Description of Procedures (Surgeries) Performed this Admission:
Section II
Pathophysiology
(Points 10)
In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan)
List all interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.
(Points 10)
Interventions
Rationale
Section VI
Teaching and Health Promotion(Points 5)
List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.
1)
2)
3)
4)
5)
Section VII (Points 5)
List of Nursing Diagnoses Use your assessment, the client’s medications, and history to write your diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your client’s signs and symptoms. (List the nursing diagnosis in order of priority.)
1)
2)
3)
4)
Section VIII (Points 10)
Medications
Medication
Dose/ Brand/
Generic Name
Mechanism of Action/Indication for Use
Contraindication
Adverse Effects/Side Effects
Nursing Implications
Outcomes
Section IX
Nursing Interventions
(Points 15)
CAREPLAN FOR “3 ” (MINIMUM) NURSING DIAGNOSES
Assessment
findings
Nursing Diagnosis
(Actual & Potential Deficits, Wellness Diagnoses)
Outcomes
Short and Long Term
Interventions/ Nursing Systems
(Dependent & Independent)
Rationale
(Why are performing that intervention?)
Evaluation/ Outcome
(What was the actual result?)
School of Health Professions, Science and Wellness
General Data, Health History, and Review of Systems
10 Points
Section II
Attached references in APA Format
5 Points
Pathophysiology of Disease Process
10 Points
Classic Signs and Symptoms of Disease Process
5 Points
Section III Physical Assessment
15 Points
Section IV Diagnostic Data
5 Points
Section V Treatments and Procedures
5 Points
Section VI Teaching and Health Promotion
5 Points
Section VII List of Nursing Diagnoses
10 Points
Section VIII Medications
5 Points
Section IX Care Plan with 4 minimum nursing diagnoses
20 Points
TOTAL POSSIBLE POINTS
100 Points
Name of Clinical Professor: ____________________________________________
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Who We Are
We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.
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We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
GuaranteeNURS 489 – Synthesis of Complex Nursing Care
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Community Assessment and Analysis Presentation Instructions
Community Assessment and Analysis Presentation Instructions
The RN to BSN program at Grand Canyon University meets the requirements for clinical competencies as defined by the Commission on Collegiate Nursing Education (CCNE) and the American Association of Colleges of Nursing (AACN), using nontraditional experiences for practicing nurses. These experiences come in the form of direct and indirect care experiences in which licensed nursing students to engage in learning within the context of their hospital organization, specific care discipline, and local communities.
Select a community of interest in your region. Perform a physical assessment of the community.
Perform a direct assessment of a community of interest using the “Functional Health Patterns Community Assessment Guide.”
Interview a community health and public health provider regarding that person’s role and experiences within the community.
Interview Guidelines
Interviews can take place in-person, by phone, or by Skype.
Develop interview questions to gather information about the role of the provider in the community and the health issues faced by the chosen community.
Complete the”Provider Interview Acknowledgement Form” prior to conducting the interview. Submit this document separately in its respective drop box.
Compile key findings from the interview, including the interview questions used, and submit these with the presentation.
PowerPoint Presentation
Create a PowerPoint presentation of 15-20 slides (slide count does not include title and references slide) describing the chosen community interest.
Include the following in your presentation:
Description of community and community boundaries: the people and the geographic, geopolitical, financial, educational level; ethnic and phenomenological features of the community, as well as types of social interactions; common goals and interests; and barriers, and challenges, including any identified social determinates of health.
Summary of community assessment: (a) funding sources and (b) partnerships.
Summary of interview with community health/public health provider.
Identification of an issue that is lacking or an opportunity for health promotion.
A conclusion summarizing your key findings and a discussion of your impressions of the general health of the community for the Community Assessment and Analysis Presentation
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA format ting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
Interview Guidelines
Interviews can take place in-person, by phone, or by Skype.
Develop interview questions to gather information about the role of the provider in the community and the health issues faced by the chosen community.
Complete the “Provider Interview Acknowledgement Form” prior to conducting the interview. Submit this document separately in its respective drop box.
Compile key findings from the interview, including the interview questions used, and submit these with the presentation.
Here is the Community Assessment and Analysis Presentation GCU
Community Assessment and Analysis Presentation
Create a PowerPoint presentation of 15-20 slides (slide count does not include title and references slide) describing the chosen community interest.
Include the following in your presentation:
1. Description of community and community boundaries: the people and the geographic, geopolitical, financial, educational level; ethnic and phenomenological features of the community, as well as types of social interactions; common goals and interests; and barriers, and challenges, including any identified social determinates of health.
2. Summary of community assessment: (a) funding sources and (b) partnerships.
3. Summary of interview with community health/public health provider.
4. Identification of an issue that is lacking or an opportunity for health promotion.
5. A conclusion summarizing your key findings and a discussion of your impressions of the general health of the community.
While APA style, and thesis is required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA format ting guidelines.
Community Assessment and Analysis Presentation
Functional Health Patterns Community Assessment Guide
Functional Health Pattern (FHP) Template Directions:
This FHP template is to be used for organizing community assessment data in preparation for completion of the topic assignment. Address every bulleted statement in each section with data or rationale for deferral. You may also add additional bullet points if applicable to your community.
Value/Belief Pattern
Predominant ethnic and cultural groups along with beliefs related to health.
Predominant spiritual beliefs in the community that may influence health.
Availability of spiritual resources within or near the community (churches/chapels, synagogues, chaplains, Bible studies, sacraments, self-help groups, support groups, etc.).
Do the community members value health promotion measures? What is the evidence that they do or do not (e.g., involvement in education, fundraising events, etc.)?
What does the community value? How is this evident?
On what do the community members spend their money? Are funds adequate?
Predominant health problems: Compare at least one health problem to a credible statistic (CDC, county, or state).
Immunization rates (age appropriate).
Appropriate death rates and causes, if applicable.
Prevention programs (dental, fire, fitness, safety, etc.): Does the community think these are sufficient?
Available health professionals, health resources within the community, and usage.
Common referrals to outside agencies.
Nutrition/Metabolic for the Community Assessment and Analysis Presentation
Indicators of nutrient deficiencies.
Obesity rates or percentages: Compare to CDC statistics.
Affordability of food/available discounts or food programs and usage (e.g., WIC, food boxes, soup kitchens, meals-on-wheels, food stamps, senior discounts, employee discounts, etc.).
Availability of water (e.g., number and quality of drinking fountains).
Fast food and junk food accessibility (vending machines).
Evidence of healthy food consumption or unhealthy food consumption (trash, long lines, observations, etc.).
Provisions for special diets, if applicable.
For schools (in addition to above):
Nutritional content of food in cafeteria and vending machines: Compare to ARS 15-242/The Arizona Nutrition Standards (or other state standards based on residence)
Amount of free or reduced lunch
Elimination (Environmental Health Concerns)
Common air contaminants’ impact on the community.
Waste disposal.
Pest control: Is the community notified of pesticides usage?
Hygiene practices (laundry services, hand washing, etc.).
Bathrooms: Number of bathrooms; inspect for cleanliness, supplies, if possible.
Universal precaution practices of health providers, teachers, members (if applicable).
Temperature controls (e.g., within buildings, outside shade structures).
Evidence of sedentary leisure activities (amount of time watching TV, videos, and computer).
Means of transportation.
Sleep/Rest
Sleep routines/hours of your community: Compare with sleep hour standards (from National Institutes of Health [NIH]).
Indicators of general “restedness” and energy levels.
Factors affecting sleep:
Shift work prevalence of community members
Environment (noise, lights, crowding, etc.)
Consumption of caffeine, nicotine, alcohol, and drugs
Homework/Extracurricular activities
Health issues
Cognitive/Perceptual for the Community Assessment and Analysis Presentation
Primary language: Is this a communication barrier?
Educational levels: For geopolitical communities, use http://www.census.gov and compare the city in which your community belongs with the national statistics.
Birth rates, abortions, and miscarriages (if applicable).
Access to maternal child health programs and services (crisis pregnancy center, support groups, prenatal care, maternity leave, etc.).
Coping/Stress for the Community Assessment and Analysis Presentation
Delinquency/violence issues.
Crime issues/indicators.
Poverty issues/indicators.
CPS or APS abuse referrals: Compare with previous years.
Drug abuse rates, alcohol use, and abuse: Compare with previous years.
Stress management resources (e.g., hotlines, support groups, etc.).
Prevalent mental health issues/concerns:
How does the community deal with mental health issues
Mental health professionals within community and usage
Disaster planning:
Past disasters
Drills (what, how often)
Planning committee (members, roles)
Policies
Crisis intervention plan
Read other examples of Community Assessment and Analysis nursing assignment
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Who We Are
We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.
Do you handle any type of coursework?
Yes. We have posted our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill out our Order Form. Filling the order form correctly will assist our team in referencing, specifications, and future communication.
Is it hard to Place an Order?
1. Click on “Order Now” on the main Menu and a new page will appear with an order form to be filled.
2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
3. Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
5. From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.
We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
GuaranteeCommunity Assessment and Analysis Presentation Instructions
We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
Looking for a Similar Assignment? Order a custom-written, affordable, plagiarism-free paper
This project is the creation of a presentation that introduces a community working group to emergency management.
The building of emergency management programs and their included emergency management plans are essential for the construction of resilient communities. Emergency managers must be able to lead all of their respective communities’ or organizations’ stakeholders to common ground on matters pertaining to protection against, prevention of, mitigation of, response to, and recovery from all hazards and threats. Emergency managers need to understand federal, state, and local regulatory drivers that govern emergency planning in their jurisdictions. Emergency managers must understand and apply Department of Homeland Security and Federal Emergency Management Agency directives and guidelines in the National Incident Management System (NIMS) and the National Preparedness System (NPS) in their planning and program building in order to ensure the greatest degree of all-hazards preparedness for their jurisdictions.
For this project, you will assume the role of a municipal emergency manager in your own community or another of your choice. As such, imagine you have put together the community’s first emergency management working group to assist you with the construction of the community’s emergency management program. The working group consists of key stakeholders from throughout the community, many of whom have no understanding of emergency management, but all are eager to help make their community more disaster-resilient.
In this assignment, you will demonstrate your mastery of the following course outcomes:
· Analyze emergency management regulatory drivers for informing development of programs that comply with federal guidelines.
· Analyze information in current appropriate federal agency reports for its applicability in guiding construction of community or organizational emergency management plans
· Assess components of real-world community or organizational emergency management plans for the extent to which they comply with appropriate federal agency guidelines
· Analyze basic federal emergency management principles for informing development of programs that comply with federal guidelines
Specifically, the following critical elements must be addressed (the order in which they are addressed in your presentation is at your discretion):
I. Emergency Management Regulatory Drivers
A. What are the provisions of the Stafford Act, and how might the act inform or impact the community’s emergency management plan? Be sure to support your position with evidence and examples.
B. What are the key points of the Post-Katrina Emergency Management Reform Act, and how might the act inform or impact the community’s emergency management plan? Be sure to support your position with evidence and examples.
C. Provide a timeline of the federal regulatory drivers (since 1950) that have impacted the nation’s emergency management system. You may include this as a diagram with text, or in parenthetical format.
D. For each of the drivers noted on your timeline, provide a brief explanation of the importance and impact each of the regulatory documents has had on the development and direction of the nation’s emergency management system. Be sure to substantiate your claims with evidence and examples.
E. Analyze the state-level regulatory drivers that pertain to your community. In other words, what effect will these drivers have on your community’s emergency management plan? Be sure to justify your rationale.
II. Trends and Constructing Plans
A. What is the “whole community” concept, and how will it help to direct the tasks that you expect the working group to fulfill? Be sure to provide examples that illustrate your point.
B. What is “community resiliency,” and how will it help to guide the activities of the working group? Be sure to support your position with evidence.
C. What aspects of FEMA’s private sector initiative do you feel can benefit your community, and why?
III. Compliance
A. What is the importance to your community of putting identified threats and hazards into context? How might this be used within an overall all-hazards analysis? Be sure to defend your rationale.
B. Analyze the risk assessment process as outlined by the Department of Homeland Security for your working group. In other words, what are some of the tasks that might be given to the working group members in gathering information to help you, as the emergency manager, to complete this process?
C. What are the basic components and tenets of the National Preparedness System, and why are they important to your working group?
IV. Basic Emergency Management Principles
A. Select multiple principles from FEMA’s eight basic emergency management principles and explain them to your working group. To comprehensively address this element, you must choose a minimum of three (3) of the principles.
B. What is the importance of the principles you selected to the process of building an emergency management program? In other words, why did you choose these particular principles with regard to the community’s plan-building process? How are they relevant or applicable?
C. How you will use the principles you selected in building the community’s emergency management program? Be sure to support your position with evidence and examples.
V. Ensuring Effective Response and Mitigation
A. What are the similarities and differences among the Department of Homeland Security’s types of formatting available for plan construction?
B. Select the plan format that you feel is most appropriate for your community’s plan in terms of effective emergency response and mitigation, and justify your rationale.
C. Analyze for your working group the role the members might be expected to play in the emergency management plan-building process. Consider providing examples of the types of tasks the members may be assigned under this process.
D. What are some of the pitfalls that your working group may encounter in the plan- building process, and what recommendations would you make for avoiding them? Be sure to support your recommendations with evidence and examples.
Guidelines for Submission: The presentation should contain 20–30 slides and include sufficient speaker notes on each slide to communicate the slide’s purpose.
All citations and references should be formatted according to current APA guidelines.
DPI Project – Proposal Defense PowerPoint and Call
This project requires using the ATTACHED PowerPoint template to complete the assignment.
Please see the ATTACHED SAMPLE from a previous student
You will need to use the CORRECTED VERSION of Word document from the initial project submission ATTACHED
In this topic, you will participate with your full DPI committee in the DPI Project Proposal Defense call. This meeting requires that you present your revised DPI Project Proposal live in PowerPoint form as it stands at this time.
General Requirements:
Use the following information to ensure successful completion of the assignment:
· While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines.
· You are required to submit this assignment to LopesWrite.
Directions:
1. Using the “DNP Project Proposal Oral Defense Template” as your guide, create a PowerPoint presentation of your DPI Project Proposal, to be used during your DPI Project Proposal Defense call.
2. Present the revised Project Proposal PowerPoint to your full DPI committee.
You are required to complete your assignment using real-world application. Real-world application requires the use of current evidence-based data, contemporary theories, and concepts presented in the course. The culmination of your assignment must present a viable application in a current practice setting.
