Building Evidence: Increasing the RN role in Diabetes Management

<table align="left" border="0" cellpadding="1" cellspacing="1" height="118" width="437">
<tbody>
<tr>
<td>
Primary Author:</td>
<td>
Ingrid M. Duva, PhD</td>
</tr>
<tr>
<td>
Co-Principal Investigators/Collaborators:</td>
<td>
<p align="left">Anne Tomolo, MD, MPH, Sharon Lewis, MSN, RN-BC, CDE</p>
</td>
</tr>
<tr>
<td>
Organization:</td>
<td>
Veterans Administration Healthcare Administration</td>
</tr>
</tbody>
</table>
<h2 class="block">
 </h2>
<h2 class="block">
 </h2>
<h2 class="block">
 </h2>
<h2 class="block">
Abstract</h2>
<h3>
Purpose</h3>
<p>This pilot was an opportunity to evaluate RNs practicing to a greater capacity by implementing an individualized, structured glucose management program, focusing on patient education and utilizing decision support to guide medication management. A better understanding of the feasibility, practice implications, and disease related outcomes of this RN led approach, within a defined context, was sought. </p>
<h3>
Background</h3>
<p>Licensed, non-provider team members can share responsibility for patient care and decompress ballooning demands on primary care providers. Nurse led patient care with attention to self-management skills is found to improve a broad array of chronic disease measures. Evidence-based practices shown to specifically improve diabetes care include: Care team changes, case management, “facilitated relay” (which is timely feedback looping between the patient and care team), and patient education. </p>
<h3>
Materials & Methods</h3>
<p>Five primary care RN volunteers and their partner providers were trained in the approach, the algorithm, and the computer software. The RNs attended a diabetes educator course and an RN expert served as a resource for the 6 month pilot. Ten patients with an A1C greater than 8.0 and no mealtime insulin participated. Pre and post disease measures and qualitative data were collected.</p>
<h3>
Results</h3>
<p>A1C and glucose variability showed overall improvement. Focus group and individual nurse and patient interview data provided insight into implementation facilitators and barriers. Challenges to participation and expansion of care team roles were identified and can begin to be addressed. </p>
<h3>
Conclusion</h3>
<p>This study serves as a model for evaluating the use of algorithms designed to improve quality of care and as a tool for increasing scope and responsibility of RNs in chronic disease patient management. The nurse-led approach was well received by patients and showed preliminary support for improving patient self-management skills and associated outcomes. However, results also provide considerations for future intervention studies designed to increase the scope of the RN and improve care for patients in this setting. </p>
<p> </p>
<h3>
Bibliography</h3>
<ul>
<li align="left">
Bodenheimer, T.S., & Smith, M.D. (2011). Primary Care: Proposed solutions to the physician shortage without training more physicians. Health Affairs, 32(11), 1881-1886. doi: 10.1377/hlthaff.2013.0234</li>
<li align="left">
Cohen, J. (2013). Impact of nurse-led diabetes medication management clinic on glycemic control AACE Paper presented at the AACE.</li>
<li align="left">
Juul, L., Maindal, H.T., Frydenberg, M. , Kristensen, J. , & Sandbaek, A. . (2012). Quality of Type 2 Diabetes management in general practice is associated with involvement of general practice nurses. Primary Care Diabetes, 221-228.</li>
<li align="left">
Mathias, M.S., Miech, E.J., Myers, L.J., Sargent, C., & Bair, M.J. (2012). An expanded view of self- management: Patients’ perceptions of education and support in an intervention for chronic musculoskeletal pain. . Pain Medicine(18), 1018-1028.</li>
<li align="left">
Tricco, AC., Ivers, MN., Grimshaw, JM., Moher, D., Turner, L., Galipeau, J., . . . Shojania, K. (2012). Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. The Lancet, 379, 2252-2261.</li>
<li align="left">
Tshiananga, J.K., Kocher, S., Erny-Albrecht, K., Berndt, K., & Neeser, K. (2012). The effect of nurse-led diabetes self-management education on glycosylated hemoglobin and cardiovascular risk factors. A meta-analysis. Diabetes Educator(38), 108-123.</li>
<li align="left">
Wakefield, B.J., Scherubel, M., Ray, A., & Holman, J. (2013). Nursing Interventions in a Telemonitoring Program. Telemedicine and e-health, 19(3), 1-6. Doi: 10.1089/tmj.2012.0098</li>
</ul>
<p>© Improvement Science Research Network, 2012</p>
<p>The ISRN published this as received and with permission from the author(s).</p>