Nursing Research Proposal Research Paper Examples
Implementing a Diabetic Education Program for Patients and Caregivers
Background: Diabetes mellitus is becoming prevalent in the United States of America across all ethnic, socioeconomic, and demographic lines. Precisely, children, elderly people, and pregnant women of childbearing age are at a high-risk of developing the disease. It is the fourth leading cause of death globally, and “currently affects 246 million peoplearound 380 million people will have diabetes by the year 2025” (Ricci-Cabello , Ruiz-Perez, deLabry-Lima & Marquez-Calderon, 2010 p. 572).
Purpose: The purpose of this study is to evaluate the effects of implementing a patient education program with social support for both caregivers and patients within 1, 3 and 6 intervals.
Theoretical framework: Bandura’s theory of self-efficacy supports the hypothesis of this project. According to Albert Bandura, self-efficacy is “rooted in the core belief that one can produce effects by one’s actions. people are significant contributors to their life circumstances not just products of them (Bandura, Caprara, Barbaranelli, Regalia, & Scabini, 2011).
Review of literature: There are many studies that evaluate the effect of caregiver/ patient relationships which the invaluable contributions in the management of diabetes mellitus. Programs have been implemented in the past to develop more effective patient-caregiver relationships, and studies have shown the effectiveness of these programs.
Method (method you are considering):
Implementing a Diabetic Education Program for Patients and Caregivers
Diabetics who participate in educational programs along with their caregivers have the opportunity to improve patient outcomes as a result of being educated together concerning strategies employed in a DM management care plan. Caregivers are individuals who assist patients with their daily activities and are responsible for their care. Importantly, they are not limited to family members or significant others, but health agencies also provide these services as home health aides and companionship.
The social support provided combining patient and caregivers’ involvement in management of DM proves beneficial towards improving quality of life, well-being and effective adaptation to coping interventions. Diabetics manage their condition better when healthcare providers offer educational programs that teach patients how to design care plans in keeping blood sugar levels under control. The establishment of a diabetic management team, which includes the patient, their primary health care provider and a patient identified caregiver, would also facilitate their education. Patients with social, economic and emotional support from a caregiver benefit from the intervention and develop the ability to control the condition better. Nurses and clinical staff can educate patients and their caregivers empowering both parties to maintain a high quality of care. There are often discrepancies between the health care professionals’ objectives and patients’ goals especially, if he/she is not an active participant in his/her care. Caregivers are in a position to improve social support by increasing their knowledge base through diabetic education regarding the care of DM, the effectiveness of the patient’s involvement as well as the entire family (spouse, children and patient). Nurses play a critical role in resolving many discrepancies in further aligning patient’s goals in management of DM utilizing an effective care management plan.
The question then, is, “How does implementing a DM education program for both patients and caregivers improve patient adherence and outcomes?”
In poorly controlled type 2 DM managed through primary care strategies, how does implementing a patient education program with social support for both caregivers and patients promote better outcomes after 1 month, 3 months and 6 months?
Diabetes mellitus is becoming prevalent in the United States of America across all ethnic, socioeconomic, and demographic population boundaries. Precisely, children, elderly people, and pregnant women of childbearing age are at a high-risk of developing the disease. It is the fourth leading cause of death globally, and “currently affects 246 million peoplearound 380 million people will have DM by the year 2025” (Ricci-Cabello , Ruiz-Perez, deLabry-Lima & Marquez-Calderon, 2010). Regarding the incidence some populations are affected more than others. Research has shown more complications, higher mortality rates and more diagnosis for DM “among women, ethnic minorities and people with a low socioeconomic level” (Ricci-Cabello et al, 2010).
More research shows that the national cost of DM in the U.S. in 2007 exceeds $174 billion (Moser, van der Bruggen, Widdershoven & Spreevwenberg, 2008). This estimate includes $116 billion in excess medical expenditures attributed to diabetes, as well as $58 billion in reduced national productivity (Moser et. al, 2008). People with diagnosed DM, on average, have medical expenditures that are approximately 2.3 times higher than the expenditures would be in the absence of DM (Moser et. al, 2008). Approximately $1 in $10 health care dollars is attributed to DM. Indirect costs include increased factors such as absenteeism, reduced productivity, and lost productive capacity due to early mortality (Moser et. al, 2008).
Caregivers provide efficient support in the self-management process of type 2 DM. Their involvement in a patient’s care plans “has a different meaning to each diabetic” (Moser et. al, 2008). Families can contribute in various ways towards enacting these care programs. Caregivers who have been targeted for social support intervention are empowered to produce improved outcomes such as delayed complications and controlled blood sugar levels (Idalski- Carcone, Ellis, Weisz, & Naar-King, 2011).