Improving Medication Adherence in Diabetic Patients in Home Health Care Settings
Submitted by
Bola Odusola-Stephen
Direct Practice Improvement Project Proposal
Doctor of Nursing Practice
Grand Canyon University
Phoenix, Arizona
December 10, 2020
GRAND CANYON UNIVERSITY
Improving Medication Adherence in Diabetic Patients in Home Health Care Settings
by
Bola Odusola-Stephen
Proposed
December 10, 2020
DPI PROJECT COMMITTEE:
Mary Guhwe, DNP, Manuscript Chair
Bamidele Jokodola, RN, MSN, FNP, CMSRN, DNP, Committee Member
Full Legal Name, EdD, DBA, or PhD, Committee Member Comment by Author:
Abstract
Home-based healthcare is useful in managing some conditions as it is cost-effective and is known to improve the quality of life and longevity of patients. Home-based care is known to improve the mortality of patients due to the mental well-being associated with home-based care such as independence, mobility and the comfort of family and home. While beneficial, it can also be detrimental to patients if mishandled resulting in fatalities and complications in patients. Even though home-based care is popular and cost-effective, the adherence to medication by patients is unknown thus this project hopes to find out if educating patients undergoing home-based care improves their medication adherence. The project also aims to find out if family-led strategies lead to better medication adherence in home-based diabetes patients. Attachment and social cognitive theories will be used as the theoretical framework for this study. The project will be conducted in Urban Texas and will include 50 patients undergoing home-based care. Medical records of diabetes patients undergoing hospital-based care will also be reviewed for comparison. A standard questionnaire as well as the Morisky Medication Adherence scale (MMAS-8) will be used to collect data from patients. Data will be analyzed using excel and SPSS. Descriptive statistics and inferential statistics will both be used in analyzing data, Factor analysis will be used to analyze the data from the MMAS-8 tool. Comment by Author: The DPI template has the correct format for the abstract. Please refer to that and adjust your abstract. For the proposal you obviously will not have the results yet but you can complete the rest of the abstract requirements using the correct format Comment by Author: Make sure you have a change theory as part of your theories. As I mentioned previously, you do not need both the attachment and social cognitive theories but it is difficult to pin point which as you have not yet clearly identified what your intervention is for the project
Table of Contents Table of Contents Chapter 1: Introduction to the Project 1 Background of the Project 5 Problem Statement 6 Purpose of the Project 7 Clinical Question(s) 9 Advancing Scientific Knowledge 11 Significance of the Project 13 Rationale for Methodology 14 Nature of the Project Design 15 Definition of Terms 17 Assumptions, Limitations, Delimitations 20 Summary and Organization of the Remainder of the Project 23 Chapter 2: Literature Review 25 Theoretical Foundations 27 Review of the Literature 29 Theme 1 31 Theme 2 32 Summary 36 Chapter 3: Methodology 40 Statement of the Problem 41 Clinical Question 42 Project Methodology 44 Project Design 46 Population and Sample Selection 48 Instrumentation or Sources of Data 51 Validity 52 Reliability 53 Data Collection Procedures 54 Data Analysis Procedures 56 Potential Bias and Mitigation 59 Ethical Considerations 62 Limitations 64 Summary 66 References 68 Appendix A 70 Appendix B 72 Appendix C 74
Revised 4/21/2020 by: Dr. Suzette Scheuermann (Please remove this footer)
Chapter 1: Introduction to the Project
Improving Medication Adherence in Diabetic Patients in Home Health Care Settings Comment by Author: You have numerous formatting issues throughout the proposal that need to get fixed. My advise is to use a new template and re-enter your information in the new template as the template is already formatted for you in APA format
It is important that there should be proper and effective medication to the patients that are living with diabetes especially those that are under home -based care. More than half of the population does not take the medicine as it has been prescribed and this in most cases is resulting in costly health care challenge. The poor medication taking habits and the lack of adherence to the medicine creates complex problems. It is important that those who are under home care based should work hard to ensure that the patients are taking medications as they are supposed to be so that they do not develop more complications as a result of not adhering to medication. There are key interventions that should be identified, and effective measures made from this. Comment by Author: Why? Comment by Author: Citation? This whole section has numerous sections that need citations. I have given you feedback previously that you need some assistance with writing/editing. Please see DC network for resources. Comment by Author: The healthcare workers? Probably better to name the group you are referring to avoid confusion with the patients
Some medical situations inevitably require home healthcare services, this is important since it can help especially a person who is aging manage diabetes. Home –based care is also important in managing health issues, which are chronic in nature and also important in assisting people to live independently. Home-based care is also helpful in a person who is recovering from medical setback. Some patients that are under home care based may be unable to recover as well because in some instances they may not get the correct guidance as compared to when they are in the hospital. Comment by Author: See comments about citations above
The project is about the strategies and the methods that home-based care patients should follow to improve their health especially in adhering to medication to ensure that they get maximum benefits of their home-based care. This is because it has proven to be a challenge to follow the right medication strategies when the person is under home-based care. Comment by Author: This is not correct. Please see previous feedback about this. Your DPI project should be translating evidence into practice and not generating new knowledge/research. Please also refer to the DPI template for all the components you need in your various sections of the proposal. It is important to avoid missing any items but also so you can stay focused in your writing and be clear
Background of the Project
Home-based healthcare has been around since 1909 (Choi et al., 2019). It was perceived as a cheaper way to take care of patients who would have the benefit of enjoying the comfort of home and save money that would be have used up in paying hospital bills. In the early 20th century, home-based healthcare was mainly practiced due to adversities, in that the patients practiced it due to insufficient funds to afford proper health care. It was also practiced due to hardships in accessing medical care (Choi et al., 2019). In the present times, however, it is practiced out of choice, after a patient has weighed their options. Some of the situations where a patient can choose to practice home-based healthcare are when a patient is elderly and prefers to get home-based care instead of hospital care since at home, they would be more independent than they would be in a hospital. Home-based care is ideal when the condition can be managed without admission to a hospital such as in patients who have diabetes or those with hypertension (Szanton, et al.., 2016).
There is also a high rise of lifestyle diseases and conditions, such as diabetes. These chronic disease conditions require that a person engages in self-care behaviours at home to keep the situation controlled and prevent complications. Diabetes, for example, requires a patient to keep checking their glucose level. Many patients who are under home-based care do not have sufficient knowledge of the requirements that diabetes treatment entails. They do not practice medication adherence, causing more health complications due to unmanaged health conditions. Home-based care can increase the mortality and morbidity of diabetic patients if it is handled correctly by ensuring that diabetes patients have sufficient knowledge of what is required of them in terms of adherence (Neupane, et al, 2017). Comment by Author: This statement is incorrect. How does home correctly rendered home based care increase mortality and morbidity?
This proposed project is looking to tackle an increase in the fatality rate of diabetic patients practicing home-based healthcare. Most of the fatalities are caused by medical non-adherence, caused by a lack of sufficient knowledge of home-based care related to diabetes and other conditions. Patients at home are unaware of the requirements for medication, dosages, and required follow-up. Comment by Author: Citation? Also, I gave you feedback on this. This is not the aim or purpose of your project. Need to really adjust this and edit for clarity and scholarly writing
Problem Statement Comment by Author: This needs significant editing. You need templated language that clarifies what your problem is. I have given feedback multiple times previously and you have it in the DPI template as well.
Even though home-based care has certain advantages such as increasing the mortality of patients and the mental well-being of patients, it also has challenges in its implementation and successful outcomes. The adherence rate of home-based care patients is unknown and the implementation of strategies to aid in adherence is also unknown. It is important to measure these strategies and also to evaluate the adherence success rate of home-based care patients as this could make the difference between life and death for the home-based care patients.
The quality improvement project aims to find out how many patients have the required knowledge about their medical conditions and how to manage them. This includes learning about the vital medication, the importance of medicine, and the expected outcome if they do not adhere to the medical recommendations regarding diabetes and other conditions. The intervention for this problem can be done before a person is given a go ahead of having home-based care. Patients should first be given knowledge and the tips that are required on adherence to medication so that their health can continue improving and not to deteriorate as happens in many people who undergo home-based care. The nutritionists will be in charge of the diet education while nurses and practitioners will be responsible in offering general healthcare education regarding diabetes and the right lifestyle changes have to be taken into account. Nutrition education will examine the types of foods to be consumed, amount and frequency with which they should be taken. Lifestyle education changes will examine the healthy life activities that diabetic patients ought to be involved with. Medication adherence will be measured using self-report questionnaires that will be given to patients and health care providers during data collection. The tool will involve asking patients questions about the missed doses within a specific period of time. For accuracy purposes, the patients will be asked about medication adherence in the last three days because asking for more than three last days will be difficult for the patients to recall.
Purpose of the Project Comment by Author: This needs significant editing. You need templated language that clarifies what your problem is. I have given feedback multiple times previously and you have it in the DPI template as well.
The purpose of the project will be to determine medication adherence amongst home-based diabetes patients in Urban Texas. The project aims at determining the level of knowledge about diabetes and home healthcare requirements in 50 diabetes patients in Urban Texas. The project will focus on ways to reduce fatalities in diabetes patients under home-based healthcare. Many diabetes patients suffer due to medication non-adherence. This means that they do not follow the guidelines in managing their condition at home by the physician.
The main reason for medical non-adherence is the lack of knowledge of what they should do at home as healthcare measures to ensure they continue to improve their health. This could be due to home nurses’ failure to sensitize the patients on proper medication adherence or lack of proper follow-up through home visits.
The main aim of the project is to evaluate the implementations of some strategies which are important when it comes to defining clearly impacts that are present in case a person is on home-based care and the implications of not adhering to set times of taking medication
By conducting this project, the medical field can devise ways of ensuring that the useful information on diabetes management at home reaches everybody in Texas and other parts of the country. This should be incorporated in all systems like schools, workplaces, hospitals, and homes.
Clinical Questions Comment by Author: Put your PICOT question in this section and use that as your clinical question. Then add all the other information needed in the section based on guidance from the DPI template
Does Medication Adherence Education Increase Medication Adherence?
The project will focus on medication adherence of diabetes patients who are undergoing home-based care. The variables measured in this project will be adherence to medication and the outcomes of adherence or the lack of adherence in the patients and how this impacts home-based care. The project also hopes to understand the differences that are present in adherence to medication in diabetes patients undergoing home-based care as compared to those undergoing hospital-based care.
The data will be collected from both patients and health care providers engaged in home-based care programs. The aim is to find out to what extent medication adherence is utilised and what strategies are in place to ensure that patients adhere to their medication. The project will also seek to understand if the patients have sufficient knowledge on medication adherence. The following questions will guide this quantitative project: Comment by Author: This is research. Remember only limit your project to translating evidence into practice. Be very clear about what your problem is , what your intervention is and what your outcome is. Then you can be a good position to edit your manuscript. If you continue to edit the manuscript without clarity on those things it will be difficult for you
1. Does education on diabetes increase medication adherence in diabetic patients in home healthcare?
2. Do family-led strategies lead to better medication adherence in home-based diabetic patients?
Advancing Scientific Knowledge
This quality improvement project will help ensure that there is sufficient information available for the public regarding diabetes and the recommended home healthcare requirements to manage the condition. Seeing that there are so many patients without the necessary information regarding diabetes and how to manage it, there is a need to diversify the sources of information on diabetes and manage it. Comment by Author: Citation?
Sensitizing the population on the importance of adherence to medical recommendations and finding alternatives for expensive home healthcare facilities will solve problems even in the future, ensuring that the fatality rate in-home healthcare drops significantly. Adherence to medication by diabetes patients has been shown to improve their lives and reduce the development of more complications and premature death of patients (Delameter, 2006). This project will improve the overall quality of life for both the patients and their caregivers. This quality improvement project is also a gateway to more sensitization to people. The information can be shared in institutions. Future generations will also benefit from the knowledge on how to implement effective home-based care strategies to improve medication adherence and reduce diabetes related fatality rates. Comment by Author: How is this related to your project since these patients are home health patients?
The project will fill the literature gap on adherence to medication by diabetes patients undergoing home-based care. This project aims to provide all the necessary information to all Texas people to people all around the world. This information should be accurate and certified medically so that it will help reduce fatalities among diabetic patients in home healthcare settings.
Significance of the Project
This project is significant in current times. With the rise in chronic diseases, many people are opting for home-based care and not getting their treatment from a healthcare facility and thus they must know the importance of medication adherence even at home. Also, with the COVID-19, many people are undergoing more home-based due to congestion in hospitals and to also reduce the risk of spreading COVID-19 to other patients (Choi, Choi, & Shon, 2019). This DPI project provides a scope upon the general level of knowledge about diabetes and home healthcare. By focusing on medication adherence, the fatalities in home-based management can be reduced thus making the project very important to the management of diabetes at home. Though the project focuses on diabetes patients, it gives insight into the gap in a lack of knowledge on medication adherence for home-based care for other conditions as well including hypertension, heart disease and presently COVID-19. Other scholars interested in projects of this nature regarding other conditions will know the factors to consider and what to expect. Comment by Author: You need to make more of an argument for this as this is not the focus of your project so need to develop this argument further. You immediate impact for the project is improve medication adherence which improves control of the condition and prevents complications
After following through with content on the different ways of adhering to medical recommendations, other researchers can come up with ways to provide more information on current conditions to ensure that there is enough information guiding patients on the care measures required for a healthy life. Some situations that need looking into in the future are hypertension, and COVID-19, which are very urgent currently. Comment by Author: This is not what your project is about so need to edit
Rationale for Methodology
The DPI project employs quantitative methodology. This is where I will employ questionnaire as a way of collecting information. The data collected will be quantitative in nature to establish the medication taking behaviours of the patients under home-based care. In addition to the questionnaire developed, the Morisky Medication Adherence Scale (MMAS-8) will be used to determine how effectively the patients are adhering to medication. The MMAS-8 is a tool developed and widely used to determine patients’ adherence to medication in different conditions. It is a tool that eliminates bias from the patients and health care providers by asking questions in a method that avoids ‘yes-saying’ by patients. Numerical data is important as it focuses on trying to reduce the number of diabetes fatalities in home-based healthcare. Comment by Author: Can not use first person in scholarly writing. Pleas edit Comment by Author: You can not develop your own questionnaire/instruments for your project. You will need t utilize an already evidence-based instrument/questionnaire Comment by Author: Citation?
According to Creswell &Creswell (2017), a quantitative methodology is best suited for projects that require data in numerical form. This is to know the interventions that are happening to those who are under home based care to ensure that the strategies are working, and mortality rate of such people are reduced.
The information is then analyzed using quantitative methods and represented in charts and graphs. The conclusion on the findings is then drawn from the analysis of data, after which recommendations are thought of and implemented to curb the problems in scope.
Nature of the Project Design
This project will adopt the quasi-experimental design in that it deals with a random population that will be targeted will be all the stakeholders that have interacted with those patients that are in health care basis, and the DPI research project does not happen in a controlled environment. This design is more cost-effective than the actual experiment project design. In this project, the sample population is diabetes patients in Texas. The questionnaires, both the MMAS-8 scale and the questionnaire developed by the researcher, provide insights into the information intended for collection, thus providing accurate findings. Another mode of data collection used in this project surveys involves the diabetic patient or their caregiver to answer some questions related to diabetes, medical adherence, and home healthcare. Comment by Author: This is not really true. There is no requirement for randomization in quasi experimental design Comment by Author: The writing here needs editing for grammar and flow. Also please see prior feedback about removing any references of research a it pertains to the project. Comment by Author: Citation? Comment by Author: Only use evidence based instrument which you have provided as the MMAS so do not include caregiver interview etc that pertain to research
The project will use the data collected through the course time allocated. A detailed analysis of the data will be done, the date represented for interpretation, after which solutions to the research problem will be solved and tackled. It is a very descriptive project aimed at unravelling some of the truths that are not too obvious to develop solutions that are well needed in the current times. Comment by Author: If you are going to discuss data analysis then you need to just state what specific statistical tests you will run and what specific data you will analyze. This section is very vague and unclear as there are lot of research related statements
The research designs will help in the smooth process of data collection, analysis, and conclusions, which will help draft the recommendations for a healthy life for diabetic patients in Texas and possibly in the world who practice home-based healthcare.
Definition of Terms
Medication adherence:
This is the extent to which a patient, caregiver, or home nurse follows the recommended guidelines on managing a medical condition.
Home-based healthcare
Refers to the medical care given to a patient in the comfort of their home instead of going to the hospital.
Facilities
A thing, place, or person necessary to make the home healthcare process for a person with diabetes easier for both the patient and the caregiver.
