously used instrument or data source clearly identified for each variable; demographic variables identified and appropriate to the study. Comment by GCU: In quantitative studies various demographics can be variables. One might compare transformational leadership behaviors for males and females or different management levels within an organization or between different age groups. Or demographic variables might be one of the predictor variables in a hierarchical regression · Describes sample; various permissions needed; recruiting and select final sample; data collection steps; how data will be stored, security maintained, privacy maintained |
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10. |
Data Analysis – Describes the specific data analysis approaches to be used to address research questions. |
· Quantitative: Include testing assumptions; descriptive statistics; specific inferential statistics appropriate for design and type of variables; appropriate for hypotheses · Data analysis approach aligned to the design/variables/RQs & hypotheses |
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Quantitative 10 Strategic Points, v. 9.0 August 10, 2020
10 STRATEGIC POINTS DOCUMENT 2
THE 10 STRATEGIC POINTS 2
Grand Canyon University
DNP-820A: Translational Research and Evidence-Based Practice
August 29, 2022.
10 Strategic Points Document for a Quality Improvement Project
Ten Strategic Points
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The 10 Strategic Points |
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Title of Project |
1) Impact the number of depression screenings and referrals to a child psychologist |
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Background Theoretical Foundation Literature Synthesis Practice Change Recommendation |
2) List the primary points for six sections. i) Background of the practice problem/gap at the project site One of the primary causes of disability worldwide, depression affects a sizable percentage of the population. Persistent feelings of sadness and guilt, changes in sleeping patterns (insomnia or oversleeping), changes in appetite, decreased mental and physical energy, unusual irritability, inability to enjoy once-enjoyed activities, difficulty working, and thoughts of death or suicide are all symptoms that can be associated with any type of depressive disorder. These “down” symptoms alone may indicate a unipolar depressive disorder like dysthymia or severe depression if they are present. A person may be diagnosed with bipolar illness if they experience alternating spells of depression and euphoria. Adolescents and young adults increasingly have difficulties with their mental health (Poppen et al., 2016). An individual’s mental health is something only they can fully comprehend, making it difficult for friends and loved ones to spot warning signs in time to intervene. Juvenile and young adult suicide is a major problem in today’s world. A lack of life experiences, self-confidence, and faith in one’s own skills contribute to the suicides of many young individuals. ii) Significance of the practice problem/gap at the project site Mental illness has been a problem that is affected the population for a long period and worryingly young people and adolescents are experiencing many effects that lead to some committing suicide. The stress that today’s youth encounter nowadays is the most significant of all these issues, especially the pressure they receive based on their academic expectations and poor communication about their troubles to their parents. There is also a gap in the schools in terms of students receiving counseling services because there are limited professional counselors that attend to student needs. Despite the fact that psychologists claim stress could be caused by anything, many young people find the rapid pace of modern life to be a significant source of anxiety. Many young individuals are inspired to take their own lives by the media’s glorified depiction of suicide (Poppen et al., 2016). The reality that suicide is always fatal seems to be lost on many young people. Young people, in other words, consider suicide an option for self-expression or as a means of making up for past misdeeds. iii) Theoretical Foundations (choose one nursing theory and one evidence-based change model to be the foundation for the project): The most likely reasons for people to take their own lives are outlined in Emile Durkheim’s theory of suicide. According to the theory, a person’s lack of social integration may be a contributing factor in their decision to take their own life after experiencing chronic depression. It is possible that individuals do not have adequate psychosocial assistance to help them deal with the difficulties of life (Poppen et al., 2016). There is limited psychological assistance in schools making it a significant cause of the burden of psychological issues that leads to chronic depression. These individuals have weak egos because they lack sufficient social networks in their immediate environment. It is society’s fault, according to Durkheim, because the regulations that restrict people’s actions are so lax. He is of the opinion that individuals’ actions are influenced by social problems such as the economic crisis, pressure from academic work for high school adolescents, and particularly when such people are unable to cope with their depression. Additionally, the notion indicates that an individual may choose to end their own life if they have the perception that the regulations that are in place restrict their freedom. Evidence-Based Change Model A wide number of approaches can be taken to bring about change in healthcare organizations. The data, assessment, and plan (DAP) project’s activities, which include community and adolescent education, community presentations to improve awareness of depression, and teaching positive coping strategies, will be efficiently implemented with the use of the PDSA model’s four steps: plan, do study, and act. During the “plan” phase of the DAP program, a group consisting of school nurses, parents, instructors, and students themselves will serve as the program’s leaders. After the planning stage comes to the “Do” stage, which is where the actual execution of the program takes place. The DAP program will include a variety of components, including public education, the promotion of healthy emotional expression among adolescents through the medium of painting, and the instruction of coping skills (Poppen et al., 2016). The “Study” step is where you’ll be doing any kind of analysis or assessment of the program. A few of the factors that are taken into consideration are the return on investment, any necessary adjustments, and the possibility of unfavorable repercussions. The final phase of the PDSA process is referred to as the “Act.” It includes conducting an in-depth analysis of the project’s goals and results. iv) Create an annotated bibliography using the “Preparing Annotated Bibliographies (APA 7th)” located in the Student Success