Further research was conducted to provide evidence that education is valuable in DM self-management. Ka mrath & Timmer (2012) in their Cochrane Collaboration Systematic review stated that education is essential in caring for DM patients (Kamprath & Timmer, 2012). Decrease in the cost of and postponement of complications ought to be the goals embraced by caregiver training programs as they provide matching professional support (Neufeld, Harrison, Hughes & Stewart, 2007).
A treatment plan to increase life expectancy should include reducing the risk for morbidity and mortality, incorporating individualized therapy and “judiciously manages symptoms . while remaining consistent with the patient’s . healthcare preferences” (Cayea, Boyd & Durso, 2007). These preferences need to be detailed, explained and highlighted to the caregivers of DM patients in developing and accessing the optimum program for care. The involvement of diabetic caregivers needs to include taking part in consultancies finding ‘answers to their caring questions to contribute effectively to the diabetes self-management of their kin” (Moser et. al, 2008).
The American Association of Diabetes Educators has identified seven self-care interventions to assist the categorizing of patient’s activities. Interventions are measures taken by a patient to monitor lifestyle ultimately reducing the risk of DM. These include healthy eating, being active, monitoring, taking medication, problem solving, reducing risks and developing healthy coping strategies (Miller, Krusky, Franzen, Cochran, & Zimmerman, 2012). Research shows that the best way to improve diabetic care is through education, and both care givers and patient education should be implemented on the clinical sites, as well in the home setting. (Neufeld, Harrison, Hughes & Stewart, 2007). Further, research conducted by Sinclair, Armes, Randhawa and Bayer (2010) noted that both patient and caregiver diabetes education strategies are require as many as one in seven careers felt regularly overwhelmed and lacked adequate support ( Sinclair, Armes, Randhaw & Bayer, 2010) . By aiming at the improvement of diabetic knowledge to both care givers and patient, management of the condition would be greatly enhanced since the disease affects major organ systems (Miller et.al, 2012)
It is possible to align interventions with the patient’s specific needs. Caregivers and patients must make mutual decisions regarding DM care. This is the only way caregiver/patient diabetes mellitus management programs can be successful. Project Help Educate to Eliminate D.M or HEED “was successful in obtaining significant group differences in weight loss at 12 months” (Kanaya et. al, 2012) in patients with DM. Healthy-Living Partnerships to Prevent Diabetes (Help PO), is another community-based translation program that found reductions in fasting glucose levels offered to well-educated patients of high risk (Kanaya et. al, 2012).
Live Well, Be Well is a translation program that produced favorable outcomes. The researcher utilized telephone-based models in the study (Kanaya et.al, 2010). It allowed participants in minority communities to work with local clinically based experts providing interventions through text messaging. This ultimately helped reduce the incidence of diabetes mellitus complications by managing the condition more effectively. It was a translation evidence based strategy with priorities focused on vulnerable understudied groups, offered generalizable information, developed partnerships between researchers and local public health departments. The translation process was organized for sustainability being designed and managed within the public health department’s chronic disease prevention program (Kanaya et.al, 2010).
Similar translation strategies are expected to be adapted in this intervention. A care giver support group to improve patients’ outcomes will be designed and thereafter known as the patient/caregiver team (Miller, Krusky, Franzen, Cochran, & Zimmerman, 2012). In conducting this study, patients with caregivers will be recruited from a primary care practice community office visit setting. Office visits will be scheduled at weekly intervals. To evaluate effectiveness of the program patient outcomes including blood sugar levels, blood pressure, weight control and predispositions to complications will be evaluated over a six month interval.
It would involve an intense patient education program, which forms the core of translation of evidence into practice. Precisely, specific needs of each patient/care giver team will be identified during interviews weekly. Responses to the intervention will be recorded from the patents’ perspective as well as care giver. Caregiver stress levels will be evaluated using a likert scale 1-5 for recording levels of stress (Intense, moderate, mild, none, cannot decide).