Diabetes
A medical condition that is characterized by high sugar levels in the blood. It can be managed with drugs and insulin.
Assumptions, Limitations, Delimitations
This project assumes that medical non-adherence by diabetes patients’ is caused by a lack of sufficient knowledge on the matter. Education in the area as well as providing information on managing diabetes from home will solve the problem. It is also assumed that after education, the patients will automatically practice medical adherence because the knowledge will be easy to understand and the benefits of adhering to medication will be outlined to patients thus, they should be able to implement the knowledge. It also assumes that many people practicing diabetes home healthcare cannot afford the required facilities and equipment for treatment and care which is why they chose home-based care in the first place. Additionally, this project assumes that all patients and their caregivers are literate. Therefore, they can understand the physician’s diabetes and home healthcare recommendations for a long healthy life. Comment by Author: This is not correct as home health is not based on financial limitations bur rather other factors Comment by Author: Why are you assuming literacy when there is literature evidence that the average patient education material needs to be at the 5th grade level?
The project is limited because it focuses on only diabetes home-based care and does not consider patients undergoing home-based care who have different conditions. The project is also limited to an urban location and thus Texas state only and further limited to Urban Texas thus excludes rural Texas patients who may have different needs or challenges related to medication adherence. The project will also be limited to medication adherence of home-based care patients and does not cover other aspects such as mental health and health related quality of life of the patients. The project also includes all diabetes home patients, even those who are not necessarily ill and who are only practicing home-based care due to old age. In this case, the data may be a little imbalanced since it may record diabetes fatalities of patients who succumb to old age as a medical non-adherence fatality. Comment by Author: This is not a limitation as your population is diabetic patients in home health
Delimitations in this project include the project areas namely adherence and diabetes patients. The project will only collect data from diabetes patients and will only be interested in their medication adherence. The project study area is also only being conducted in an urban Texas area in the South East Unites State thus it will exclude patients from other states as well as rural rural locationsTexas.
The findings of the project will be applicable to medication adherence in patients with other conditions who are undergoing home-based care. They will also be applicable to all patients with diabetes throughout the country who are in the home-based care program to help them better adhere to medication and reduce the number of fatalities associated with the home-based health care programs.
Summary and Organization of the Remainder of the Project
Chapter one provides support for the assessing of interventions and their effectiveness especially those that are in home-based care, (Creswell & Creswell, 2017). This will bring about changes in the quality of life for people practicing diabetes home-based care not just currently during the COVID-19 pandemic but also in the years to come. People need to know the importance of medical adherence since it provides a chance to improve a patient’s quality of life. Chapter two will review literature both theoretical and empirical on the variables home-based healthcare, diabetes and also medication adherence to give the project a literary and empirical framework on which it will be based.
Chapter three will discuss the research methodology employed in the project. This will include research design, the target population, sample size, data collection tools, data analysis, reliability and validity of research instruments and ethical considerations when collecting data. Chapter four will present research findings and discussion of the findings. This will include both descriptive and inferential data analysis as well as discussions of the findings. Chapter five will present conclusions and recommendations drawn from the project.
Diabetes patients should also be enlightened on maintaining a healthy lifestyle and managing the condition at home (Choi et al., 2019). The data collected will make it easier to spot the problem and the gap, and therefore come up with ways to bridge it. One way to bridge the gap and reduce home-based healthcare fatalities of patients with diabetes is by providing adequate information on the management of diabetes at home. All the people involved in the home healthcare provision process should be sensitized to the significance of medical adherence. Comment by Author: See previous feedback on this
The projects also include data collection, where the data is presented and analyzed. The data gives insight into the situation, enabling ease of discussion of solutions and recommendations to increase medication adherence in home-based healthcare, which will reduce fatality rates of diabetic patients in home-based healthcare.
Chapter 2: Literature Review
Diabetes is a medical condition that is characterized by high sugar levels in the blood. It can be managed with drugs and insulin. Blood sugar serves as the major producer of energy in the body. Any condition interfering with blood sugar levels and mechanisms would bring about disruptions to the normal body activities. Optimal diabetes control usually needs patient associated engagement in various types of self-care associated activities, including the adherence of patients to the identified medication associated regimens along with adjustments to various lifestyle associated modifications and even the monitoring of the blood glucose associated levels, (Jajarmi, et al, 2019).
Since diabetes is a lifestyle disease, it can be easily prevented and avoided by making lifestyle changes. Managing the disease can also be made easier by making lifestyle changes as well as adhering to medication. This is important since it will help in avoiding of many challenges and complications that may arise from diabetes. one of the most problematic issues associated with home care for the patients suffering from Diabetes is Adherence to medications. According to Bonney (2016), patients usually take their identified medication as is prescribed solely 50% of the time. This along with the reluctance to be involved in the sharing of the details associated with medication taking behavior have been identified as less than optimal by healthcare providers. This project hopes to shed light on medication adherence and how it affects the quality of home-based care in diabetes patients. It hopes to understand the role of educating patients on medication adherence in improving their adherence to medication and also understand the impact of improved adherence on the patients.
This chapter provides both a theoretical and empirical framework through which the medication taking behaviors of diabetes patients undergoing home-based healthcare is investigated. The chapter is divided into theoretical and empirical sections. The theoretical section reviews two theories namely attachment theory and social cognitive behavior theory. In the empirical section, literature from previous studies and projects is reviewed and study gaps are identified in them which differentiate the reviewed projects from this project. The DPI project utilized databases as well as literature sources which have been systemically searched for the identified systematic reviews that report various aspects associated with diabetic adherence. A total of eighteen18 systematic reviews were realized as well as utilized in the advancement of the DPI conceptual framework. In overall, there was a total of six key sub-themes and many other subthemes for the project and that emerged which are all focused on thoroughly to enhance the comprehension of the DPI. Each of these key sub themes are discussed comprehensively along with in in-depth study. Most of the identified interactions were considered to be within the patient associated elements which usually not only interact with other kinds of theses but are also within the same theme. Comment by Author: I gave you feedback on this previously, you can not only have systematic reviews in your literature review. You need to revisit this Comment by Author: The writing is unclear here and needs editing for grammar and flow
Background
Non-adherence to diabetic medications in patients that are being treated from home usually leads to poor recovery along with ineffective treatment associated outcomes and even an increment in the healthcare associated costs is usually reported (Bosworth, 2015). A variety of elements that are usually related with the identified medication associated adherence have also been highly studied. However, it is vital to understand that a comprehensive framework along with a clear disease specific conceptual framework associated model which is involved in the capturing of all the probable elements has not been fully established. The main aim of the project is to assess the effectiveness of the interventions that have been put into place so as to ensure that there is improved home based care.
The demographics along with the cultural beliefs of the patients were considered to be the most notable elements of the given interactions with other types of categories as well as themes. The intricate network as well as the various interactions regarding the elements that have been identified between the distinct themes as well as within the individual types of themes usually reveal the identified complexity associated with the issue of adherence of medication especially those that are diabetic.
Theoretical Framework Comment by Author: One of your theories needs to be a change theory. As previously indicated, it is difficult to see the link between attachment theory and medication adherence. Not yet clear on your intervention so hard to say if it aligns with that or not. The social cognitive theory I can see how it aligns with your project.
According to Liu & Butler (2017), medication adherence is considered to be the largest challenge that healthcare workers and patients are facing in their daily lives. It is often considered to be a critical issue, which usually deserves higher level of attention. Inspiration along with the act of supporting patients to take their identified medications as prescribed can be a great issue. The Direct Practice Improvement (DPI) project utilizes two key theories to explain the relationship between medical non-adherence to patients and how medical adherence can be enhanced among the diabetic patients through improved interventions. Comment by Author: The writing here needs editing for flow and clarity
Attachment theory
The first theory is the attachment theory. This is defined as being a psychological, evolutionary, and ethological associated theory in relation to the aspects of relationships between individuals. This is a famous theory that had been used in the healthcare practices for a long time thus will be a suitable framework to be used in this case that entails creating the best interventions made for enhancing medical adherence with the diabetic patients.
The most vital tenet concerning the attachment theory is usually considered to be that young children usually need to advance a relationship with at least a single primary caregiver for the identified normal social and emotional advancement. The theory was designed by the prominent psychiatrist and psychoanalyst John Bowlby. Within this theory, the term attachment is usually utilized to refer to an affection bond or tie that is between a person and their attachment figure who in this case is usually considered to be the caregiver (Liu & Butler, 2017).
Some types of bonds may be considered to be reciprocal such as those occurring between two adults, however, the bond between a child and a caregiver are usually on the basis of the need of the child for safety, security and even protection. This is usually considered to be essential in both infancy and childhood phases of life. This given theory usually proposes that children are involved in the creation of attachment to their careers instinctively for the key associated purpose regarding survival along with the untimely as well as genetic replication.
The biological purpose for the use of this theory is the facilitation of survival while the psychological aim about the theory is to offer security thus making it a suitable theory to use. Attachment theory is considered to not be an exhaustive description associated with human relationships nor is it considered to be synonymous with love or affection, however these can be utilized in indication of the fact that bonds still exist. In the child to adult types of relationships, the child is usually referred to as the attachment while the caregiver is usually defined as being the reciprocal equivalent who in this case is called to be the care giving bond (In Hunter & In Maunder, 2016).
The modern attachment theory is usually focused on three key principles which entail bonding as an intrinsic human need along with regulation associated with emotion as well as fear to improve vitality and in the promotion of addictiveness along with development. Common attachment behaviors as well as emotions are usually displayed in most of the social primates including humans and are considered to be adaptive. The long-term associated evolution possessed by these types of species usually involves selection for the identified social behaviors which enable people and group survival more likely.
The commonly observed types of attachment behavior in toddlers staying near the familiar individuals are based on safety advantages in the identified environment both in early adaptation and our current world. Bowlby perceived the identified environment associated with the early adaptation as being the same to the current and also similar to the hunter-gatherer communities. There is a survival advantage in the identified capacity to effectively sense possibly dangerous conditions like the issue of unfamiliarity, loneliness, and rapid approach. In the identified internal models is entailed the regulation, interpretation and the prediction of attachment associated behavior in the identified self and the attachment figure.
The advancement of attachment is considered to be a transactional process. Particular attachment associated behavior usually starts with the predictable apparently innate behaviors in the infancy stage of life. They usually alter with age in various ways that are usually determined partly by the identified experience as well as partly by the various sit-upon elements. As the various attachments get altered throughout life, they do so in techniques that are shaped by the identified relationships.
In accordance with Hunter & Maunder (2016), there are two key reasons why the attachment theory is considered as being effective to be utilized in the following DPI. First and foremost, the theory acts as a solid foundation for the enhanced comprehension regarding the identified development of ineffective coping techniques as well as the underlying dynamics associated with the emotional difficulties of the person. Clinicians can help those people that have attachment anxiety and avoidance in the comprehension of the manner in which previous experiences with their caregivers or their significant others have helped in shaping their identified coping patterns to their various experiences of distress.
Secondly, the clinicians can help the people who have attachment anxiety and avoidance to find the best alternative way to meet their various needs. Most of the individuals who usually seek help want to learn the way in which they can employ different strategies for coping with the various dysfunction in their daily lives along with effectively modifying their various dysfunctional or even inappropriate coping techniques. This is an essential aspect since the caregivers need to form attachment first before delivering the advice and interventions to the diabetic patients on how they can adhere to their medications. It is important to note that for effective outcomes to be realized in these diabetic patients, there is the need to ensure that all the basic needs of the patients are effectively met as well as other types of strategies that are considered effective for changing the individual maladaptive techniques used in conjunction with the theory (In Hunter & In Maunder, 2016).
Social Cognitive Theory
The other vital theory that can be utilized in the facilitation of the DPI project is the social cognitive theory. Social cognitive theory is a famous theory that is usually utilized in the explanation of the manner in which human behavior is associated with dynamic, reciprocal, and progressive types of interaction that exist between the person and the given surrounding (Bosworth, 2015). The common types of theoretical basis associated with the cognitive theory is considered to be learning since it usually posits that the identified human behavior is effectively learned. Therefore, the Social Cognitive Theory (SCT) is famous because it often proposes that identified behavior aspects are an outcome of the cognitive processes which individuals usually develop via the social acquisition associated with knowledge.
According to Bosworth (2015), the theory usually bases its focus on the identified concept regarding behavioral capability which usually states that prior to any individual acting in a certain situation, the individual needs to have knowledge on what they need to do and the manner in which they need to do it. Bandura’s conceptual model regarding the reciprocal associated determinism is often utilized in addressing all the personal determinants associated with health. He postulated that an identified person or individual is engaged in a cognitive, vicarious, self-reflective, and even a self-regulatory process to attain a given goal. He went further to state that individuals usually effect alterations in themselves via their identified actions in anticipatory and proactive ways through the exercising of control over their given behavior via their well thought types of procedures and even motivations (Bosworth, 2015).
Bandura asserted that without having any kind of aspirations individuals usually course through life unmotivated and uncertain regarding their specific capabilities. Nonetheless, he also stated that people who take part in health promoting behavior have self-belief which enables them to fully take part in control over their thoughts, feelings, and actions. Therefore, the individuals who usually take part in self-control associated with health associated habits is involved in the reduction of key health associated risks leading to healthier and highly productive lives (Bosworth, 2015). In accordance with Bandura, although the prominent SCT usually acknowledge that the associated knowledge regarding the health associated risks along with the given benefits associated with treatment are considered to be necessary in the performance of health associated behaviors, this is in itself not adequate. Comment by Author: Need Citation Comment by Author: Comment by Author: This reads award, please edit
Self-influences are regarded as necessary in the attainment or the various alterations which will lead to the desired health associated outcomes in the identified patients. This concept is usually referred to as self-efficacy. The two types of cognitive processes which are involved in influencing behavior in the identified SCT are usually referred to as the self-efficacy and outcome expectations (Bosworth, 2015)
In accordance with Hadler (2020), the social cognitive theory is considered to be essential during healthcare workers’ counseling regarding various patients that have chronic medical illnesses like HIV and even diabetes. It can be utilized in the offering of help to the given patients in the learning of the vital information associated with HIV and AIDS as well as the related health issues like adherence. Support groups for people who have this could also utilize this social cognitive associated theory along with various behavioral techniques to effectively empower patients to effectively negotiate the various issues that are around medication adherence along with the establishment of effective supportive types of relationship which are efficient in strengthening the ability of the patient to stick to medication plans.
All these are associated with improved adherence as well as effective clinical results. Issues that are around the disclosure associated with the underlying conditions that some patients are subjected to are considered to be skills which could be effectively taught in the identified support groups and which could cause improved medication adherence. The reason why these two theoretical frameworks are used in this situation of diabetic patients who do not adhere to medications is because special intervention is needed to convince diabetic patients to adhere to medications and this will be installed in them as knowledge for behavioral change that will influence a positive change that will cause the patients to adhere to their medications.
Review of the Literature Comment by Author: You are missing any citations in these few paragraphs as indicated before. You need citations to support your assertions or thoughts. Remember that the hall mark of the DNP scholarly journey is translating evidence into practice so all aspects of the project need to have literature support
Medication adherence is considered to be the largest challenge that the healthcare workers as well as their patients are facing in their daily lives. It is often considered to be a critical issue which usually deserves higher level of attention. Inspiration along with the act of supporting of patients to take their identified medications as has been prescribed can be a great issue. The cognitive associated perspective on the identified health associated behavior is usually on the identified assumption that our thoughts along with beliefs usual influence our personal emotions and behavior.