Center. https://www.gcumedia.com/lms-resources/student-success-center-content/documents/writing-center/preparing-annotated-bibliographies-apa7-mla8-turabian9 utilizing the five (5) original research articles that support the evidence-based intervention. This will be the foundation of the Literature Synthesis you will have to do in DNP-820A. Kroning, M., & Kroning, K. (2016). Teen Depression and Suicide: A Silent Crisis. Journal of Christian Nursing, 33(2), 78. https://doi.org/10.1097/CNJ.0000000000000254 Kroning et al. discuss the hidden epidemic of adolescent depression. They discovered that over 11% of all teenagers and nearly a third of all high school students suffer from depression. About one-fifth of high school pupils (about 17%) have seriously considered suicide. Intriguingly, adolescent depression is rarely given the attention it deserves. The article describes the events leading up to the death of a 17-year-old girl and discusses the warning indicators of depression that could have been observed. Teen depression is a major public health problem. Many adults have witnessed kids’ melancholy and incorrectly assumed it was due to hormonal changes, defiance, or general adolescent irritability. When comparing causes of mortality among people aged 15–24, suicide is by far the most common worldwide. The article provides a detailed plan that can save the life of a depressed person and keep them from even considering suicide. Best, P., Manktelow, R., & Taylor, B. (2014). Online communication, social media, and adolescent wellbeing: A systematic narrative review. Researchers in this study used a narrative synthesis method and a valued appraisal instrument to read the articles and analyze the findings. The research aimed to answer the following question: “What are the positive and negative consequences of social media among youth?” (Best et al., 2014). Further, this study illustrates the beneficial and bad effects of social media use on adolescents’ mental health; this outcome aids me in my investigation of the relationship between adolescent use of the internet and their physical and mental well-being. Evidence from Best et al. (2014) shows that social media can have both beneficial and negative effects on adolescents’ mental health; however, the authors also suggest that further research is needed to strengthen the connection between social media and adolescents’ psychological well-being. O’Reilly, M., Dogra, N., Hughes, J., Reilly, P., George, R., & Whiteman, N. (2018). Potential of social media in promoting mental health in adolescents. The study details the examination of three primary topics: the role of social media in the mental health of teenagers, the benefits and problems of social media and mental health, and the future directions for research on these topics. Further, this lends credence to the idea that social media can have both beneficial and detrimental effects on young people’s mental health. Finally, the study does a fantastic job of disaggregating responses by gender and age, resulting in a wide range of perspectives on the potential effects of social media. The concepts of social media opinion, mental health, and views for the future of social media in the context of health informed the design of the focus group. Wang, X., Cai, L., Qian, J., & Peng, J. (2014). Social support moderates stress effects on depression. International Journal of Mental Health Systems, 8(1), 41. https://doi.org/10.1186/1752-4458-8-41 The paper explores how social support plays a role in mitigating depression and other stress-related outcomes. A survey of college students was administered to assess their levels of social support, stress, and depressive symptoms. In a regression study, it was discovered that social support mitigates the association between depression and stress. Undergraduate students who had high-stress levels were discovered to be having depression. The students who reported having social support from faculty and peers were in a different situation. Anxiety manifests itself mentally when the needs of the spirit exceed the capabilities of the body. It’s very uncommon for this to lead to additional feelings of negativity, despair, and anxiety, all of which can stunt a person’s ability to mature and flourish as a person. Individual and environmental variables both play a role in the development of depression. Albert, P. R. (2015). Why is depression more prevalent in women? Journal of Psychiatry & Neuroscience: JPN, 40(4), 219–221. https://doi.org/10.1503/jpn.150205 The article discusses how common depression is among women. Major depressive disorder is a serious health problem that affects many people. It is estimated that in 2010, depression disorders were the second-leading cause of burdens for Canadians with disabilities, after mobility impairments. When people are depressed, it often results in their own death by means of suicide or a stroke. Depression ranks as the third leading cause of death around the world because of all these deaths. Education and income, maltreatment, and other socioeconomic issues all have a role in exacerbating women’s already high suicide incidence. v) Summary of the findings written in this section. The adolescents that suffer from depression are contributed by multiple factors that include social issues, academics, lack of support, and the influence of social media. The limited resources for addressing mental health in high school result in cases of chronic depression. There is a need for screening to assist adolescent students in the preliminary stages and avoid cases of depression. |
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Problem Statement |
3) Depression is a huge problem among adolescents in high school and prior screening through schools having enough counsellors and creating awareness help in mitigating the risks and consequences. |
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PICOT to Evidence-Based Question |
4) The purpose of this quantitative, quasi-experimental quality improvement project is to determine if or to what degree the translation of research by Anand et al. utilizing the Patient Health Questionnaire-9 (PHQ-9) will impact the number of depression screenings and referrals to a child psychologist when compared to current practice among adolescents at a high school setting in urban Texas over eight weeks. |
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Sample Setting Location Inclusion and Exclusion Criteria |
5) The sample size targeted is 15 participants and the study setting is the urban area of Texas. High school adolescents and counselors are the target participants. |
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Define Variables |
6) i) Independent Variable (Intervention): Therapy/counseling and having enough counsellors. ii) Dependent Variable (Measurable patient outcome): Depression |
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Project Design |
7) However, research findings do not have to be immediately integrated into clinical practice, the fundamental purpose of quality improvement programs is to improve patient care. To identify a problem, research must be undertaken, and quality enhancement entails gathering evidence that can be used to better the topic of interest. |