The theoretical basis of this nursing research is guided by Albert Bandura’s theory of self-efficacy. According to Albert Bandura, self-efficacy is “rooted in the core belief that one can produce effects by one’s actions. people are significant contributors to their life circumstances not just products of them” (Bandura, Caprara, Barbaranelli, Regalia, & Scabini, 2011). Caregivers are expected to involve patients in planning the self-care process. Bandura and colleagues argue that an individual’s self-efficacy plays a major role in how goals are achieved, tasks executed, and challenges approached (Bandura et.al, 2011). Others have contended that caregivers should encourage self-management support (SMS). This is considered “a cornerstone of chronic disease care encompassing such strategies as individualized assessment, collaborative goal-setting, skills enhancement, access to resources and continuity of care” (Schillinger, Handley, Wang & Hammer, 2009). Family based interventions were reviewed in a study by Keogh (2007) to highlight strategies for improving outcomes for patients with uncontrolled type 2 D.M. The researchers found that family members caregivers “may influence outcomes in physical health by means of a psychological and/or health behavior pathway” (Keogh et. al, 2007).
It must be understood that when family members take on the caregiver‘s responsibility they can become overwhelmed in caring for the person. Factors associated with the caregiver burden syndrome are “the care recipient’s disabled state, the measureable observed variables of MFS, PGC scale, caregiver’s age, care self-efficacy, having a cooperator, spouse caregiver and the J-ZbI-8 (caregiver burden)” (Makizako et. al, 2009). Theorists agree those caregivers’ goals “are to achieve the maximum longevity consistent with an optimal quality of life” (Cayea, Boyd, Burso, 2007).
Caregiver/ patient relationships have repeatedly shown their invaluable quality in the management of DM Programs have been implemented in the past to develop more effective patient-caregiver relationships, and studies have shown the effectiveness of these programs. However, there are studies showing how implementing a diabetic education program for both patients and caregivers can improve patient adherence and outcomes.
Already it is known that with efficient caregivers, self- management of DM can be more effective. Studies on DM self-management with care giver input have indicated immense improvement in outcomes. Importantly, Cohen, Christensen, & Feldman (2012) examined methods that disease management organizations can adopt in increasing adherence to self-management techniques. Precisely, the study measured effectiveness of adherence programs targeting chronic illness including DM. Investigations reviewed whether adherence strategies are being coordinated with payers’ use of value-based insurance design, in which patient cost sharing a function of the relative value of pharmaceuticals. The results suggested that disease management might be falling short in terms of comprehensive commitment to expert recommended at-home devices used to self-diagnose and measure health indicators (Cohen, Christensen, & Feldman, 2012).
It also involved early adoption of expert-recommended new technologies to measure and improve adherence, and intensity use of standard tests in outpatient clinics. Therefore, this study provided data concerning incorporating technologies in arriving at as well as measuring outcomes (Cohen, Christensen, & Feldman, 2012). Similarly, Kim, Love, Quistberg, & Shea (2004) reviewed how literacy influences compliance with care guideline. Researchers contend that there is limited health literacy among diabetics. They performed a literacy analysis during a prospective observational study. It was observed after 3 months trial that diabetes education was effective in improving self-management, knowledge, and glycemic control for patients with adequate and limited health literacy. Further observations were that by expanding educational programs in cases of low literacy disparities in DM outcomes may be narrowed (Kim, Love, Quistberg, & Shea, 2004).
A startling discovery, however, was that after 3 months of education intervention diabetics with lower literacy showed more adherence to self-management techniques than those which begun the program with a higher literacy level. The conclusion was that ‘reinforcement of previously taught behaviors may have led to greater improvement in the limited literacy
Group’ (Kim et.al, 2004). Likewise, Khan, Al-Abdul Lateef, Al Aithan, Bu-Khamseen, Ibrahim, & Khan (2012) researched non-compliance/adherence to diabetic self-management among patients in Saudi Arabia. They discovered that there was a high noncompliance rate due to lack of education. Of 535 patients enrolled in this cross sectional study, the noncompliance rate was 67.9%. However there was a significant difference between noncompliant and compliance among patients with varying levels of education. They concluded that education has a strong influence in adherence to diabetic self-management programs (Khan, Al-Abdul Lateef, Al Aithan, Bu-Khamseen, Ibrahim, & Khan, 2012).