It is important to note that the key focus of people working in the healthcare facility with diabetic patients, consider them as critical patients in the manner in which the identified patients are entailed in the conceptualization of the different health associated threats along with is involved in the appraisal or the elements which are involved in facilitating adherence or even serving as barriers to effective treatment of people.
Although adherence to antiretroviral therapy is considered a predictor of effective clinical associated outcomes among diabetic patients, it is a crucial challenge, and strict adherence is usually considered not to be usual
Medication adherence: Comment by Author: Please see DPI template for appropriate formatting of your headings and subheadings i.e differentiating between themes and subthemes
This refers to the art of taking medication in the right way as prescribed by healthcare practitioners. This is done in most cases by people in the hospital, and these are health care practitioners. This is through giving prescriptions as they are supposed to. For home-based diabetic patients, they might be missing the opportunity to have a physical person monitoring their recovery process. For those that are home-based, the process is done by those present in that very time. However, their adherence and track of the body changes can play a significant role (Ahmed et al., 2018). Comment by Author: The writing here is not clear, please edit
What can be done to enhance Medication adherence?
To handle the issue of medication adherence among the diabetic patients who have had an issue with the adherence to medication needs to come up with a variety of strategies that have been attained from scholarly reviews as well as journals for purposes of well researched data on the concept. Appropriate types of medications are usually considered to be the identified cornerstone regarding the prevention as well as disease treatment yet according to numerous research carried out, there is solely about half of the individual patients who adhere the instructions of their prescribed medication (Bosworth, 2015). This usually causes a common as well as a costly public health associated challenge especially for the healthcare system in the US.
Since the aspect and issue of inappropriate as well as inefficient medication adherence is considered to be a complex change with a variety of contributing causes, there is no universal solution (Rodriguez, 2019). The following theme breaks down into three subcategories which form the basis of the sub-themes associated with this theme. The sub-themes are used to offer comprehensive analysis of all the vital types of interventions which are considered to be effective at enhancing medication Adherence among the diabetic patients but were also considered to be potentially scalable that is they are easy to implement in any given scenario in even large population (Bosworth, 2015). Key traits that make these interventions effective are discussed throughout the DPI. The information offered under each sub-theme is vital in enhancing proven as well as low rescue and even the cost-effective solutions to enhance Medication Adherence.
Strengthening the Relationships with Patients
Patients usually put into consideration their identified HCPs the major along with most dependent source of data regarding their health associated condition along with the treatment, and they are usually considered to be highly likely to effectively follow the treatment types of plan when they are involved in having good relationship with their HCP due to confidence and trust that has been built over time. Relationship building in healthcare is considered to be a vital aspect in the day to day lives of healthcare practitioners due to the nature of their job which necessitates that they all maintain long term relationship with their patients for enhanced medication as well as treatment outcomes (In Heston, 2018).
Trust is usually developed throughout time with the same types of HCP in any kind of mutual relationship between them and the identified specific patients. The patients in these cases usually consider that their identified HCP possesses the highest level of competence along with actually cares about their identified health. Mistrust usury develops when the given patients attain unrealistic as well as inconsiderate and even insensitive advice from their identified HCPs as well as feel some kind of emotional distance from them.
Medication Nutrition Education Therapy
Appropriate nourishment assumes a vital function in infection counteraction and treatment. Numerous patients comprehend this connection and seek doctors for direction, diet, and diligent work. Nonetheless, real doctor practice is regularly deficient, intending to the nourishment parts of infections, for example, malignancy, adiposity, and diabetes. Doctors do not feel significant, specific, or sufficiently set up to give nourishment guiding, which might be identified with problematic information on fundamental sustenance science realities and comprehension of potential sustenance intercessions. Truly, nourishment training has been underrepresented at numerous clinical schools and residency programs.
This usually makes it hard for the desired coordination as well as level of friendship that is needed for the effective as appropriate manage the issue of diabetes to be attained. When the caregivers are considered to be not friendly as well as not welcoming, it becomes hard to convince the patients on taking their medicine, yet they have a negative perception and attitude towards their care giver (In Mahmoud, 2019). The identified patients who are usually engaged in some meaningful types of partnerships are usually considered to be highly receptive to the various messages that have been delivered by their identified health care associated team.
As an outcome, the given patients usually tend to be in possession of some kind of anti-ballistic perceptions regarding the identified severity of the disease along with the benefits that come with the treatment of the disease and how medical adherence can attend to enhanced efficiency along with results in the healthcare work with the diabetic patients. Therefore, in this case, the factors that are entailed in impacting medication adherence are referred to as the severity of the diabetes illness along with the advantages associated with the treatment.
It is a vital theme which helps in understanding that the different types of patients that have close relationship with their caregivers are associated with high likelihood of following medications prescribed to them (In Sherman & Bednash, 2015). Any patient who is considered to be engaged in an identified partnership or even relationship with the caregiver is usually considered to be highly likely to be entailed in disclosing their various clues which helps the identified HCPs in the employment of numerous personalized models to offering support to medication adherence efforts. Attaining a careful comprehension is considered essential in the comprehension or the needs of patients via appropriate patient- provider types of Communication which are vital in the employment of the practical approaches to enhancing medication adherence as has been suggested throughout this DPI.
How and Why to Adhere to Medications
An estimated American adult of about 35 percent is considered to possess basic as well as the below-basic health associated literacy. This has been recognized globally and is associated with causing their incapability to read as well as write and understand any kind of message that is indicated on the prescribed medicines or the treatment sheets. Health literacy had been considered to be a vital aspect in the receiving of any kind of services. First and for foremost, it helps in helping the identified diabetic patients to not miss out on any fine detail needed for them to put into consideration and has not been written carefully thus can seek clarification on such aspects unlike if one cannot read not clarify on anything. Literacy is the ability to read as well as be able to understand the different aspects that people highlighted them to them (Glanz& Viswanath, 2015).
For these same reasons, the world practitioners have been involved in the coming up with different strategies that can be used in the reduction of health literacy levels among taunts that have diabetes. It is vital to put this theme into consideration and should be a first priority since it is what makes the basis along with the foundation of having long term sustained profitability rates as they will be able to explain themselves to the identified people that will help them in making sure that they adhere to all their given medication.
It is always vital to adopt the universally implemented as well as published precautions that are made against the identified medication non-adherence as well as the low health associated literacy. This is famous for its nature of purpose. It is always utilized to offer effective encouragement of the various identified HCPs to carry out an assumption that the given patients are not being involved in taking their identified medications as they are prescribed to. Prescriptions need to be taken seriously for them to offer exceptional results and for the continued well-being for the patients who have critical illnesses like Diabetes.
The use of simple language by HCPs as well as medication manufacturers is another vital way, they can be utilized to help in teaching back types of techniques. These methods have been utilized in the enhancement of adherence among many types of non-adherence medication patients. Most of the times people opt to not take their medication as they cannot read all the instructions written on the medicine and are afraid that they will die especially in the cases that they mistake those drugs for poison or some drug that may look like a famous poison causing deash. This is a key issue that has left most of the people victims of non-adherence (National Academies of Sciences, Engineering, and Medicine (U.S.), 2018).
Reading instructions and making a patient understand what is written in a medicine bottle or package should never be taken for granted as it is key for determining the manner in which patients will effectively or ineffectively adhere to the given drugs for treatment and disease control purposes. So that the identified medical practitioner can be aware and sure that what they have explained to the patients has been delivered safely as well as appropriately, there is the need for them to do a verification test. The patients as well as their identified support individuals need to be effectively asked to offer an explanation in their own words what they have understood from everything the practitioner have told them regarding their health along with drug management and intake. This teaching back method is vital in offering additional data on the key topic of interest thus should be used often.
Concerns associated with the issues of side effects can be considered to be challenges to the aspect of medication associated regimen adherence especially when the given advantages associated with taking the identified medication are not properly along with effectively comprehended. To minimize the identified potential associated concerns that are associated with the side effects of drugs since this can be identified as one of the reasons why these patients may opt to not adhere to the medications in fear that they will experience the side effects and be greatly inconvenienced, there is the need for HCPs to offer the relevant data regarding the common types of side effects when they are entailed in the prescription process.
There have been issues of people and patients dying or experiencing very negative and disturbing side effects when it comes to them taking the desired drugs by their doctors. These cases have always been used as forms of examples to explain the reason why people have been reluctant to take the medications for prolonged periods. For most of the critical illnesses, the medication is usually made to be taken for a long time for increased efficiency. This has caused many to withdraw from the medication due to the prolonged side effect issues that is associated with it (Institute of Medicine (U.S.), 2016).
For instance, when offering a prescription or the metformin, there is the need to inform patients that are suffering from diarrhea during their time of prescription to anticipate that the loose bowel issues will be over in about a week if the drug is continued to enable the adherence of the drug. It is also vital to offer brief expansions due to the issue of time limitations along with engaging other members regarding the health care associated team in the provision of more additional education can be essential. This can be in the form of printed handouts as well as websites and in the use of teaching module which should be readily available for use with the identified patients.
In summary, the level of medication illiteracy among Americans is assumed to be high. This significantly contributes to the difficulties faced by patients when they are required to follow instructions. There is need for practitioners to take time and educate the patients on the right measures to take. Learned patients will have better understanding of the actions to take, and which can positively impact what they are after.
Tools for Building Patient Self Efficacy as well as Support Adherence
Using tools along with instruments that are considered effective along with appropriate is vital in supporting adherence in different ways and in achieving self-efficacy among the various patients. Positive family along with social support are considered to be vital aspects associated with adherence to the issue of Diabetes management (In Rodríguez, 2019). If vital, the engagement of the family members can enhance self-care activities for the patients suffering from Diabetes, including the eating of effective and healthy foods as well as keeping fit and in monitoring the identified blood glucose and even adherent to medication.
An innovative method that entails patients in the identified medication associated reconciliation process through a given web portal to undertake the verification of their various regimens along with the clarification and the verification of any types of inaccuracies after the identified hospital discharge has been received to enhance Medication adherence as well as in the decrement of the potential adverse drug associated events (In Forman & In Shahidullah, 2018).
In this case, there may be higher roles for the engagement of patients with their identified electronic medical types of records so that they can appropriately verify along with help in the maintenance of accuracy associated with their medication list to undertake the reflection of their actual taking of drugs. Also, the use of screening tests is vital in understanding how well patients are taking their drugs. If there is no consistency in medication taking then motivation aspects should be utilized to enhance Adherence (European Medical & Biological Engineering Conference & Nordic-Baltic Conference on Biomedical Engineering and Medical Physics, 2018).
In summary, the utilization of tools and instruments simultaneously plays an essential role in upholding medication adherence. Having a supporting and positive minded family also plays an essential role in supporting self-efficacy of the patients. Innovation should be incorporated in searching for medications. This will be advantageous because of the contemporary rapid advancement in technology.
Diabetes Care Concepts
When dealing with patients that have been considered to be reluctant in taking their medication, it is vital that the various care concepts in diabetes patients is understood. It helps in the effective integration of all the Interventions that have been mentioned in theme 1 for enhanced efficiency in the overall improvement of diabetic patients concerning adherence to medications that she been prescribed to them to help them in quick recovery and in the management of the illness for a longer term.
The following theme offers comprehensive knowledge as well as in depth illustrations on the distinct components associated with the clinical control regarding patients have been diagnosed with diabetes. The review offers effective clinical practice associated guidelines which have been considered to be the key to the enhancement of the population associated health, however for the identified optimal outcomes as well as diabetes care ought to be individualized for every identified patient.
Patient-Centeredness
Patient centeredness entails ensuring that all the identified interventions described in the first theme are focused on the individual patient who is being helped in having effective adherence to the given medication during home care settings. Patients who have been diagnosed with various critical illness and have been asked to go home for home-based care have been associated with lack or poor adherence to the medications they are given when they are discharged from the hospital. It is a global issue that has raised consent for the need to understand how to go about it for enhanced feasibility in treatment of illnesses (Steinberg & Miller, 2015).
Practice recommendations whether they are focused on the identified evidence as well as expert opinion are usually intended to offer the desired guidance on an overall approach to care (In Costa & In Alvarez-Risco, 2018). The science as well as the art associated with medicine usually come together when the identified clinician is experiencing or has experienced some sort of situation whereby, they have to make treatment associated recommendations for any patient who would be considered to not have effectively met the eligibility associated criteria for the studies on which the given guidelines were based.
Recognition of what an individual needs is vital, and it can be achieved through the use of the studies that offer standards for when as well as the manner in which to adapt the given recommendations. Since the Patients that suffer from Diabetes usually possess highly increased risk for the identified cardiovascular illness, a patient centered approach needs to entail a plan that should be utilized in the reduction of the various cardiovascular risk through offering the address of the identified blood associated pressure along with the identified lipid control and even in smoking associated prevention and even creation and other aspects (Major Topics in Type 1 Diabetes, 2020).
Diabetes Across the Life Span
An increment in the identified proportion associated with patients that suffer from diabetes are usually considered to be mostly the adults (In Balogh & Institute of Medicine (U.S.), 2015). For the less salutary reasons, the identified incidences associated with type 2 diabetes is considered to be highly increasing in the creating in the children as well as the young adults. Patients that possess the type 2 diabetes as well as those that have type 1 diabetes are considered to be having good lives even in their older age which is regarded as a stage of life whereby there is minimal evidence from the identified clinical traits to be used in the guidance of therapy (Bonney, 2016). All these toes of demographic alterations are usually involved in highlighting another key challenge to the high-quality diabetic patients care. In this case, the identified need is usually considered to be the enhancement of the coordination between clinical teams as well as patients in the effective transitioning via the dysfunction phases enticed in life span (In Corcora & In Roberts, 2015).
Advocacy for People with Diabetes.
Advocacy is a very vital aspect in healthcare since they deal with patients that need their utmost help as well as care for them to go back to their previous health state (In D’Onofrio & In Sancarlo, 2018). Advocacy is an aspect that can be referred to as an active support as well as engagement to effectively develop a cause as well as a policy (Mollaoglu, 2018). Furthermore, advocacy is usually needed to enhance the loves of individuals suffering from patients. Given the various issues in diabetic patients such as the high toll that the issue of obesity as well as physical inactivity and even the various alterations that take place in the society determinants at the identified root regarding these issues can be solved using Advocacy (Stanislaw & Michael, 2017). Comment by Author: Bola, there are significant formatting as well as content and writing issues with your literature review. Please take the time to review examples of DPI projects in DC network as well as the template before our teleconference to discuss all of these changes. You definitely also need writing/editing assistance as it is really difficult to get your point across if the writing has mechanical errors etc We will need to discuss your literature review during our teleconference Comment by Author:
Summary
Medication associated adherence among most of the critical illness patients such as those suffering from Diabetes as illustrated in the project is considered to be a key challenge for the identified patients that have chronic diseases like Diabetes. Optimal adherence to the identified prescribed medications can be entailed in the decrement of complications along with enhancing clinical outcomes and in saving healthcare associated costs. The following DPI has been comprehensive through the review of diabetic patient care concepts issue of non-adherence along with the time to look deeper for the issue of non-adherence as well as the manner in which to undertake the evaluation of the identified patients appropriately along with effectively in a clinical setting along with has offered practical solutions to helping in the improvement of the medication associated adherence (Major Topics in Type 1 Diabetes, 2020).