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Purpose Statement |
8) The purpose of this quality improvement project is to determine if the implementation of therapy/counseling intervention would impact the mental health well-being among high school adolescents. The project was piloted over eight weeks in an urban setting within Texas state. |
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Data Collection Approach |
9) To gather and analyze demographic data, I plan to use an Excel spreadsheet. By consulting with healthcare professionals and conducting the survey with 15 participants, I will be able to collect valid and trustworthy data on patient outcomes. To ensure that the collected data can be replicated, the survey instrument employs a standardized, organized format. In the realm of data collecting and analysis, spreadsheets are widely regarded as among the most efficient and trustworthy tools available. i) Describe the step-by-step process you will use to collect the data, explain where the data will come from, and how you will protect the data and participants. I would first seek the approvals from necessary authorities and also get the consent from the target participants that is the counsellors and high school adolescents. The participants are 15 in number from Urban Texas. High school adolescent patients in mental health care are given an evaluation questionnaire to fill out, with two weeks allotted to finish the process. The questionnaire itself takes only a few minutes to complete. To acquire this data, we have them fill out a questionnaire and record their responses in a spreadsheet. A copy of the encrypted data is subsequently uploaded to a remote server. ii) Discuss potential ethical issues pertaining to your project. Ethical Considerations in Human Research Protection (i.e., confidentiality vs anonymity of the data, informed consent, and potential conflict of interest.) Participants are needed to sign the informed consent form as soon as they agree to take part in the study, demonstrating their willingness to allow the data to be shared. The participants’ anonymity is protected by the confidentiality guarantees inherent in the informed consent process. The participant has the moral right to expect that their date would be kept private and discreet. There should be no potential conflict of interest between the researcher and the participant. iii) Discuss how you will adhere to the principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, within the theoretical framework, clinical problem, and clinical questions. I would analyze the Belmont report and make sure that all the requirements are adhered to in the research study. |
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Data Analysis Approach |
10) Using a descriptive statistical method and demographic analysis, I would examine the provided descriptive data and demographic information. If I were to analyze the quantifiable patient outcomes, I would use the chi-square test. In this case, I would resort to the techniques employed by statisticians. A possible source of error in the data is that respondents provided false information, especially about demography. To deal with this difficulty, we can establish a range within which each given piece of data should lie to ensure that our results can be reproduced. |
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References |
Albert, P. R. (2015). Why is depression more prevalent in women? Journal of Psychiatry & Neuroscience: JPN, 40(4), 219–221.
https://doi.org/10.1503/jpn.150205 Best, P., Manktelow, R., & Taylor, B. (2014). Online communication, social media, and adolescent wellbeing: A systematic narrative review. Kroning, M., & Kroning, K. (2016). Teen Depression and Suicide: A Silent Crisis. Journal of Christian Nursing, 33(2), 78. https://doi.org/10.1097/CNJ.0000000000000254 O’Reilly, M., Dogra, N., Hughes, J., Reilly, P., George, R., & Whiteman, N. (2018). Potential of social media in promoting mental health in adolescents. Poppen, M., Sinclair, J., Hirano, K., Lindstrom, L., & Unruh, D. (2016). Perceptions of Mental Health Concerns for Secondary Students with Disabilities during Transition to Adulthood. Wang, X., Cai, L., Qian, J., & Peng, J. (2014). Social support moderates stress effects on depression. International Journal of Mental Health Systems, 8(1), 41. https://doi.org/10.1186/1752-4458-8-41 |
CONHCP: Doctor Of Nursing Practice Final PICOT-D Approval
The department has conducted a review of your PICOT-D question in an effort to support the development of your project. Please note that this review is a FINALAPPROVAL of the PICOT-D and will require permission by the DNP Program Lead for any changes to this statement beyond the date of this approved review. We highly discourage changes as they may prevent you from progressing.
PICOT-D Question: In the adolescent population with mental health problems in healthcare settings, how does PHQ-9 tool impact in-patient referrals to the mental health department for over 9 weeks?
In the adolescent population with mental health issues: To what degree would the implementation of the PHQ-9 depression screening tool increase the rate of referrals, as compared to current practices, among adolescents aged 14-18 in a period of 8 weeks?
P-Adolescents aged 14-18 years.
I- Implementation of the PHQ-9 depression screening
C- Compared to current practice.
O- Increase the rate of referrals.
T- Time frame to conduct project is eight weeks.
Does the implementation of the Patient Health Questionnaire (PHQ-9) tool impact the depression screenings and referrals when compared to current practice among adolescents in an urban high school in Texas over eight weeks?
Are you an APRN? (mandatory question) I am an APRN having earned a graduate-level degree All projects must have a minimum of
3 original research studies to support the intervention. (One of the three original research articles to support your intervention need to come from the US or Canada). The other research studies can come from the UK, Denmark, India, New Zealand, or Australia (preferred) or from any of the 131 countries listed in the International Compilation of Human Research Standards 2020.
*** In DNP-955A You will be required to have a total of 15 research articles to support the intervention (3 from PICOT, plus other original research)
Original Research Articles (Use permalinks and attach a pdf copy of each of the quantitative original research articles):
Alvarez, C. (2022). Enhancing Depression Screening for the Adolescent Population in the Pediatric Emergency Department by Utilizing the Patient Health Questionnaire: A Quality Improvement Project. Retrieved from:
https://digitalcommons.sacredheart.edu/cgi/viewcontent.cgi?article=1020&context=dnp_projects
Costantini, L., Pasquarella, C., Odone, A., Colucci, M. E., Costanza, A., Serafini, G., … & Amerio, A. (2021). Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): A systematic review.