Subsequently, Keyvanara, Hosseini, Emami’s (2012) study assessed how social support is related to the control of DM. The findings of this research showed where social support in diabetic care could result in low blood sugar, favorable self-care behaviors and decreasing depression. Further the researchers showed that there is a positive relationship between social support and control of DM. The patients with better instrumental, emotional, informational social support had better controlled DM (Keyvanara, Hosseini & Emami, 2012)
Yet in another study conducted by Sinclair, Armes, Randhawa, Bayer (2010) where they interviewed caregivers of diabetics, it was observed that patient and caregiver knowledge of DM was inadequate in producing favorable outcomes. Often education and training provided very important strategies in resolving adherence issues and arriving at more favorable outcomes (Sinclair, Armes, Randhawa & Bayer, 2010). Likewise, Hirakawa, Kuzuya, Masuda, Enoki and Iguchi, (2008) conducted studies showing the influence of diabetes mellitus support management on caregivers within the community among frail elderly diabetics. Support management of DM was not overwhelming to these caregivers. Findings also proved that there was no difference between male and female caregivers with respect to expressing stress due to execution of their duties (Hirakawa, Kuzuya, Masuda, Enoki and Iguchi, 2008)
Alternatively, further research has revealed that DM caregivers play an important role in endorsing self-management skills. Keogh, White, Smith, McGilloway and O’Dowd’s (2007) study assessed the effectiveness of education on poorly controlled DMpatients and caregivers. The study determined how to improve patients’ outcomes by nominating family member’s participation, following up with a phone call, and developing personalized action plans to improve diabetes management. Results were that of the 230 participants, there was a retention rate of 92%. ‘6-month group differences for weight and triglycerides were significant. The intervention group lost 2 pounds more than did the control group (P=.03) and had decreased triglyceride levels (difference in change, 23 mg/dL; P=.02). At 6 months, the intervention group consumed 7.7 fewer grams per day of fat (P=.05) and more fruits and vegetables (P=.02) than did control participants (Keogh, White, Smith, McGilloway & O’Dowd, 2007).
The purpose of Bandura, Caprara, Barbaranelli, Regalia & Scabini (2011) study was to assess the effectiveness of self-efficacy on the family as a whole. The study result showed that the family is efficacious if patients are self-reliant in their care management plan (Bandura, Caprara, Barbaranelli, Regalia & Scabini, 2011). Educational and support interventions are important for managing DM according to the Konradsdottir and Svavarsdottir (2011). This study assessed the effectiveness of short-term educational and support interventions for families of an adolescent with type 1 DM. The study reviewed the adaptation and coping strategies of parents who had adolescents with DM and the effect of a short-term educational and support intervention. The short-term education and support intervention consisted of three sessions namely, educational lectures, support interviews for the parents and support groups for the adolescents. A significant difference was found between parents’ coping patterns before and after the intervention. These results suggest that mothers and fathers use different coping patterns when coping with their adolescents’ chronic illnesses (Konradsdottir & Svavarsdottir, 2011).
American Medical Association. (2010). Diabetes Education Services. In American Association
of Diabetes Educators: American Association of Diabetes Educators.
Bandura, A., Caprara, G., Barbaranelli, C., Regalia, C., Scabini, E. (2011). Impact of family
efficacy beliefs on quality of family functioning and satisfaction with family life. Applied
Psychology: An International Review, 60(3), 421-448. DOI: 10.1111/j.1464-
Cayea, D., Boyd, C., Durso, S. (2007). Individualizing therapy for older adults with Diabetes
Mellitus. Drugs & Aging, 24(10), 851-863. EBSCO Database: Academic Search Premier.
Cohen, J., Christensen, K., & Feldman, L. (2012). Disease management and medication
compliance. [Research Support, Non-U.S. Gov’t]. Popul Health Manag, 15(1), 20-28.
Fowler, M. (2009). Pitfalls in outpatient diabetes management. Clinical Diabetes, 27(2), 82-85.
Hirakawa, Y., Kuzuya, M., Masuda, Y., Enoki, H., Iguchi, a. (2008). Influence on diabetes
mellitus on caregiver burden in homecare: A report based on the Nagoya Longitudinal
Study of the Frail Elderly (NLS – FE). Geriatrics & Gerontology International, 8(1), 41-
47. DOI: 10.1111/j. 1447-0594.2008.00445.x.
Idalski Carcone, A., Ellis, D., Weisz, A., & Naar-King, S. (2011). Social support for diabetes
illness management: supporting adolescents and caregivers. J Dev Behav Pediatr, 32(8),
581-590. DOI: 10.1097/DBP.0b013e31822c1a27.
Kamprath, S., & Timmer, A. (2012). Prioritization of clinical research by the example of Type 2
Diabetes: A caregiver-study on perceived relevance need for evidence, PLoS ONE,
7(3), 1-7. DOI: 10.1371/journal.pone.0032414.
Kanaya, A., Santoyo-Olsson, J., Gregorich, S., Grossman, M., & Moore, T. (2012).
The Live Well, Be Well Study: A community-based, transactional lifestyle program to
lower diabetes risk factors in ethnic minority and lower-socioeconomic status adults.