Medication adherence is considered to be the largest challenge that the healthcare workers as well as their patients are facing in their daily lives. It is often considered to be a critical issue which usually deserves higher level of attention. Inspiration along with the act of supporting of patients to take their identified medications as has been prescribed can be a great issue, however it is considered to possess the capability to possess the highest effect on their identified long term associated health as the well as on the economic well-being regarding the healthcare system of the nation.
The identified theories point to the possibility of solving the problem of poor medication taking behaviors by the use of attachment and social learning. The theories point out that medication taking is learnt and can be enhanced through the use of cognitive behavior change. The theories also point out that attachment between a health care provider and patient can form the basis of positive interaction between them leading to trust which then enables the health care provider to ingrain adherence into their patients. Comment by Author: This did not really come out doing your discussion of the attachment theory and this is why my feedback was that it does not really align with your project. Remember that you only need two and one has to be a nursing theory. In addition a change theory is needed since this is a change you are making based on evidence.
The empirical review point to the complications caused by lack of medication adherence in diabetes patients. It also highlight possible ways in which health care providers can help patients better adhere to medication through strategies such as advocacy and patient centeredness. Overall, medication adherence is important to the treatment and effective management of diabetes in patients and health care providers can play a vital role in ensuring that diabetes patients learn the importance of adherence. Comment by Author: This summary section still needs work. Remember that the summary needs should:• Synthesize the information from all of the prior sections in the literature review and use it to define the key strategic points for the project.• Summarize the gaps and needs in the background and introduction and describe how it informs the problem statement.• Identify the theories or models describing how they inform the clinical questions.• Use the literature to justify the design, variables, data collection instruments or sources, and population to be evaluated. • Relates the literature back to the DPI-project topic and the practice problem.• Build a case (argument) for the project in terms of the value of the project and how the clinical questions emerged from the review of literature.• Explain how the current theories, models, and topics related to the project will be advanced through your project.• Summarize key points in Chapter 2 and transition into Chapter 3.This section should help the reader clearly see and understand the relevance and importance of the project to be conducted.
Chapter 3: Methodology
Medication adherence is important to minimize the impact of chronic illnesses and reduce emergency visits to hospitals. Medication adherence refers to how well a patient in home-based care can take their medication correctly in the absence of health practitioners as prescribed by the doctor (Ahmed et al., 2018). It requires the patient to totally adhere and comply with all the medical instructions given. The number of people with diabetes diagnosis in the United States of America is too large and a most of them are living with underlying conditions which increases their risks being under medication. The challenges faced in keeping such large patient numbers on hospitals has necessitated the introduction of home-based care programs (Brown & Bussell, 2018).
Various models and therapies are available for people with diabetes. The medication nutrition therapy determines the types of foods that patients with diabetes will be consuming at various stages of their treatment. It also calls for the education of these patients about nutrition (Brown & Bussell, 2018). The ongoing care management dictates that patients with diabetes need to receive care from multiple integrated teams. These two models help in maintaining home-based care for diabetic patients (Brown & Bussell, 2018). Pharmaceutical-led therapy cannot be ideal for home-based patients because the pharmacist will not always be there to ensure medication adherence. The role of family members in upholding the patient’s health is therefore vital. Various approaches have been designed to improve care in diabetic patients. The patient-centered communication approach focuses on the interest and preferences of the patient and identifies any barriers (Voortman et al., 2017). Chronic care models ensure that any form of care required by the patient is well taken care of.
This quality improvement project will be guided by the following question: To what degree does the implementation of family-led strategies impact medication (what) compared to pharmaceutical-led strategies among diabetic patients in home-based care in Texas over four weeks? Comment by Author: Remember that this section includes both a restatement of project focus and purpose statement for the project from Chapter 1, to reintroduce reader to the need for the project and a description of contents of the chapter. This is not your purpose statement
This chapter will be explaining the methodology of this project. Information such as the project design, selection of the sample, instrumentation, validity, and reliability, data collection procedures, data analysis procedures, ethical considerations, and limitations will be included in this chapter.
This chapter will be explaining the methodology of this project. Information such as the project design, selection of the sample, instrumentation, validity, and reliability, data collection procedures, data analysis procedures, ethical considerations, and limitations will be included in this chapter.
Statement of the Problem
It is not known to which extent are the interventions working so as to ensure that home-based care is having positive implications as it is supposed to as well as to what extent is the implementation of the strategies that are making the patients that are in the home-based care to adhere to the medications despite being out of the hospital set up. Diabetes home-based healthcare can be very effective since the patients are acting independently away from the health facility as and the necessary medical recommendations are adhered to Therefore, they can be of great importance to the patients as they can give ready support compared to doctors. Comment by Author: See prior feedback on the problem statement in chapter 1. Remember there are certain parts of your project that stay consistent regardless of where in the proposal they are. The purpose, problem statement , population, PICOT questions, data collection procedures etc are the same throughout
This is important since it will help in saving lives especially for those that are in this kind of medication.
The quality improvement project aims to find out how many patients have the required knowledge about their medical conditions and how to manage them. This includes learning about the vital medication, the importance of medicine, and the expected outcome if they do not adhere to the medical recommendations regarding diabetes and other conditions
The number of patients in the United States with diabetes diagnosis is very high. This, therefore, makes it impossible to accommodate all of them in hospitals (Brown & Bussell, 2018). This means further that most of these patients have to be placed under home-based care programs. In these programs, there are no medical practitioners to ensure that patients adhere to their medication. For diabetic patients in home-based programs, they miss the opportunity of having someone monitoring their recovery process. For instance, there will be nobody to remind them how to take their medication or stick to healthy diets (Norman et al., 2018).
According to Norman et al. (2018), family members are closer to the patient in home-based programs than the healthcare practitioners. For this reason, they can be of great help in offering support to diabetic patients as compared to doctors.
Clinical Questions
Prior studies have demonstrated that medication adherence for patients in home-based care has not been a smooth process. Evidence shows that this is usually because there is nobody to monitor the progress of these patients. There is usually nobody to remind them to take medication the right way or adhere to their dietary instructions (Wolff & Baker, 2019). However, there are chances of improvement in this. The implementation of family-based medical adherence strategies can help to enhance medication adherence among diabetic patients in home-based programs. A family-led health education intervention will be carried out by the health care providers who will educate patients on the disease and how-to manage it, medication they should be taking and also the importance of adherence. This will be done during follow up sessions with patients in home-based healthcare.
There are a number of Strategies and the outcome is strict medication adherence. A quantitative, quasi-experimental design approach has been chosen for this report. This approach will help to assess the effectiveness of family-led strategies in enhancing medication adherence among diabetic patients in home-based care as compared to pharmaceutical-led strategies. The project will be guided by the following clinical questions:
1.Does education on diabetes increase medication adherence in diabetic patients in home healthcare? Comment by Author: Use your PICOT question here
2. Do family-led strategies lead to better medication adherence in home-based diabetic patients?
The following table shows the characteristics of the variables involved.
Table 1
Characteristics of Variables
Variable
Variable Type
Level of Measurement
Family-led strategies
Independent
Nominal
Pharmaceutical-led strategies
Independent
Nominal
Medication adherence
Dependent
Ratio Comment by Author: You only have one independent variable because there are no comparisons
Project Methodology
A quantitative methodology is appropriate for use in this project because of the feasibility and clinical relevance associated with the practice improvement measurement. This will facilitate the discovery of the effectiveness of family-led strategies as compared to pharmaceutical-led strategies in medication adherence of diabetic patients in home-based care. It will get quantifiable and objective data related to the research question through the statistical analysis. This methodology was preferred rather than the qualitative methodology in this project because there will be a need to collect numeric data to assess the effectiveness of family-led strategies. The numerical data will be collected before and after the study. The results will then be compared and contrasted prior to making the necessary conclusions from the study. Qualitative data cannot be used to conduct this comparison. The quantitative methodology also allows for the numerical representation of the DPI findings so that specific and observable conclusions can be drawn. Descriptive statistics will be used to determine the relationship between the variables and to explain the differences in the two strategies and their impact (Queiros et al., 2017). Comment by Author: This will need editing as this is not research. There is still work to be done in this section re. clarifying exactly what variables you will quantitatively measure and how
The quantitative methodology aims to predict, control, or explain certain theories. To analyze data, this research methodology relies heavily on statistical analysis. According to Fain (2017), this research methodology focuses on objective measurements and analyzes the data collected through statistical, numerical, or mathematical analysis. It also uses computational techniques to manipulate preexisting statistical data. Usually, it is applied to test if or confirm whether certain theories and assumptions are true or false. According to Zaccagnini and Pechacek (2019), the two important foundational aspects of projects that use this research methodology are that they build on results and evidence from past research and that they usually form the basis for future research.
Project Design
This quality improvement project will use the quasi-experimental design as the principal evaluation method (Handley et al., 2018), while the design will assess how family-led strategies compare with pharmaceutical-led strategies in ensuring ensure medication adherence among patients with diabetes in home-based care programs. This approach will be used to determine if family-led strategies make a difference in medication adherence among diabetes patients in home-based care programs. Since this project aims to find out how the two interventions compare, measurement of numerical data will be necessary. An evaluation of the impact of each of the two strategies on medication adherence among diabetic patients in home-based care will also be conducted before and after the application of the strategy.
Family-led strategies among diabetic patients in home-based care have very notable differences with pharmaceutical-led strategies among patients in this care. The design of this project is a two-group pre- and post-intervention quasi-experiment design. The project design chosen for this project is a quantitative quasi-experimental design which will be used to assess the impact of family-led strategies on medication adherence among diabetic patients in home-based care programs. This research design is suitable for this project because the variables cannot be changed by the researcher (Handley et al., 2018).
Information on the gender and age of the patients identified for this project will be collected. A population of 50 diabetic patients has been identified for the project. The project research intends to use entire population as a sample diabetic patient in home-based care and the most valid and reliable instrument to be used in this project is questionnaires. Close- ended questionnaires will be utilized in this case. The project lead, in this case, is a comparison between the impact of family-led strategies and pharmaceutical-led strategies on medication adherence among diabetic patients in home-based care programs. Meanwhile, the pretest and posttest data that will be collected using questionnaires will be analyzed using the Statistical Package for the Social Sciences (SPSS) software.
An impact assessment of the strategies will be conducted before the implementation of the strategies and four weeks after the implementation of the strategies. This design will be applied to determine the relationship between the variables in the study. The project design chosen will facilitate the analysis of the comparison in the impact of family-led strategies and pharmaceutical-led strategies.
Population and Sample Selection
The population from which the sample to be used in this project is diabetic patients in home-based care programs in Texas. This sample is convenient because it includes participants who would be directly impacted by the interventions involved in this research. For this project, patients in home-based care who are interested in increasing their knowledge of medication adherence will be the participants. The population will comprise of diabetic patients aged 35 years and above. The population will comprise of patients who are not in a position of being admitted to hospitals. According to a Texas Medicaid and Texas Diabetes council report (2018), there were 8,700 inpatient hospital claims and 88,988 outpatient hospital claims made by diabetes patients in the year 2018. The figure that will be used as target population in this project is the 88,988 outpatient claims. The sample size will be determined using the Taro Yamane formula: Comment by Author: Do not use this number as your N. Your home health agency only sees a percentage of this number so use the volume of diabetic patients at your home health agency for this calculation
n=N/1+ N(e)2
Where:
n= sample size
N= target population (88,988)
e=error term in this case 10% (0.1)
Thus, sample size is determined to be 99.88 rounded off to 100 patients.
Before data is collected from patients, they will be asked to sign an informed consent form which will explain to them the purpose of the project and also assure them of their confidentiality should they choose to participate in the study. The informed consent form will be administered with care making sure that patients are not coerced or promised benefits for participation. Only patients who agree to participate and sign the informed consent form will be included in the project.
Instrumentation or Sources of Data
Data in this project will be collected through a pre-implementation and a post-implementation survey. Questionnaires and the MMAS-8 tool will be used in this project to gather information about the impact of the family-led strategy on medication adherence among diabetic patients in home-based care programs (Krosnick, 2018). Patients in home-based care programs will be given questionnaires to fill. There will also be questionnaires for family members offering direct support to these patients to fill. The questionnaires in this case will require ‘yes’ or ‘no’ responses. There will also be scaling questions in the questionnaire where participants will be required to assess certain information on a scale of 5 (1=strongly disagree, 2=slightly disagree, 3=neither agree nor disagree, 4=slightly agree, and 5=strongly agree). A questionnaire like this fit perfectly and it is the most effective for this project because it is easy to statistically analyze (Krosnick, 2018). The MMAS-8 questionnaire on the other hand will measure the medication adherence of patients and will be used in both pre and posts assessment.
The questionnaires will include two sections, the first section is where the socio-demographic information of the participants will be captured. This will include information on gender and race, while the other section will capture information about the impact of the respective intervention strategies on the medication adherence of the patients. It will involve getting data from the assessment, which will be compiled in a spreadsheet. The SPSS software will then be used to analyze the data so that conclusions can be drawn from it.
Validity Comment by Author: This section as well as the reliability section still needs some work. You will need to specifically discuss the validity and reliability of the evidence-based tool/instrument you are using. You can find this data in prior research done to validate the tool. Remember you can not make up your own instruments/questionnaires. You need to utilized evidence-based tools/questionnaires/instruments
The validity of the questionnaire will be established through the exploration of its social theoretical construction. The validity of closed-ended and scaling questionnaires has been confirmed through research. According to research, the test for the validity of these types of questionnaires would be a normal distribution curve. The research found the use of closed-ended and scaling questionnaires to be acceptable. According to research, these questionnaires are effective in linking existing knowledge to current findings. Questionnaires will be the only source of data in this research. Research on the validity of these types of questionnaires shows that existing theoretical, as well as empirical constructs, should be well represented in the questionnaires to increase their validity (Francis et al., 2017). For the standard questionnaire that uses Likert scale, Cronbach’s alpha will be used to determine the validity of the questionnaire items. The value of Cronbach’s alpha will be at 0.7 for the questions to be deemed valid. For the MMAS-8 questionnaire, factor analysis will be used to both asses the validity of the items as well as analyze the adherence levels of the patients.
Reliability
The reliability of this project, just like the validity of questionnaires impacts the research findings and consequently the conclusions drawn from the research to a great extent. Reliability is the extent to which a questionnaire produces similar results in different trials. Regarding the reliability of these types of questionnaires, reliability cannot be achieved unless the measurements are based on numerical values. Reliability is closely related to the objectivity of the research. Since this is quantitative research, the objectivity lies in the instrumentation used in the research. Research shows that there are several threats to the reliability of questionnaires in research. These include using unclear and complicated questions, the use of arbitrary and illogical codes, and giving unclear response options (Francis et al., 2017). To ensure that reliability of the standard questionnaire is met, the questionnaire will be given to a few experts in the diabetes management sector to determine if the questions are appropriate and if there are any internal inconsistencies in them. Their opinions will be incorporated into the final questionnaire. Use of the MMAS-8 questionnaire ensures reliability because it is a widely used and tested tool for collecting information on adherence.
Data Collection Procedures Comment by Author: Section still needs work. Remember this is basically a step by step recipe regarding how you will complete your project and collect your data. Use the words pre implementation and post implementation instead of pre test /post test. It is not clear exactly your intervention is and how it will be implemented so makes this section unclear
Informed consent will first be sought from the participants in this research. This will be after informing all the participants in detail what this project is all about. The participants will be provided with a letter explaining the purpose of the project and its benefit to them and the nursing profession. Participants will be notified how their data will be used and will be assured of confidentiality. Personal data regarding the patients and other participants will not be collected and their medication plans will not be affected.