Journal of affective disorders,
279, 473-483.: retrieved from:
https://air.unipr.it/bitstream/11381/2881953/1/1-s2.0-S0165032720328287-main
Nandakumar, A. L., Vande Voort, J. L., Nakonezny, P. A., Orth, S. S., Romanowicz, M., Sonmez, A. I., … & Croarkin, P. E. (2019). Psychometric properties of the patient health questionnaire-9 modified for major depressive disorder in adolescents.
Journal of child and adolescent psychopharmacology,
29(1), 34-40. Retrieved from:
Psychometric Properties of the Patient Health Questionnaire-9 Modified for Major Depressive Disorder in Adolescents – PMC (nih.gov)
Sekhar, D. L., Schaefer, E. W., Waxmonsky, J. G., Walker-Harding, L. R., Pattison, K. L., Molinari, A., Rosen, P., & Kraschnewski, J. L. (2021). Screening in high schools to identify, evaluate, and lower depression among adolescents: A randomized clinical trial.
JAMA Network Open, 4(11), e2131836.
https://doi.org/10.1001/jamanetworkopen.2021.31836
IMPORTANT PLEASE STOP AND READ:
This is your Final Approved PICOT-D statement. Please maintain this copy and please include it in each course ISP going forward, in addition, this is the FINAL approved statement to be shared with all DNP course instructors going forward.
If you need to make a change to this PICOT-D statement, you must work with your current course instructor to review and approve any possible changes and your instructor must notify the DNP Program Lead. Making a change to your PICOT-D statement past this date may lead to your delay and success in this program, there must be a valid significant reason to change this PICOT-D statement going forward. It will require you to stop and re-gain permission prior to progressing. This final approval is tracked in CRM.
You
may not begin your intervention or collect any data
related to your project until you have GCU IRB approval, which typically occurs in 960A. Prior to your project courses, you will be working on designing a project in preparation for the submission of your proposal in 955A. Ensure you are accessing the resources in the DC network and in the classroom. You do not need to resubmit your PICOT to the department.
Congratulations on your work so far! We are so glad you have chosen Grand Canyon University.
THIS FINAL PICOT-D STATEMENT IS APPROVED.
_______________________________________________________Date: _____________________________
DNP PICOT-D REVIEWER Name/Credentials
“For it is God who works in you to will and to act in order to fulfill his good purpose.” (Philippians 2:13)
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Grand Canyon University
DNP-830A: Data Analysis
October 6, 2022
10 Strategic Points Document for a Quality Improvement Project
Ten Strategic Points
The 10 Strategic Points
Title of Project
1)
Title of Project
Using continuous glucose monitoring to monitor blood glucose in adult patients with type II diabetes
Background
Theoretical Foundation
Literature Synthesis
Practice Change Recommendation
2)
Background to Chosen Evidence-Based Intervention:
i. Background of the practice problem/gap at the project site
Several chronic conditions negatively impact the lives of patients. Among such conditions is diabetes. Diabetes causes numerous other complications, such as kidney disease, heart disease, and stroke (Skinner et al., 2020). The other concern about diabetes is that it affects millions of people, making them unable to live normal lives. The implication is that various researchers and stakeholders have, in the past and present, been pursuing effective ways or strategies to better manage diabetes. Non-the less, diabetes is still among the most prevalent chronic conditions (Khan et al., 2019). According to Khan et al. (2019) the diabetes global prevalence among the adult population is as high as 9%. The interventions currently in use among patients living with diabetes majorly focus on helping patients attain better healthcare outcomes, such as better glycemic control and keeping in check the risky lifestyle behaviors that may hinder the control and management of the condition (Maiorino et al., 2020). Even though effective interventions should be applied, the management strategies used in the practice site have not achieved the desired results as most of the patients fail to achieve the required HbA1c levels. Indeed, uncontrolled levels of HbA1c have been connected to myocardial infarction and stroke disease (Azhar et al., 2022). It hurts to use an invasive glucometer. The discomfort is the same even if the needle is very small. Some individuals may be able to adjust to it and tolerate it, but for others, it may be too much to handle, leading to the issue of non-compliance. The patient’s ability to regulate their blood sugar may suffer as a result, leading to bouts of hyperglycemia and hypoglycemia The risk of diabetic complications is increased by noncompliance, making it a potentially life-threatening issue, hence the need to have a different way to measure glucose more effectively and non-invasively.
