Target individual needs to boost diabetic compliance
Target individual needs to boost diabetic compliance
Diabetes education gets fine-tuned
Diabetes educators at Parkland Memorial Hospital in Dallas thought they had designed an effective patient education program because they had used the guidelines established by Alexandria, VA-based American Diabetes Association.
But they soon found out the program was too advanced for the hospital’s patients. Patients were having trouble applying the information and skills they were taught about diabetes. So the diabetes team went back to the drawing board. They redesigned the educational materials to make the program more user-friendly by simplifying the information.
"We noticed that patients were being admitted to the hospital and to the emergency unit more often than we wanted. We were getting telephone calls from patients about problems such as low blood sugar, and some were just walking in [to the inpatient diabetes center] and complaining about not being able to manage their diabetes," says Naomi George, MSN, RN, CDE, clinical nurse specialist and program coordinator for the University Diabetes Treatment Center at Parkland.
Meeting the needs of patients at Parkland is perhaps more of a challenge than most hospitals face. The 900-bed county hospital serves a low-income area, and about 50% to 60% of the patients are uninsured, in addition to a large Medicare and Medicaid patient load. Most of the patients admitted to the 11-bed inpatient diabetes treatment center have low literacy skills or do not speak English.
In addition, many have problems such as alcohol abuse and homelessness. Patients often were not able to implement what they were being taught, George explains. For example, people living in shelters could not easily follow the foot care regimen because they did not have access to showers daily or to a place with the equipment to sand calluses and clip toenails.
To better meet the needs of Parkland’s diabetic patients, George began to redesign the program. As a result, Parkland’s program now includes the following modifications:
1. Using illustrated educational materials.
First, George created low-literacy patient education materials with lots of illustrations. "We have a few patients who don’t read at all, so we wanted the education materials to have enough pictures so people could follow instructions without being able to read," says George.
George and nurses from the inpatient unit and outpatient diabetes clinic rewrote the materials at a fourth- or fifth-grade level. Patients reviewed the material for content and suggested some rewording and additional illustrations. All written education materials are available in Spanish and English.
2. Offering continuous telephone support.
A clinical nurse specialist is now available 24 hours a day, seven days a week to answer telephone calls from patients who are having problems managing their diabetes. More frequent follow-up care in the outpatient clinic also is arranged. When patients are discharged from the inpatient diabetes center, an appointment is automatically made, and future appointments are made as needed. Patients unable to follow the foot care regimen at home, for example, see the foot-care nurse every two to three months to have their toenails trimmed and calluses sanded.
3. Identifying learning barriers early.
While the curriculum is generic, the teaching is individualized to fit the needs of each patient. To determine what the patient needs to learn to manage his or her diabetes, a lot of time is spent on assessment, George says. Assessment includes readiness to learn, motivation, communication skills, self-care skills, and ability to solve problems.
If a patient has a learning barrier such as poor eyesight, the nurse will tailor materials to the patient’s needs. For example, rather than giving the patient pre-printed materials, the nurse may write instructions in large letters on a sheet of paper.
4. Using a self-management skills assessment.
Skills are assessed on an ongoing basis by having patients perform the tasks of daily care, such as drawing up and administering insulin. Teaching is evaluated and then reinforced during the patient’s hospital stay, which is usually three to four days.
For example, if a nurse teaches a patient the signs and symptoms of low blood sugar and what to do when they occur, she would ask the patient what might be wrong if he or she were weak and sweaty, and how to solve the problem. Often, patients know that the symptoms indicate low blood sugar, but they don’t know what to do about the problem, George says. The practice of having a clinical nurse specialist available 24 hours a day to answer patients’ questions was implemented in response to the patient population’s difficulty with problem solving.
5. Documenting education efforts on a checklist.
To ensure patients learn all the things they need to know, education is carefully documented on a diabetes education checklist. Assessment codes help the nurses doing the education know whether information previously covered needs to be reinforced. Assessment codes include "K" for knowledgeable, "R" for needs review, and "P" for needs practice. Parkland’s education curriculum is based on ADA standards and covers 15 areas, including medications, meals, foot care, and complications.
Education categories on the checklist include general facts, medications, monitoring (blood glucose), nutrition, exercise, acute complications (hypoglycemia/hyperglycemia), chronic complications (eyes and feet), psychological adjustment, support systems, and lifestyle management.
Patients are admitted to the University Diabetes Treatment Center from the emergency department and hospital outpatient clinics, or are transferred from other inpatient units. If patients are well enough to learn, education begins as soon as the patient is admitted. There is no group teaching on the unit. All teaching is one-on-one.
Before the patient is discharged, staff develop a self-management plan based on the patient’s lifestyle. "We don’t ask patients to make too many changes in their lifestyle. That is what has helped us be successful. We’ll adapt the insulin and insulin schedule to that lifestyle," George says.
For example, if patients don’t like to eat breakfast when they first get up in the morning, they would take their insulin when they are ready to eat breakfast, and then plan additional meals at four- to five-hour intervals. Because many of the patients won’t or can’t make major changes in their diet, nurses interview the patients on what they eat, and the insulin is adjusted to the diet.
In order to comply with ADA requirements, patients must set goals prior to discharge, and staff must follow up with the patients three to six months later to see if goals were achieved. Goals are something a patient plans to change to improve his or her health, such as drinking diet soda rather than regular soda.
Can they apply the knowledge they’ve gained?
Follow-up with the diabetes patients at Parkland is difficult because many of the patients don’t have telephones or they move around a lot. To track patients, nurses from the diabetes center call patients to see if they are meeting their goals. In addition, they check the computer to see when those patients have appointments scheduled in the outpatient clinic, and ask the nurse to send the patient to the center following the appointment or meet the patient in the outpatient area.
The effectiveness of the program is assessed each time a patient is discharged from the unit. Before discharge, patients are given a 21-question multiple-choice test to see if they can apply the knowledge they’ve gained. For example, one question is: "What would you do if you felt sweaty and were shaking? A. Take more insulin. B. Walk to the hospital. C. Drink a regular soda." If the patient can’t read, a nurse reads the test to him or her. When a patient receives a low score, nurses review the information with patients.
An appointment with a physician at the outpatient diabetes clinic at Parkland Hospital is scheduled before the patient is discharged from the center. "Once the patient keeps that appointment, the doctor and the patient decide on further follow-up," says Pat Challis Sellards, MSN, RN, CDE, diabetes clinical nurse specialist in the Diabetes Nursing Clinic at Parkland Outpatient Center. If the physician identifies a need for further teaching at the time of the appointment, the patient sees a diabetes nurse for one-on-one teaching.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.