The participants will be asked to complete a pretest and post-test survey which will be anonymous. Participants will be identified using numbers rather than names to protect anonymity. The pre-test will be conducted before the family-led health education strategy is introduced to patients. This will give baseline I formation on adherence. The post-test will be carried out after three months of constant reminders and follow up on the patients to evaluate of the intervention was successful. Post-test and pretest results will be identified in such a way that they correlate for easier and right analysis.
The data will be collected using a questionnaire that is already set by other stakeholders in the health sector so that the right information can be collected so that the research
Data Analysis Procedures
The data will be collected and analyzed using the SPSS software. Through descriptive statistics, the numeric and categorical variables in the questionnaires will be summarized. Comment by Author: How? On paper? Electronically?
Descriptive statistics will be used to describe the patient’s demographic information such as age, weight, gender, level of education and marital status. Central measures of tendency such as mean and standard deviation will be used to describe the population under study and also in the adherence-based questions. Comment by Author: Why do you need this information?
Common Factor analysis will be used to determine common factors amongst patients in regard to adherence and infer from the results which factors are common to all patients and which are least common. Comment by Author: Why do you need 3 different statistical tests for your data analysis? Try to determine what is the best way to analyze your data to answer your clinical question and pick a statistical test that best does that. You do not need more than one unless it is necessary
Logistic regression will also be used to determine the relationships existing between adherence and patients’ sociodemographic characteristics to determine how they interact or influence patient’s medication taking behaviors. Chi-square and Odds ratio will also be used to determine the effectiveness of the intervention in the post assessment phase of the project.
The analysis is important in quality improvement project will begin only after the nature and statuses of the patients and their caregivers are understandable. The SPSS software that will be used in this project will help to determine the relationship between the different variables in the research. It will establish the relationship between family-led strategies of intervention and medication adherence among diabetic patients in home-based care. It will also show how this compares to the impact of pharmaceutical-led strategies of intervention on medication adherence among diabetic patients in home-based care. This software will further be used to predict the possible application of the results drawn from this research. Comment by Author: This section still needs works as well to distinguish the project from research analysis
The data will be analyzed by comparing the results of the pretest and those of the post-test. The characteristic of this research design is to apply an intervention so that it can help to determine the relationship between two variables in the research. The quasi-experimental design that will be used in this project will help to analyze the impact of family-led strategies on medication adherence among diabetic patients in home-based care. It will also help to analyze how this impact compares to that of pharmaceutical-led therapies on medication adherence among diabetic patients.
Potential Bias and Mitigation
There exists a number of possible sources of bias throughout the project. However, the most important issues is formulating solution strategies on how the bias can be addressed. One potential source of bias is recall bias causes. This will emerge from the responses that the respondents will be required to provide. For instance, the diabetic patients will be required to respond to self-report survey based on the medication adherence. In such situations, the researchers normally rely on the information that has been issues out by the respondents, and majorly their memory. Based on the patients’ memory, the information might or might not be accurate, but the investigator will have to rely on it. Two mitigation strategies to recall bias are empathy and acknowledgement. The investigators should empathize with patients, assume their situations and circumstances, and try digging deeper to get an understanding possible causes why the information given out might be true or untrue. Acknowledging that there are possibilities of the problem to exists is important in a number of ways. This will help suppress the bias that might be available in respondents. Comment by Author: Great job as recall bias is pretty evident in self report surveys/tools. However the writing needs work and you need citations for your assertions
Ethical Considerations
An authorization letter has been obtained from the project site (appendix …). The project has also been submitted to the project site IRB exemption ( Appendix…..). The project will need to be submitted to GCU IRB for review. This project will get approval from the university. The participants will be informed on all aspects of the project including how the data will be collected, analyzed, and used. They will also be informed about the importance of this project to them and the nursing field in general. Written informed consent will then be sort from all the participants in this research. This quality improvement project will to the latter the principles and standards of ethical research (Fiesler, 2019). Comment by Author: This section still needs editing for the writing
The participants will answer the questionnaire questions anonymously and they will be assigned numbers will be used to identify participants to further protect anonymity. Also, the questionnaires will be handled with great care to ensure privacy. Data collected for the project will be kept on a password protected computer only accessible to the DPI investigator. The computers that will be used to compile and analyze data in this project will be secured with strong passwords to protect data. Aggregate dData will only be shared among people who are directly affected by the project. Personal information about the participants will not be collected in this research. The participants will be informed of the results of this project via the contact information they would have been provided in the questionnaires. After completion of the project, the questionnaires containing participant information will be disposed of safely (Fiesler, 2019). Comment by Author: Which people? Comment by Author: But previously you said you would collect some information regarding education status etc?
Limitations
The quantitative quasi-experimental approach that was chosen for this project is the best in determining the relationship between variables in this research and showing how the two main interventions compare. However, there are several limitations to this project. One of them is that the time frame set for this project may not be enough to show the impact of an intervention. Four weeks is a relatively short time to determine whether an intervention has had any impact or not. The second limitation is that the sample size set for this research project is also relatively small. This will make it difficult to generalize the results of this project. The fact that only diabetic patients will be participating in this quality improvement project also makes it difficult to establish whether family-led strategies can be effective among other patients with chronic illnesses and those who are in home-based care. The method of data collection chosen for this research could also be a limitation. Participants can give wrong information in their questionnaires which will affect the overall results of the study. Comment by Author: Great start, you need some citation to support your assertions
Summary
Medication adherence among patients with diabetes remains a crucial determiner of their well-being. The purpose of this project is to determine to what extent the implementation of family-led strategies would impact medication adherence when compared to pharmaceutical-led strategies among diabetic patients’ in-home care settings in Texas over four weeks. The problem that aims to be solved in this research is to bridge the gap in knowledge about the impact of family-led strategies on medical adherence among diabetic patients in home-based care programs as compared to pharmaceutical-led strategies. Moreover, the methodology that has been selected for this project is the quantitative methodology (Fain, 2020). A quasi-experimental design will be used in this quality improvement project. The design will facilitate the identification of the relationship between the variables in the research. Questionnaires will be used as the only method of data collection in this research. The validity and reliability of questionnaires for data collection in this research has already been established.
The pretest-posttest approach will be used to collect data in this research. Data will be collected before the application of the intervention and after. An analysis of the two sets of data will be used to determine the impact of the independent variables of this research on the dependent variable. The data gathered will be compiled in excel spreadsheets. The SPSS software will be used to analyze data in this research. This software will ensure that the dependent variables in the research are not manipulated.
To ensure that ethical research is conducted, this project will follow to the latter the principles and standards of ethical research. It will also ensure that written informed consent is sought from the participants prior to beginning the research. The anonymity of the participants and the privacy of data will be upheld at all costs. Among the limitations of this project is the small number of participants used in the research. The short duration of the project and the use of questionnaires as the only method of data collection are also limitations in the study. In chapter four, this project will present the data analysis and results. The chapter will also discuss the findings and results. Chapter five of this project will conclude the project and give directions for future use.
HADLER, A. N. D. R. E. W. S. U. T. T. O. N. S. T. E. P. H. E. N. O. S. T. E. R. B. E. R. G. L. A. R. S. (2020). WILEY BLACKWELL HANDBOOK OF TREATMENT ENGAGEMENT: Theory, research, and clinical practice. Place of publication not identified: WILEY-BLACKWELL. Retrieved from /orders/www.worldcat.org/title/wiley-blackwell-handbook-of-treatment-engagement-theory-research-and-clinical-practice/oclc/1130650913
In Forman, S. G., & In Shahidullah, J. (2018). Handbook of pediatric behavioral healthcare: An interdisciplinary collaborative approach. Retrieved from /orders/www.worldcat.org/title/handbook-of-pediatric-behavioral-healthcare-an-interdisciplinary-collaborative-approach/oclc/1062418920
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In Heston, T. (2018). Ehealth: Making health care smarter. Retrieved from /orders/www.worldcat.org/title/ehealth-making-health-care-smarter/oclc/1099336057
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In Sherman, S., In Hansen-Turton, T., In King, E. S., & Bednash, G. (2015). Nurse-led health clinics: Operations, policy, and opportunities. Retrieved from /orders/www.worldcat.org/title/nurse-led-health-clinics-operations-policy-and-opportunities/oclc/1034939410
Institute of Medicine (U.S.). (2016). A framework for educating health professionals to address the social determinants of health. Washington, DC: The National Academies Press. Retrieved from/orders/www.worldcat.org/title/framework-for-educating-health-professionals-to-address-the-social-determinants-of-health/oclc/1021273933
Glanz, K., Rimer, B. K., & Viswanath, K. (2015). Health behavior: Theory, research, and practice. Retrieved from /orders/www.worldcat.org/title/health-behavior-theory-research-and-practice/oclc/1085343214
National Academies of Sciences, Engineering, and Medicine (U.S.). (2018). Health-care utilization as a proxy in disability determination. Retrieved from /orders/www.worldcat.org/title/health-care-utilization-as-a-proxy-in-disability-determination/oclc/1030971027
Choi, D., Choi, H., & Shon, D. (2019). Future changes to smart home based on AAL healthcare service. Journal of Asian Architecture and Building Engineering, 18(3), 190-199.
Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and mixed methods approaches. Sage publications.
Medina, M., Babiuch, C., Card, M., Gavrilescu, R., Zafirau, W., Boose, E., … & Boissy, A. (2020). Home monitoring for COVID-19. Cleveland Clinic journal of medicine.
Parker, M. L., Yip, P. M., DeCherrie, L. V., Escobar, C., Füzéry, A. K., Price, C. P., & St John, A. (2018). There’s No place like home: exploring home-based, acute-level healthcare. Clinical chemistry, 64(8), 1136-1142.
Ahmed, I., Ahmad, N. S., Ali, S., Ali, S., George, A., Danish, H. S., … & Cox, B. (2018). Medication adherence apps: review and content analysis. JMIR mHealth and uHealth, 6(3), e62. Retrieved from /orders/mhealth.jmir.org/2018/3/e62/
Brown, M., & Bussell, J. (2018). Medication Adherence: WHO Cares? Mayo Clinic Proceedings, 86(4), 304-314. Retrieved from /orders/doi.org/10.4065/mcp.2010.0575
Fiesler, C. (2019). Ethical Considerations for Research Involving (Speculative) Public Data. Proceedings of the ACM on Human-Computer Interaction, 3(GROUP), 1-13. Retrieved from /orders/dl.acm.org/doi/abs/10.1145/3370271
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Norman, G. J., Orton, K., Wade, A., Morris, A. M., & Slaboda, J. C. (2018). Operation and challenges of home-based medical practices in the US: findings from six aggregated case studies. BMC health services research, 18(1), 45. Retrieved from /orders/link.springer.com/article/10.1186/s12913-018-2855-x
Queirós, A., Faria, D., & Almeida, F. (2017). Strengths and limitations of qualitative and quantitative research methods. European Journal of Education Studies. Retrieved from http://oapub.org/edu/index.php/ejes/article/view/1017
Voortman, T., Kiefte-de Jong, J., Ikram, M., Stricker, B., van Rooij, F., & Lahousse, L. et al. (2017). Adherence to the 2015 Dutch dietary guidelines and risk of non-communicable diseases and mortality in the Rotterdam Study. European Journal of Epidemiology, 32(11), 993-1005. Retrieved from /orders/doi.org/10.1007/s10654-017-0295-2
Improving Medication Adherence in Diabetic Patients in Home Health Care
Literature Review
2. Literature Review:
a. Background of the Problem/Gap:
· Medication adherence can be defined as how well patients in home-based care can correctly take the medication that has been prescribed by the doctors in the absence of health practitioners.
· Medication adherence incorporates total adherence and compliance with the medical instructions that the patients have been giving.
· Proper medication adherence can significantly minimize chronic illness and emergency visits to hospitals.
· The number of patients who have been diagnosed with diabetes in America alone cannot be hospitalized (Brown & Bussell, 2018). This is the reason why home base health care programs for these patients has been initiated.
b. Theoretical Foundations (models and theories to be the foundation for the project):
· Medication Nutrition Therapy: It is commonly abbreviated with MNT. Every patient will be enrolled on a three-week mentorship teaching and education program which will be administered and facilitated by nutritionists, nurses, and healthcare practitioners. The nutritionists will be in charge of the diet education while nurses and practitioners will be responsible in offering general healthcare education regarding diabetes and the right lifestyle changes to be incorporated. Nutrition education will examine the types of foods to be consumed, amount and frequency with which they should be taken. Lifestyle education changes will examine the healthy life activities that diabetic patients ought to be involved with. For example, they should exercise regularly for body fitness and hence, reduce the possible effects of the disease. Patients should get out of comfort zone and execute physical duties on their own. It is defined as an evidence-based approach in which the family members are tailored towards implementing an individual nutrition plan. Ideally, the plan is designed, ordered ad approved by qualified and registered health practitioner. This model is responsible for determining the types of foods that diabetic patients are supposed to be consuming at any given time and stage of their treatment efforts. No one size can fit all eating requirements for diabetic patients (Brown & Bussell, 2018). The model demands that diabetic patients be involved in at least one form of education and collaborative care. Educating the patients about nutrition will enable themselves to take care of while in homebased care.
· Ongoing Care Management: There is a need for diabetic patients to receive care from multiple integrated teams that comprise the expert. The team’s possible members include but are not limited to the nurses, physicians, nurses, and mental health professionals (Brown & Bussell, 2018). Although the team members might not physically meet the team, communication between them and the home care diabetic patients will be maintained remotely.
c. Review of Literature with Key Organizing Themes and sub-themes (Identify at least two themes, with three sub-themes per theme)
Theme 1- What can be done to enhance Medication adherence
To handle the issue of medication adherence among the diabetic patients who have had an issue with the adherence to medication needs to come up with a variety of strategies that have been attained from scholarly reviews as well as journals for purposes of well researched data on the concept. Appropriate types of medications are usually considered to be the identified cornerstone regarding the prevention as well as disease treatment yet according to numerous research carried out, there is solely about half of the individual patients who adhere the instructions of their prescribed medication (Bosworth, 2015). This usually causes a common as well as a costly public health associated challenge especially for the healthcare system in the US. Dietary Adherence
· This refers to the art of adhering to the preset diet obligation. In summary, this is the process by which the home-based diabetic patient sticks to the physician recommended by the physician (Brown & Bussell, 2018). This demands that the patients stick to healthy foods alone, which can positively boost growth.
Drug Adherence
· This is the art of sticking to the drug prescription as being presented by the doctors. There are many reasons why home care patients might fail to take drugs as prescribed. For instance, when there is no person to remind them of what is supposed to be taken and at what time (Brown & Bussell, 2018). Some patients go ahead of suffering conditions that make it difficult for them to progress in life.
Pharmacist- Led Drug Therapy
· According to Campbell et al. this is a medication therapy which involves direct contact and communication between patients and health practitioners. (Campbell et al., 2018)
· This form of medication might not be an ideal one for home-based patients.
· It is not applicable in this case of medication because they are not always with the home care members.
· Family members can play a vital role in upholding the person’s health compared to medical practitioners because they tend to spend much time with the patient at home.
Strategies to Improve Diabetic Care Patients:
Patient-Centered Communication Approach
· This approach will incorporate the interests and preferences of the patients. It will also serve to determine the possible barriers which people might be facing in this situation (Voortman et al., 2017)
Chronic Care Models
· Any form of care should be associated with chronic care models. Adopting the models will ensure that any form of care needed by the patients has been taken good care of.