ii. Significance of the practice problem/gap at the project site
As earlier highlighted, diabetes causes other undesirable problems apart from making those who live with it spend more money on treatment and management (Bommer et al., 2018). Therefore, the need to control and manage the disease has attracted the attention of several stakeholders, including nurses, doctors, and other researchers in the medical and nursing fields. There have been advancements in the management of diabetes, largely due to the new innovative technologies used in diagnostics and treatment (Haque et al., 2021). However, the annual number of people who get the disease still runs into millions. In addition, the prevalence rates have been rising in recent years, while several others die annually due to diabetes (Khan et al., 2019). The negative impacts caused by the disease can reduce through using nursing interventions based on the current technology and technological applications such as continuous glucose monitoring. The intervention can dictate the rate of practitioners ordering Continuous glucose monitoring as directed by the results to further improve outcomes. The implication is that, in the event that continuous glucose monitoring leads to improvement in the expected HbA1c levels, then the practitioners at the project site are more likely to increase the rates of the ordering of continuous glucose monitoring for better outcomes (Root et al., 2022). Modern intensive diabetic care relies on regular and precise monitoring of blood glucose levels. This used to require many time-consuming and uncomfortable daily random blood glucose readings, which served as a substantial deterrent to reaching intended blood glucose targets. Self-monitoring blood glucose (SMBG) simply gives you a single reading of the blood sugar level and doesn’t tell user anything about the trend or pace of the sugar levels even if used consistently. This means that most individuals, notwithstanding the checking their glucose concentration multiple times a day, nonetheless fail to meet their goals. CGM is a major improvement because it offers immediate evaluation on the efficacy of diabetic therapies (such insulin delivery), and it gives alerts when serum sugar levels reach critically excessive or inadequate. more importantly, it offers real-time glucose reading at regular intervals. This is significant to the research, since benefits of CGM out do the shortcomings, which include high cost.
iii. Theoretical Foundations (choose one nursing theory and one evidence-based change model to be the foundation for the project):
Nursing theories are key in implementing nursing interventions as they offer a framework upon which to base the aspects of interventions (Brandão et al., 2019). Therefore, this project will use Dorothea Orem’s self-care theory. The theory is mainly defined as the act of helping others by offering and maintaining self-care to maintain and improve human functioning at the home level effectiveness. The theory states that an individual has an ability to perform self-care as “the practice of activities that individuals initiate and perform on their behalf to maintain life, health, and well-being (Butts & Rich, 2018). Dorothea’s theory has three interconnected sub-theories; the theory of self-care, the self-care deficit theory, and the theory of nursing systems (Orem & Calnan, 19
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2). Dorothea Orem’s theory is one of the nursing theories widely applied in nursing quality improvement and change initiatives. This theory will be used in guiding the DNP project on diabetes management and prevention. Self-care is key in diabetes management. Therefore, the underpinnings will be key in helping the individuals evaluate themselves and choose the necessary actions required to attend to the needs of self-care by accomplishing the actions (Butts & Rich, 2018), which in this case is continuous glucose monitoring. Therefore, patients can be motivated to follow the interventions for better care. The theory underlines that self-care is learned and is more natural to adults. Therefore, it will guide the project toward promoting self-care for healthcare, well-being, and self-maintenance among the identified patients living with diabetes.
The theory is also appropriate for the management of diabetes as it also focuses on the possible deficits that the caregivers or the patients may be having in terms of appropriate resources and information key to better management (Orem & Calnan, 1972). In addition, the theory also highlights the inability of patients to take care of themselves, hence the need for support. The patients will, therefore, be able to lower the chances of emergency room visits by taking instructions on the use of continuous glucose monitoring. The use of continuous glucose monitoring also focuses on self-care as the patients will be required to use the monitors, and the existence of a deficit will be a springboard to help the caregivers to collaborate and offer the best to achieve the set goals. Another aspect of the theory is the application of innovative and creative ideas (Orem & Calnan, 1972). Such ideas are key if the evidence is to be used to positively impact patient outcomes. As such, upon the improvement of patient outcomes through glucose monitoring, the impact and the next set of goals will be communicated to the care teams to help facilitate the new practice with the major focus of improving patient outcomes.
Lewin’s change theory will provide the theoretical foundation and constructs in the change practice by addressing behaviors, fears, anxieties, and attitudes and reducing stakeholder worries. Kurt Lewin’s change theory comprises three stages, unfreezing, change, and refreezing (Lewin, 1947); (Hussain et al., 2018). The theory asserts that there are two types of forces, the driving and restraining forces pushing in the direction that makes change happen and the direction that hinders the change, respectively (Lewin, 1947). A change only occurs when the driving forces override the restraining forces (Cummings et al., 2016). In the unfreezing stage, a method is proposed to help individuals move from old behavior patterns and accept change. The change or moving stage entails changing behavior, feeling, and thoughts. The final step, refreezing, entails making the new change as a new habit or standard (Lewin, 1947). When applying the change model, the unfreezing stage will involve asserting the need for patients to have improved HbA1c levels hence the need for more effective intervention. During this stage, the nurses involved will ensure that the patients see the urgency of the need to have well-controlled HbA1c levels. The second step will involve implementing the proposed intervention to reduce HbA1c levels in diabetic patients. Support is offered to nurses who offer the intervention to patients, and the patients are encouraged to adhere to the intervention requirements. At this stage, the intervention is rolled out, and the patients are encouraged to use continuous glucose monitoring. The final step will involve making the intervention part of standard practice to ensure that patients have better outcomes. Therefore, nurses will be advised to apply the intervention to patients with diabetes for better diabetes outcomes. Besides, ordering continuous glucose monitoring by the practitioners will be expected to be the standard part of the diabetes management practices at the facility.
iv. Annotated bibliography.
Beck, R. W., Riddlesworth, T. D., Ruedy, K., Ahmann, A., Haller, S., Kruger, D., … & DIAMOND Study Group. (2017). Continuous glucose monitoring versus usual care in patients with type 2 diabetes receiving multiple daily insulin injections: a randomized trial.