American Journal of Public Health, 102(8), 1551-1558. DOI10.2105.AJPH.2011.300456
Keogh, K., White, P., Smith, S., McGilloway, S., O’Dowd, T., & Gibney, J. (2007, October).
Psychological Family Intervention for Poorly Controlled Type 2 Diabetes. Psychological
Family Intervention for Poorly Controlled Type 2 Diabetes. Retrieved October 10, 2007,
Keogh, K., White, P., Smith, S., McGilloway, S., O’Dowd, T., Gibney, J. (2007). Changing
illness perceptions with poorly controlled type 2 diabetes, a randomized controlled trial of a
family-based intervention: protocol and pilot study. BMC Fam Pract., 81(36). DOI:
Keyvanara, Hosseini, Emami (2012). Social Support and Diabetes Control: a Study Among
Patients Admitted to Specialized Clinic of Dr. Gharazi Hospital in Isfahan N.p. Web.
Khan, A. R., Al-Abdul Lateef, Z. N., Al Aithan, M. A., Bu-Khamseen, M. A., Ibrahim, I. A., &
Khan, S. (2012). Factors contributing to non-compliance among diabetics attending
primary health centers in the Al Hasa district of Saudi Arabia. J Family Community
Med, 19(1), 26-32. DOI: 10.4103/2230-8229.94008.
Kim, S., Love, F., Quistberg, A., & Shea, J. (2004). Association of Health Literacy with Self-
Management Behavior in Patients With Diabetes. Diabetes Care, 27(12). Retrieved
October 10, 2012, from http://care.diabetesjournals.org
Konradsdottir, and Svavarsdottir (2011). How Effective Is a Short-term Educational and Support
Intervention for Families of an Adolescent with Type 1 Diabetes. N.p. Web.
Makizako, A., Abe, T., Shimada, H., Ohnuma, T., Furuna, T., Nakamura, Y. (2009). Combined
effect of factors associated with burdens on primary caregiver. Geriatrics &Gerontology
International, 9(2), 183-189. DOI: 10.1111/j1447-0594.2009.00523.x.
Miller, A. Krusky, A. Franzen, S. Cochran, S., & Zimmerman, M. (2012). Partnering to
Translate Evidence-Based Programs to Community Settings: Bridging the Gap Between
Research and Practice. Retreived on 19th January, 2012 from
Moser, A., van der Bruggen, H., Widdershoven, G., & Spreevwenberg,C. (2008). Self-
management of type 2 diabetes mellitus: a qualitative investigation from the
perspective of participants in a nurse-led, share a-care programme in the
Netherlands, BMC Public Health, 8, 91-99. EBSCO Database: Academic Search
Premier.National Diabetes Education Program (U.S.). (2009). Guiding principles for
diabetes care: For health care
professionals. 9(4343), 1-24. The Program. Retrieved from
Neufeld, A., Harrison, M., Hughes, K., & Steward, M. (2007). Non-supportive interactions in the
experience of women family caregivers. Health & Social Care in the Community,
15(6), 530-541. DOI: 10.1111/j.1365-2524.2007.00716.x.
Ricci-Cabello, I., Ruiz-Perez, I., deLabry-Lima, a., Marquez-Calderon, S. (2010). Do social
inequalities exist in terms of the prevention, diagnosis, treatment, control and monitoring
of diabetes? A systematic review. Health & Social Care in the Community, 18(6), 572-
587. DOI: 10.1111/j.1365-2524.2010.00960.x.
Schillinger, D., Handley, M., Wang, F., Hammer, H. (2009). Effects of self-management support
on structure, process, and outcomes among vulnerable patients with diabetes: a three-
arm practical clinical trial. Diabetes mellitus Care, 32(4), 559-566. Epub2009 Jan 8.
Schiotz, M. L., Bogelund, M., Almdal, T., Jensen, B. B., & Willaing, I. (2012). Social support
and self-management behaviour among patients with Type 2 diabetes. Diabet Med,
29(5), 654-661. DOI: 10.1111/j.1464-5491.2011.03485.x.
Sinclair, A. Armes, D. Randhawa, G., & Bayer, A. (2010). Caring for older adults with
diabetes mellitus: characteristics of carers and their prime roles and responsibilities.
DiabeticMedicine, 27(9), 1055-1059. DOI: 10.1111/j.1464-5491.2010.03066x.
Zulman, D., Kerr, E., Hofer, T., Heisler, M., Zikmund-Fisher, B. (2010). Patient-provider
concordance in the prioritization of health conditions among hypertensive diabetes patients,
JGIM: Journal of General Internal Medicine, 25(5), 408-414. DOI: 10.1007/s11606-009-