Capitalize on Advocacy
· This involves the provision of active support to patients to positively boost their lives.
d. Summary
· Gap/Problem: Implementation of Medication nutrition therapy strategy that will support medication adherence in diabetic patient’s in-home health care.
· Prior studies: Prior studies reveals that medical adherence for home-based patients has not been a smooth process.
· Quantitative application: WHO reports with numerical data about medication adherence to home-based patients.
· Significance: Increase the number of ways through which homecare medical adherence can be attained.
Problem Statement
3. Problem Statement:
It was not known if or to what degree the implementation of a nurse led lifestyle education intervention in adult diabetic patients under home health care would impact medication adherence over a 4-week period. Medication adherence will be measured using self-report questionnaires tool. The tool will involve asking patients questions about the missed doses within a specific period of time. For accuracy purposes, the patients will be asked about medication adherence in the last three days because asking for more than three last days will be difficult for the patients to recall.
Literature holds that family members are closer to home-based patients with healthcare practitioners. Therefore, they can be of great importance to the patients as they can give ready support compared to doctors
Clinical/ PICOT Questions
4. Clinical/PICOT Questions:
To what degree does the implementation of home-based care interventions so as to ensure that they are up to the place so that there will be a positive outcome within the stipulated time to ensure that mortality rate is reduced.
Sample
5. Sample (and Location):
a. Location: Texas urban region. This is because the urban part hosts more people, compared to the rural region of the state.
b. Population 50 diabetic patients. These will be adults, aged 18 years and above. The population will comprise of mixed gender. A sample population of 50 was arrived at based on outcome measures.
d. Inclusion Criteria
· Interested parties striving to increase an understanding of medication adherence among home care adult patients aged 18 years and above diagnosed with diabetes and whom have been found to have medication nonadherence by their home health team.
e. Exclusion Criteria
· Patients aged 18 years and above and who are in the initiation stage that is starting of diabetic treatment in case there is a need to be.
· Exclude patients with cognitive impairment
Define Variables
6. Define Variables and Level of Measurement:
a. Intervention: helping people to know the challenges that are they may present themselves when they are dealing with home care-based interventions.
b. Outcome: medication adherence.
Methodology and Design
Methodology and Design:
Quantitative with a pretest and posttest design. This is an ideal methodology and design because it will incorporate collection of the retrospective baseline and prospective intervention rates.
Purpose Statement
Purpose Statement:
The purpose of this quantitative research project or to what degree the implementation of Medication nutrition therapy would impact medication adherence when compared to pharmacist drug-led strategies among diabetic patient’s in-home care in Texas over four weeks.
Data Collection Approach
Data Collection Approach:
Data collection will involve a pretest-posttest approach. Home-based patients having medication nonadherence issues will be given questionnaires to be filled with the patients under home-based care. The questionnaire will have precise questions aiming a collecting data from family members who have taken part in Medication nutrition therapy. Family members giving the patients direct support will be evaluated as well. Information gathered will be gathered and contrasted with theoretical information available. The pre-designed questionnaire will allow collection of the career views and suggestions on how the process can be enhanced. The questionnaires will be channeled to the care givers alone.
Data Analysis Approach
Data Analysis Approach:
The data mentioned above will be collected and analyzed using SPSS. The software will further be used in establishing relationships between different aspects of the information. This is important as SPSS will be used in this analysis.
References
Ahmed, I., Ahmad, N. S., Ali, S., Ali, S., George, A., Danish, H. S., … & Cox, B. (2018). Medication adherence apps: review and content analysis. JMIR mHealth and Health, 6(3), e62. Retrieved from /orders/mhealth.jmir.org/2018/3/e62/
Campbell, A. M., Coley, K. C., Corbo, J. M., DeLellis, T. M., Joseph, M., Thorpe, C. T., … & Sakely, H. (2018). Pharmacist-led drug therapy problem management in an interprofessional geriatric care continuum: a subset of the PIVOTS group. American health & drug benefits, 11(9), 469. Retrieved from /orders/www.ncbi.nlm.nih.gov/pmc/articles/pmc6322592/
Voortman, T., Kiefte-de Jong, J., Ikram, M., Stricker, B., van Rooij, F., & Lahousse, L. et al. (2017). Adherence to the 2015 Dutch dietary guidelines and risk of non-communicable diseases and mortality in the Rotterdam Study. European Journal of Epidemiology, 32(11), 993-1005. /orders/doi.org/10.1007/s10654-017-0295-2.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
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Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
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Timing: The Proposal Defense presentation should be no longer than 30 minutes.
Be sure you have the approval of your DPI Chairperson and Committee for everything in the presentation; if you are unsure of something, clarify it prior to your defense call.
Practice multiple times.
Format
DO:
Use this GCU slide layout.
Use an easy to read font size.
Use figures and tables.
DO NOT:
Do not add slide transitions, animation, or sounds that are distracting.
Do not crowd slides with excessive text.
Oral Presentation
Create notes in your presentation of the points you want to cover in your oral presentation of each slide.
Except for specific content, such as clinical questions, do not just read the slides. Paraphrase in a conversational, yet professional manner (the result of practice, as per the prior slide).
Your oral presentation should explain or expand upon what is on the slides; it should not reiterate the content.
Title Page
Start with a title page that uses the title of the DPI Project
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We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.
Late Policy
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Please use the attached DNP-DPI Project and Sample PowerPoint to complete this assignment
In this topic, you will participate with your full DPI Committee in the DPI Completed Project – Defense PowerPoint and Call. This meeting requires that you present your finalized DPI Project in PowerPoint form.
General Requirements:
Use the following information to ensure successful completion of the assignment:
· Remember to use the appropriate forms and templates (if required) for completing this assignment. These are available in the DNP PI Workspace in the DC Network.
· Locate the “Preparing for Your Final Direct Practice Improvement Project Defense” resource in the DNP-965 folder of the DNP PI Workspace of the DC Network.
· Locate the “DNP-965 Final Defense PowerPoint Template,” located in the DNP-965 folder in the DNP PI Workspace of the DC Network.
· Doctoral learners are required to use APA style for their writing assignments. The APA Style Guide is located in the Student Success Center.
· This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
· You are not required to submit this assignment to LopesWrite.
Directions:
Completing the Benchmark – DPI Completed Project – Defense PowerPoint and Call is the required deliverable to progress through the DPI Project implementation and completion phases.
1. Use the “DNP-965 Final Defense PowerPoint Template,” located in the DNP-965 folder of the DNP PI Workspace in the DC Network, to create a PowerPoint presentation of your Final DPI Completed Project to be used during your DPI Completed Project – Defense PowerPoint and Call.
2. Attach a copy of the potential poster presentation concept for your DPI Project as per the format you and your DPI chairperson predetermined; the Benchmark DPI Completed Project – Defense PowerPoint and Call submission is incomplete without this element.
Edit down your proposal presentation and add the results and discussion
Summarize Chapters 1-5
Include the poster presentation at the end
Check…and Double Check
Timing: The Oral Defense presentation should be no longer than 30 minutes
Be sure you have the approval of your DPI Chairperson and Committee for everything in the presentation; if you are unsure of something, clarify it prior to your defense call.
Practice multiple times.
Format
DO!
Use this GCU slide layout.
Use an easy to read font size.
Use figures and tables.
DO NOT!
Do not add slide transitions, animation or sounds that are distracting.
Do not crowd slides with excessive text.
Oral Presentation
Create notes in your presentation of the points you want to cover in your oral presentation of each slide.
Except for specific content, such as clinical questions, do not just read the slides. Paraphrase in a conversational, yet professional manner. (The result of practice, as per the prior slide)
Your oral presentation should explain or expand upon what is on the slides; it should not reiterate the content.
Title Page
Start with a title page that uses the title of the DPI Project
Investigator’s Background
What qualifies you to do this project?
Credentials
Experience
Etc.
BE VERY BRIEF!
Topic Background
Why this topic?
History
Need
What needs(s) in practice does the research identify? What need will your project address and implement?
You can use more than one slide to address each of the categories.
Problem Statement
Your problem statement should clearly and explicitly state the reasons you are doing your study.
The purpose of this study is to……………….
Importance of the project
How might your project impact the field of study or healthcare outcomes?
How could it impact your work as a professional?
What else is significant?
Theoretical Foundation
If it is discussed in your project, include a slide on the philosophical orientation.
For example: critical theory or social constructivism
Review of the literature
Provide an overview of the themes and subthemes provided in your project.
Theme
Subtheme
Subtheme
Theme
Subtheme
Subtheme
Theme
Subtheme
Subtheme
clinical Questions
Number your questions to facilitate easy reference during discussions with the committee members.
Methodology
Define which major category of methodology you implemented for your project.
Include your rationale as to why your chosen methodology is appropriate to your clinical questions?
Cite relevant methodology literature in support of your choice of methodology.
Specifics on Methodology
Depending on your choice of methods, you may need to outline specifics such as (including but not limited to):
Variables–PICOT
Participants—number, how selected, IRB considerations, demographics
Reliability and validity
Methods of data collection
Data analysis
Limitations
You may need multiple slides for these categories.
Results
Provide an outline of what will be discussed
Descriptive Data
Provide an overall summary of the descriptive data so the audience can observe the sample, groups, and other demographics
Data Analysis
Provide the planned analysis and any changes from the original plan
Discuss sources of error and address the assumptions
Results
Provide the results without conclusions or bias
Provide the test result and the p value
Summary, Conclusion & Recommendations
Create bullets of conclusions and recommendations
Create a final summary statement for the audience
Summarized the findings
Conclusion
Recommendations for future exploration
References
List only those cited in the DPI Project Final Manuscript defense presentation.
To start using this template you first need to delete this content and any other unwanted contents of this page. Keep the poster title and the purple section headers.
The purple headers are used to identify and separate the main topics of your presentation. The most commonly used headers in poster presentations are provided, but you can change these headers to fit your dissertation
Move the header copies approximately to where you think they need to be on the poster, so you can get a better sense of the overall poster layout. It will help you organize your content. You can now start adding your text. To add text use the text tool to draw a text box starting from the left edge of a column to the right edge and start typing in your text. You can also paste the text you may have already copied from another source Repeat the process throughout the poster as needed.
To import charts and graphs from Excel, Word or other applications, go to EDIT>COPY, copy your chart and come back to PowerPoint. Go to EDIT>PASTE and paste the chart on the poster. You can scale your charts and tables proportionally by holding down the Shift key and dragging in or out one of the corners.
Improving Medication Adherence among Type II Home Healthcare Diabetic Patients
Improving Medication Adherence among Type II Home Healthcare Diabetic Patients
Submitted by
Bola Odusola-Stephen
A Direct Practice Improvement Project Presented in Partial Fulfillment
Improving Medication Adherence among Type II Home Healthcare Diabetic Patients
by
Bola Odusola-Stephen
has been approved.
April 6, 2021
APPROVED:
Maria Thomas., DNP., DPI Project Chairperson
Bamidele Jokodola., DNP., DPI Project Mentor
ACCEPTED AND SIGNED:
________________________________________
Lisa Smith, PhD, RN, CNE
Dean and Professor, College of Nursing and Health Care Professions
_________________________________________
Date
Abstract
Medication adherence is essential in controlling chronic health conditions such as Type II diabetes in home health patients. At the project site, there was no standardized process for identifying and addressing the patient’s medication adherence. The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks. The nursing theory and change model that will guide this project is Orem’s Self-Care Deficit Theory and Diffusion of Innovation Model. Data extrapolated from Cradle Solutions and analyzed utilizing a chi-square analysis to determine the statistical significance. The clinical significance could be noted with the nurses using the tool consistently and performing the medication adherence screenings on each visit to help the patient remain compliant. The findings suggested that implementing the medication adherence program could improve patient compliance rates. A future recommendation is to conduct the project using larger populations of home health patients for a longer timeframe.
Keywords: diabetes mellitus type II, Diffusion of innovation model, home-based care, medication adherence, MAP resources, Orem’s self-care deficit theory
Dedication
An optional dedication may be included here. While a practice improvement project is an objective, scientific document, this is the place to use the first person and to be subjective. The dedication page is numbered with a Roman numeral, but the page number does not appear in the Table of Contents. It is only included in the final practice improvement project and is not part of the proposal. If this page is not to be included, delete the heading, the body text, and the page break below.
Acknowledgments
An optional acknowledgements page can be included here. This is another place to use the first person. If it applies, acknowledge and identify grants and other means of financial support. Also acknowledge supportive colleagues who rendered assistance. The acknowledgments page is numbered with a Roman numeral, but the page number does not appear in the Table of Contents. This page provides a formal opportunity to thank family, friends, and faculty members who have been helpful and supportive. The acknowledgements page is only included in the final practice improvement project and is not part of the proposal. If this page is not to be included, delete the heading, the body text, and the page break below. If you cannot see the page break, click on the Show/Hide button (go to the Home tab and then to the Paragraph toolbar).
Chapter 1: Introduction to the Project
According to the Centers for Disease Control and Prevention (2020), diabetes impacts one in ten Americans. Furthermore, the prevalence of diabetes continues to rise and is projected to increase by 0.3% per year until 2030 (Lin et al., 2018). For individuals with Type II diabetes, proper and effective medication adherence is critical (Kvarnström et al., 2018). This is particularly significant among healthcare patients because diabetes is one of the leading diagnoses for admission into a home health care facility (Sertbas et al., 2019). In this population, approximately 45% of the patients fail to maintain glycemic control (HgbA1c < 7%) (Polonsky & Henry, 2016). Poor medication adherence is linked with increased morbidity and mortality rates, increased financial expenses for the patient, hospital, and insurance companies, frequent hospitalizations, and lower quality of life (Polonsky & Henry, 2016).
At the project site, the primary investigator, in collaboration with the stakeholders, noted that the healthcare providers documented ten percent of the patients were not adhering to their medication regimen. This prompted frequent hospitalizations, infections, and other diabetic complications. In further investigation, it was found that there was not a standardized method for the healthcare providers to evaluate the patients regarding medication adherence. Hence, the introduction of the MAP resources and education intervention will be implemented.
The project is worth conducting because the primary investigator focuses on diabetic home health patients who are not the focal point of many literature reviews. Furthermore, little information is noted regarding the impact the healthcare team plays in addressing this population’s lack of medication adherence. The primary investigator aims to introduce a standardized method of addressing patient’s medication adherence using the MAP resources and education to minimize frequent hospitalizations, infections and increase their quality of life (Starr & Sacks, 2010). For this project’s purpose, the primary investigator (PI) will examine the impact/role healthcare team members play in addressing patient-related factors that affect medication adherence among home healthcare diabetic patients.
Chapter 1 introduces the project, background, and problem statements. Other segments include the purpose of the project, clinical question, advancing scientific knowledge, and project significance. The last sections consist of the rationale for using a quantitative method and quasi-experimental design, definition of operational terms, assumptions, limitations, and delimitations. The last few sentences are transitional ones providing a preview into Chapter 2.
Background of the Project
Home-based healthcare has existed since 1909 (Choi et al., 2019). Present-day, home-based healthcare is often selected due to an individual’s personal preferences. While home-based healthcare is not appropriate for all patients, Szanton et al. (2016) noted that this care option is best when an individual’s condition can be managed without admission to a hospital. Patients who have diabetes or hypertension are often recipients of home-based healthcare (Wong et al., 2020).