Annals of Internal Medicine,
167(6), 365–374. DOI: 10.7326/M16-2855.
In this study by Beck et al. (2017), the primary aim was to determine the effectiveness of continuous glucose monitoring in adults with type 2 diabetes who were getting insulin injections. By employing a randomized controlled trial as the research design, these researchers recruited one hundred and fifty-eight patients with type 2 diabetes. Seventy-nine patients were randomized into the usual care group, with the remaining half recruited into the intervention group. While the continuous glucose monitoring group used a Dexcom G4 platinum continuous monitoring system to monitor their glucose concentrations, the control groups engaged in glucose self-monitoring. The mean HbA1c levels went down to 7.7 % and 8.0% in the continuous glucose monitoring group and control group, respectively (adjusted difference in mean change, −0.3% [95% CI, −0.5% to 0.0%]; p = 0.022), showing that the intervention was efficacious. When continuous glucose monitoring was performed, there was a statistically significant decrease in HbA1c levels among the patients in the intervention groups. As a result, it suggests that continuous glucose monitoring is essential for enhancing diabetic outcomes like lowered HbA1c levels.
Gilbert, T. R., Noar, A., Blalock, O., & Polonsky, W. H. (2021). Change in hemoglobin A1c and quality of life with real-time continuous glucose monitoring use by people with insulin-treated diabetes in the landmark study.
Diabetes Technology & Therapeutics,
23(S1), S-35.
https://doi.org/10.1089/dia.2020.0666
The study by Gilbert et al. (2021) aimed to assess the changes in HbA1c levels upon using a continuous glucose monitoring system. The recruited patients were two hundred and forty-eight, with sixty having Type 2 Diabetes.The participants were requested to upload their point-of-care HbA1c measurements to an online portal. They then used continuous glucose monitoring devices to monitor their HbA1c values and uploaded them to the portal. Upon data analysis, the researchers noted that there was a significant reduction in the levels of HbA1c levels (p-value <0.001). The HbA1c fell significantly from 8.2% (1.9%) at baseline to 7.1% (1.1%) at the end of the study ( p < 0.001); besides, 54 % of those with initial HbA1c values >7% experienced absolute HbA1c reductions of >1%. This study implied that the improved HbA1c levels among the patients are the results of continuous glucose monitoring. Therefore, this study also indicated the importance of continuous glucose monitoring in improving HbA1c and the management of diabetes.
Heinemann, L., Freckmann, G., Ehrmann, D., Faber-Heinemann, G., Guerra, S., Waldenmaier, D., & Hermanns, N. (2018). Real-time continuous glucose monitoring in adults with type 1 diabetes and impaired hypoglycemia awareness or severe hypoglycemia treated with multiple daily insulin injections (Hypo DE): a multicentre, randomized controlled trial.
The Lancet,
391(10128), 1367-1377. https://doi.org/10.1016/S0140-6736(18)30297-6
This study was done by Heinemann et al. (2018). This study’s objective was to determine whether real-time continuous glucose monitoring can effectively reduce the severity and incidences of hypoglycemia. In a six-month randomized controlled study, the researchers randomly assigned 75 individuals to a real-time continuous glucose monitoring group, while 74 were assigned to the control groups. The individuals in the real-time continuous glucose monitoring group were taught how to use the monitoring system. They then used real-time continuous monitoring devices for the period of study. On the other hand, the individuals in the control group used glucometer to self-monitor their blood glucose levels at regular intervals during the day. Upon the analysis of the data, it was noted that the individuals in the intervention group reported a significant reduction in hypoglycemic events (p-value of <0.0001). The mean number of hypoglycemic events per month in the continuous glucose monitoring group was reduced from 10·8 (SD 10·0) to 3·5 (4·7); changes in the control group were not significant (from 14·4 [12·4] to 13·7 [11·6]). Incidence of hypoglycemic events decreased by 72% for participants in the continuous glucose monitoring group (incidence rate ratio 0·28 [95% CI 0·20–0·39], p<0·0001). The study implied that the use of continuous glucose monitoring led to a significant reduction in HbA1c levels hence showing the importance of the intervention in diabetes management and care.
Martens, T., Beck, R. W., Bailey, R., Ruedy, K. J., Calhoun, P., Peters, A. L., … & MOBILE Study Group. (2021). Effect of continuous glucose monitoring on glycemic control in patients with type 2 diabetes treated with basal insulin: a randomized clinical trial.
JAMA,
325(22), 2262-2272. doi:10.1001/jama.2021.7444
This article presents the findings of the research done by Martens et al. (2021). This study was done with the aim of finding the impacts of continuous glucose monitoring in improving individuals’ HbA1c levels when compared to the impact of blood glucose meter monitoring. In a randomized controlled trial, these researchers recruited a total of 175 people with diabetes. While the individuals in the intervention group used continuous glucose monitoring, the ones in the control group engaged in blood glucose meter monitoring. This study was done for a period of eight months. Upon analyzing the data, it was noted that the individuals in the intervention group showed a substantial reduction in HbA1c levels (p-value of 0.02). There was also a significant difference between the intervention and control groups (p-value of 0.001). Mean HbA1c level decreased from 9.1% at baseline to 8.0% at eight months in the continuous glucose monitoring group and from 9.0% to 8.4% in the control group (adjusted difference, −0.4% [95% CI, −0.8% to −0.1%]; p= 0.02). The results imply that continuous glucose monitoring leads to a more significant reduction in HbA1c levels, indicating that the intervention is effective.
Grace, T., & Salyer, J. (2022). Use of Real-Time Continuous Glucose Monitoring Improves Glycemic Control and Other Clinical Outcomes in Type 2 Diabetes Patients Treated with Less Intensive Therapy.
Diabetes Technology & Therapeutics,
24(1), 26-31. DOI: 10.1089/dia.2021.0212.
Authored by Grace & Salyer (2022), this study focused on using real-time continuous glucose monitoring in the management of patients with diabetes type to improve glycemic control. The researchers recruited patients suffering from diabetes with basal insulin only or noninsulin therapy. At six months, the researcher found relevant outcomes. For example, the participants showed a considerable reduction in HbA1c levels (−3.0% ± 1.3%, p-value <0.001). In addition, the researchers observed a reduction in the average levels of glucose at six months (−23.6 ± 38.8, P < 0.001). Therefore, continuous glucose monitoring was connected with significant glycemic improvements among patients suffering from the diabetes disease.
v. Practice Change Recommendation: Validation of the Chosen Evidence-Based Intervention
The standards of diabetes care have been used at the facility for years as a preference. However, this approach has not been as effective as expected. As such, this research proposes to investigate whether the increased prescription of continuous glucose monitoring as an intervention to help patients with diabetes have improved HbA1c levels, as shown in the research done by Beck et al. (2017). In a randomized controlled trial, the researchers randomized (n=79) patients in a continuous glucose monitoring group while (n=79) were in the control group. The continuous glucose monitoring group used a Dexcom G4 platinum continuous monitoring system to monitor their glucose concentrations to give a better reduction in HbA1c levels as compared to the control group (p values of 0.022). The analysis of the study findings showed that the mean HbA1c levels went down to 7.7 % and 8.0% in the continuous glucose monitoring group and control group, respectively (adjusted difference in mean change, −0.3% [95% CI, −0.5% to 0.0%]; P = 0.022), showing that the intervention was efficacious (Beck et al., 2017). As such, this randomized controlled trial study shows that continuous glucose monitoring can effectively improve HbA1c levels among these patients with the diabetes illness hence a recommendation for practice change (Beck et al., 2017).
vi. Summary of the findings written in this section.
Diabetes is one of the most common and disabling chronic conditions. However, the application of nursing interventions can be key to improving patient outcomes (Beck et al., 2017). From the annotations, it is evident that the use of continuous glucose monitoring as an intervention in managing diabetes leads to a better control in patient’s blood glucose, even though the cost of purchasing it is significantly higher. For example, the researchers reported significant improvement in the HbA1c levels upon the use of continuous glucose monitoring. When the results for the control groups were compared with intervention groups, significant improvements among the intervention groups were observed. For example, the reduction in the HbA1 levels observed between the intervention and control group by Beck et al. (2017) was significant (p= 0.022); Gilbert et al. (2021) observed (
p < 0.001), Heinemann et al. (2019) observed (
p < 0.001); Martens et al. (2021) also observed (
p < 0.001); Grace & Salyer observed (p <0.001)
Problem Statement
3)
Problem Statement:
It is not known if the implementation of the translation of research by Beck et al. (2017) on continuous glucose monitoring to improve the rate of practitioners’ ordering continuous glucose monitoring would impact HbA1c levels among patients with diabetes.
PICOT to Evidence-Based Question
4)
PICOT Question Converts to Evidence-Based Question:
Among adult patients with diabetes in an outpatient clinic, will the translation of Beck et al.’s research on continuous glucose monitoring increase the rate of practitioners ordering continuous glucose monitoring impact HgbA1C compared to current practice in 12 weeks?
Evidence-Based Question:
Provide the templated statement.
To what degree will the implementation of continuous glucose monitoring impact HbA1c levels among adult patients with diabetes in an urban outpatient clinic.
Sample
Setting
Location
Inclusion and Exclusion Criteria
5)
Sample, Setting, Location
i) Sample and Sample Size: The sample will be based on a convenient sample of 16 adult patients diagnosed with diabetes. The sample will then be divided into two, the control group and the intervention group, each having 8 patients. One of the potential biases is selection bias, as the patients recruited will be ones known to the facility and attending the facility for the management of diabetes. Another potential bias is that the samples will be from one center, hence a lack of generalizability.
The sample size of 16 patients is obtained by taking 10% of the total diabetic adults who visit the hospital, which is 160 patients
ii) Setting: The setting for the study is an urban Outpatient care primary clinic.
iii) Location: an outpatient primary care Clinic area
iv) Inclusion Criteria
Patients must be at least 18 years and above and have diabetes. The patients should also be able to speak and understand English. The patient should also not form part of another study. The participants must be willing to participate in the study and must be competent in that they should be able make sound decisions on their own.
v) Exclusion Criteria
Patients under the age of 18 years will be excluded. Only those who suffer from diabetes illness will be included. Individuals using technological management of diabetes, those who do not want to sign the consent forms, and those who have a mental disability will be excluded.
Define Variables
6)
Define Variables:
i) Independent Variable (Intervention): continuous glucose monitoring
Continuous glucose monitoring: Continuous glucose monitoring is a technological process of automatically tracking a person’s glucose concentrations throughout out the night and day.
ii) Dependent Variable (Measurable patient outcome): HbA1c levels
Glucose concentrations: In reference to this project, blood glucose levels refer to the amount of the glucose in the patient’s system as measured by the continuous glucose monitors.
HbA1c levels: In reference to this project, HbA1c levels refer to average glucose concentrations measured at baseline and at the end of the intervention to determine the efficacy of the intervention
Project Design
7)
Project Design:
This project will use a quality improvement approach.
i. Quality Improvement: A quality improvement is an initiative or project focused on improving patient care efforts and outcomes. These initiatives focus on initiating changes to lower the chances of making medical errors, improving care, and ensuring safety. Quality improvement efforts also help formulate processes and standard work to bridge gaps for better patient outcomes. Quality improvement is vital in improving an organization’s performance and reducing costs. According to Fischer & Wick, 2020, quality improvement is key in delivering quality patient care composed of six aspects: patient-centered, equitable, timely, efficient, effective, and safe. Therefore, the use of the quality improvement approach in this study will seek to explore current research and translate the found evidence into practice for the major purpose of improving patient outcomes, which in this case is better HbA1c levels among patients with diabetes. As opposed to research, quality improvement uses the existing evidence and translates the same into practice.
ii) Research: Research entails replicating or testing new ideas to improve the standard practice and current knowledge. A systematic strategy is applied to investigate a clinical question or problem, leading to the formulation of a hypothesis which then triggers efforts to prove such hypothesis and generate new knowledge (Glasofer & Townsend, 2021). Research is significant in nursing in that it produces scholarly evidence, which is then used as a guide to the professional nursing practice. Research differs from quality improvement in that it applies a systematic strategy to investigate a new idea and come up with new knowledge and theories. Therefore, research informs quality improvement.
iii) Summarize: Research and quality improvement both complement each other in terms of improving patient care outcomes. In addition, even though the two are connected, they are different. While research mainly formulates new knowledge, theories, and hypotheses, quality improvement focuses on translating the research findings into practice
Purpose Statement
8)
Purpose Statement:
Provide the templated statement.
The purpose of this quality improvement project is to determine if the increased prescription of continuous glucose monitoring would impact HbA1c levels among adult patients with diabetes disease. This project will be piloted over a twelve-week period in an urban Outpatient primary care clinic.
Data Collection Approach
9)
Data Collection Approach:
i) The demographic information or data for the patients, such as gender, co-morbidities, ethnicity, race, and age, will be collected. The demographic data for the patients will be collected through documentation during recruitment as provided by the patients. The patient’s knowledge of continuous glucose monitoring will also be evaluated using a questionnaire (Revised Brief Diabetes Knowledge Test instrument). The reliability of the Revised Brief Diabetes Knowledge Test instrument is (α ≥ 0.70), while the validity ranges from 0.83 to 0.96
ii) The patient’s HbA1c levels will be measured, and the baseline data will be obtained from the electronic health records. Data from EHR has been shown to be reliable and valid. The obtained data at the end of the study period will then be entered into a password-protected database.
iii) The step-by-step process for collecting the data,
Step 1: Obtaining IRB approval for data collection
Step 2: Baseline patient HbA1c data will be obtained from the facility’s EHR.
Step 3: The patient’s HbA1c will be measured after the intervention, and the two values will be compared. The results will also be compared between the intervention and the control group.
iv) Various potential ethical issues include the protection and storage of patient health information. This information will be stored in password-protected computers where only individuals with unique passwords will access the information. The patient data will also be de-identified to further improve security and confidentiality. In addition, the obtained data will be kept for one year after graduation before destroying them, following the Grand Canyon’s guidelines.
v) The project will adhere to the principle of Belmont by ensuring that no harm is done to the patients. Patients will also be encouraged to participate in the study without coercion freely. Besides, none will be unfairly excluded from participating in the study. Patient data will also be protected to remain confidential and unauthorized access blocked. The patients will be shown the necessary respect in terms of autonomy and be treated without bias, just, fairly, and equally.
Data Analysis Approach
10)
Data Analysis Approach:
i. The participant’s data will be analyzed using the IBM SPSS statistics software. The central tendency measures will be used in summarizing the characteristics of the patients. They will be the mean or average of continuous and discrete data and the median.
ii. Descriptive statistics will be applied in analyzing the collected demographic data such as gender, co-morbidities, ethnicity, race, and age.
iii. Descriptive analysis will also be used to describe the population as well as what happens with the computation of standard deviations, median, and mean. It will also help in describing the variables and their relationships through the use of a mixed linear regression model.
iv. Data will be obtained from EHR and the continuous glucose monitoring database platform.
v. There will be a review of the HbA1c levels obtained using continuous glucose monitors.
vi. Paired sample t-test and Pearson’s correlation will be used to determine the significant differences between the intervention data and baseline data and between the groups.
vii. A statistician will also be consulted to help with the statistical aspects of the project.
Potential data bias can result in the possible improved glycemic control could be as a result of the intervention and other self-care activities that the patient undertakes outside the study. One way of mitigating data is through the use of an appropriate study design. The Hawthorne effect is also possible since the patients will be in the know that they are part of the study and, therefore, their behavior is being kept under watch
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© 2020. Grand Canyon University. All Rights Reserved.
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