Adhering to diabetes medication regimen requirements can be complex. Raoufi et al. (2018) conducted a study using a multi-stage stratified cluster sampling method to recruit its participants. Two thousand one-hundred eight three diabetic patients participated in the study. Of the participants, 51.4% tested their glucose level more than once a month (Raoufi et al., 2018). The authors also noted that 10% of the participants did not monitor the glucose levels correctly or adhere to the medication requirements.
Patients with diabetes often express difficulties adhering to medication regimens, thereby reinforcing the critical role of receiving education from home healthcare providers (Wong et al., 2020). This is in part to the patients not having sufficient knowledge and education regarding diabetes and proper management of the disease (Wong et al., 2020). With diabetes being one of the leading diagnoses for patients needing home health services, healthcare agencies must educate their staff to evaluate the factors prohibiting patients from adhering to their medication regimen.
Problem Statement
It is not known if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas. The population affected are home health Type II diabetic patients in an urban healthcare agency in Texas. At the project site, nursing administration and staff cited that medication adherence among diabetic patients is lacking. According to data obtained from the site’s electronic health record (EHR), home healthcare providers documented that ten percent of diabetic home healthcare patients are not adhering to their medication regimen. Although this percentage four to six percent lower than other percentages cited in the literature for medication non-adherence, in terms of chronic disease management, various researchers have noted the implications associated with lacking adherence to medication regimens (Camacho et al., 2020; Hamrahian, 2020; Misquitta, 2020).
The lack of medication adherence can be attributed to inadequate drug-related knowledge, medication costs, poor understanding of medication regimen, etc., reinforcing the need for this quality improvement project (Heath, 2019; Sharma et al., 2020). Kvarnström et al. (2017) emphasized healthcare providers play a critical role in ensuring medication adherence. To promote medication adherence among patients of a home healthcare facility, the primary investigator will introduce a standardized method for the healthcare providers to assess the patient’s medication adherence. The staff will achieve greater insight by using MAP resources and an education intervention created by Starr and Sacks (2010). The tools utilized in this study, which are from Starr and Sacks’s (2010) MAP Toolkit and Training Guide resources, include: (1) the questions to ask poster, (2) an adherence assessment pad, and (3) my medications list.
The project contributes to solving the problem by introducing a standardized method of evaluating the patient’s medication adherence. It will improve the healthcare provider’s knowledge and awareness regarding the obstacles or factors the patient may face in maintaining a medication regimen. This would help the facility adhere to the current Centers for Disease Control and Prevention (2020a) guidelines in the participants maintaining their normal daily glucose levels, deter healthcare costs, frequent hospitalizations, and infections.
Purpose of the Project
The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks. The independent variable is the MAP resources and educational intervention. The dependent variable is medication adherence rates. A quantitative methodology will be used for the project to learn about this population (home health patients) (Allen, 2017).
The specific population that will be addressed are adult home health patients ages 35 to 64 years old. The primary investigator chose this population because of the prevalence of Type II diabetes rising in children, adolescents, and young adults in the United States (12:100000) (Centers for Disease Control and Prevention, 2020; Kao & Sabin, 2016; Reinehr, 2013). The selected site serves approximately 100 patients annually, and 30 patients are diagnosed with Type II diabetes. The inclusion criteria are males and females diagnosed with Type II diabetes, oral medication or insulin, and home health patients. The exclusion criteria are individuals with language or cognitive deficits and diagnosed with Type I diabetes. Five female staff nurses will be trained to help implement the quality improvement project. They are individuals who are registered nurses, work full-time, and have been employed with the facility for over one year.
The geographic location of the project is in an urban area of Houston, Texas. The County statistics show that approximately 17.6% of the population have Type II diabetes (Houston, 2021). During 2016-2018, 20.2% of the population was hospitalized due to diabetic complications (Houston, 2021). There are over 700 000 Medicare participants in a three-county radius, which is higher than the national average (Understanding Houston, 2021). Data further showed that preventable hospital stays occur in older adults 65 and above (Understanding Houston, 2021). This suggested a trend to overuse the hospitals as a primary source of care (Understanding Houston, 2021).
The project contributes to the nursing field by increasing the healthcare providers’ knowledge and awareness of the obstacles and other risk factors involved in a patient not adhering to their medication regimen. Furthermore, it would help increase dialogue between the provider and patient in sharing the details of their behavior (Bussell et al., 2017). This creates a positive, blame-free atmosphere allowing the patients to discuss their medication-taking behavior (Bussell et al., 2017).
Clinical Question
A well-developed clinical question must be related and relevant to patient care. This helps the primary investigator search for evidence-based answers. The clinical question that will direct this quality improvement project is: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks?
The independent variable is the MAP resources. The dependent variables are the medication adherence rates.
To address the clinical question, the medication adherence rate for 30-days before and 30-days after the implementation of MAP resources will be compared using a chi-square test. The chi-square test will allow for a comparison of the medication adherence rate for patients 30 days before and 30 days after the implementation, thereby answering the clinical question. The level of significance will be set to .05, indicating a p-value of less than .05 would reveal statistical significance.
Advancing Scientific Knowledge
This direct practice improvement project seeks to enhance medication adherence among diabetic home healthcare patients using the MAP resources. Various researchers have cited the benefits associated with patient-provider engagement and collaboration to improve medication adherence (Ong et al., 2018; Polonsky & Henry, 2016; Wong et al., 2020). The advancement of a small step forward at the clinical site is that by improving medication adherence rates among diabetic patients’ positive patient-related outcomes will likely occur using the MAP protocol. This will add to the current literature and address the gap found regarding non-medication factors among home health diabetic patients.
The theoretical framework that will be used in this quality improvement project is Orem’s self-care deficit theory (1995) was developed to improve patient health outcomes in in the context of nursing contribution (Yip, 2021). The theory is comprised of three related sections: theory of self-care, self-care deficit, and the nursing system (RenpenningcN et al., 2003). It fits the project because it includes healthcare providers assisting patients in their self-care and management to improve their function at a home level (RenpenningcN et al., 2003). The patients cannot effectively manage medication adherence for diabetes, which affects their quality of life and health Orem’s self-care deficit theory advances the project by contributing to previous research conducted on Type II diabetic patients using the theory (Borji et al., 2017; Ghafourifard & Ebrahimi, 2015; Shahbaz et al., 2016). This project, the theory, helps to advances the clinical practice by improving the participant’s quality of life by providing a self-care program as a solution using the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources. The theory guides the primary investigator to increase the patient’s awareness about their disease and minimize their non-compliance with their regimen (Borji et al., 2017). The theory helps to identify the educational needs of home healthcare patients, which is more needed than the proper treatment (Borji et al., 2017). Implementing Orem’s self-care deficit theory is recommended to increase a patient’s knowledge level and adherence to self-care behaviors (Shahbaz et al., 2016).
The change model that will be used in this quality improvement project is the Diffusion of Innovation Model developed by Rogers (2003). There are five stages: a) knowledge or awareness, b) persuasion or interest, c) decision or evaluation, d) implementation or trial, e) confirmation or adoption (Rogers, 2003). Diffusion is defined as a social process, which occurs among individuals in response to knowledge regarding a new strategy for improving their health (Dearing & Cox, 2018). It is also the process communicated within a specific timeframe (four weeks) (Dearing & Cox, 2018). This change model can provide the primary investigator with methods to share and educate regarding a new diabetic prevention strategy (Lien & Jiang, 2016). The model has been utilized in various fields to help healthcare providers understand and translate new concepts, treatments, disease knowledge, and educational methods (De Civita & Dasgupta, 2007; Lien & Jiang, 2016). For this project, the primary investigator using the MAP resources provide the participants a new approach to be integrated into the daily practices to improve quality of life and diabetic outcomes. Utilizing these methods will help the project advance by helping the healthcare providers to implement a standardized method in evaluating the patient’s medication-taking behaviors.
Significance of the Project
The significance of the project is that there continues to be a steady rise in chronic diseases has resulted in more patient care options (Polonsky & Henry, 2016). To meet various population groups’ unique needs, home-based care has gained popularity (Holly, 2020). Type II diabetes patients who qualify for home-based care options must demonstrate their willingness to work with the home healthcare agency at the selected project site. When patients who receive home-based care fail to adhere to the care requirements set forth, adverse outcomes can ensue (Polonsky & Henry, 2016).
The possible results based on the clinical question and problem statement should increase patient compliance related to medication adherence. The project also helps to empower healthcare providers to adequately address medication questions and patient concerns and ensure the patients keep track of their medication regimen, resulting in a reduction in adverse events. Holecki et al. (2018), when the MAP resources were utilized, medication adherence increased significantly.
The findings noted by Holecki et al. (2018) reinforce the beneficial nature of implementing the MAP resources, as this can improve the quality of patient care received. For this quality improvement project, it fits within helping to correct the gap noted in the literature (regarding medication adherence) for this population. Furthermore, it contributes to the clinical site by helping the patients maintain their medication regimen. Hence, decreasing potential infections, hospitalizations, and incurring financial costs to (patients and the facility).
Rationale for Methodology
The methodology chosen for this quality improvement project is quantitative.
Creswell and Creswell (2018) noted a quantitative methodology is best suited for projects that require data in numerical form. In this project, the numerical data will be presented using charts and graphs. These charts and graphs will allow readers to compare medication adherence rates pre-project implementation and post-project implementation.
While qualitative research studies are beneficial, they examine experiences, perspectives, and beliefs about a specific issue (Creswell & Creswell, 2018). The data collection used in this type of methodology is interviews (semi-structured, one-on-one, and focus groups). For this project, the primary investigator is not seeking to understand the participants’ feelings, behaviors, or lived experiences related to medication adherence.
A quantitative methodology supports the project because it will permit the primary investigator to remain objective in providing the project’s findings (Leedy & Ormord, 2020). Furthermore, the methodology allows the primary investigator to summarize the data that could support generalizations for a larger or similar population. The methodology is less costly with easy replication for future quality improvement projects to obtain the same results.
Nature of the Project Design
A quasi-experimental design will be used for this project. Quasi-experimental designs are used to compare data before and after the implementation of an initiative/intervention. Price et al. (2017) state in a pretest-posttest design, the dependent variable is measured once before the treatment is implemented after it is implemented. Often, these designs are used when research occurs in a controlled environment. While this project will not be conducted in a controlled environment, the primary investigator selected a quasi-experimental design because it is more cost-effective than an experimental project design (Schweizer et al., 2016). Furthermore, since data pre-project implementation and post-project implementation need to be collected and analyzed to explore the intervention’s impact, a quasi-experimental design is most appropriate.
A correlational design was considered but not appropriate for the project because the primary investigator is not seeking to understand the relationships occurring among the variables (Creswell & Creswell, 2018). This design is typically descriptive relying on a hypothesis (Leedy & Ormord, 2020). The primary investigator will not seek the relationships between the independent variable (MAP resources and education intervention) and the dependent variable (medication adherence rates).
The targeted population are home health patients ages 35 to 64 years old. The selected site serves approximately 100 patients annually, and 30 patients are diagnosed with Type II diabetes. The inclusion criteria are males and females diagnosed with Type II diabetes, oral medication or insulin, and home health patients. The exclusion criteria are individuals with language or cognitive deficits and diagnosed with Type I diabetes.
The data collection process will begin once approved by Grand Canyon University Institutional Review Board (IRB). Recruitment will occur from informational flyers given to the patients during their home health visits with the providers. The nurses will answer any questions regarding the project’s risks, benefits, and purpose and be instructed that the participation is voluntary. The primary investigator will use a convenience sample because of the access to the participants.
Data will be collected retrospectively four weeks prior to project implementation from the electronic medical records (Cradle Solutions software) (medication adherence rates) (Cradle Solutions, 2021). In the last three days of the first week the primary investigator will educate the healthcare providers regarding using the MAP resources. The staff will begin implementing the tool, and the post medication adherence rates will be assessed four weeks post-implementation. The primary investigator will document the data in a Microsoft Excel 2016 codebook developed by the primary investigator. Once completed, it will be exported into the SPSS-27 and analyzed using an independent t-test. A five-item demographic questionnaire will be used for descriptive statistics of the population. The survey will include (age, gender, years with Type II diabetes, oral or insulin, and education).
Pre-intervention and post-intervention data will be obtained via the project site’s EHR. The questions that will be analyzed are: (1) “Have you experienced any increase in thirst?” (2) “How often do you urinate?” (3) “Do you often feel fatigued even when doing little tasks?” and (4) “Do you experience blurred vision?” In addition to the questions, home healthcare providers will ask the patient “Are you taking your medications?” Any information attained from the question and due to probing, observation of patient’s medications, and patient-related medication adherence will be documented in the project site’s EHR. The data will be analyzed using an independent t-test to determine the statistical significance.
Definition of Terms
The following operational terms will be used interchangeably throughout the manuscript:
Adherence Assessment Pad.
The Adherence Assessment Pad is part of the MAP resources that explores answers via the patient perspectives. Using the Adherence Assessment Pad, nursing staff members will be able to explore the concerns of patients and adjust, pending further project team review, to the patient’s medication regimen (Starr & Sacks, 2010).
Home-based Healthcare.
The term home-based healthcare or home healthcare references the medical care that is provided to patients in the comfort of the patient’s home (Polonsky & Henry, 2016). Home-based healthcare services differ depending on a patient’s needs, diagnosis, and other factors.
Medication Adherence.
The term medication adherence references the extent to which a patient, caregiver, or home nurse follows the recommended guidelines on managing a medical condition (Ahmed et al., 2018).
My Medications List.
Is a list that provides a breakdown of the patient’s medications, in an easy-to-follow chart format, thereby improving patient medication adherence (Starr & Sacks, 2010).
Questions to Ask Poster.
Is a part of the MAP toolkit, which will be utilized during this project. When using the Questions to Ask Poster, home healthcare providers answer six questions to patients about medication adherence and medication knowledge. The questions that providers will answer include: (1) “Why do I need to take this medicine?,” (2) “Is there a less expensive medicine that would work was well?,” (3) “What are the side-effects and how can I deal with them?,” (4) “Can I stop taking any of my other medicines?,” (5) “Is it okay to take my medicine with over-the-counter drugs, herbs, or vitamins?,” and (6) “How can I remember to take my medicine?” Providers must answer all the questions and should assume that individuals have no medication knowledge, thereby confirming that patients know and understand these critical answers (Starr & Sacks, 2010).
Type II Diabetes.
For this project, Type II diabetes is the topic of exploration. It is described as an impairment of the body regulating and using glucose as a fuel source. Type II diabetes is a chronic condition where an excess amount of sugar is circulating in the blood stream (Mayo Clinic, 2019).
Assumptions, Limitations, Delimitations
As with all practice improvement projects, assumptions, limitations, and delimitations must be addressed. Assumptions are considered self-evident truth (Grand Canyon University, 2021). They are statements that are deemed plausible by other individuals and peers who read the project. The first assumption is that the participants will self-report honestly to the best of their recollection. To minimize social-desirability bias, the primary investigator will compare the participant’s answers with other data (laboratory values for glucose levels) (Leedy & Ormrod, 2020).
The second assumption is that the primary investigator will provide an accurate description of the current situation at the project site. To ensure that fabrication and falsification of the project findings do not occur, the primary investigator will observe the nurses during the patient visit to monitor the interactions. The primary investigator will use an outside source as a statistician so that the project results are not skewed.
Leedy and Ormrod (2020) stated that limitations are factors that the primary investigator has no control over. The first limitation is the primary investigator’s lack of control over the environment related to the novel coronavirus pandemic (COVID-19). The pandemic has affected the method in which the project will be implemented. The primary investigator will not interact with the participants during the project. Instead, five registered nurses were educated to implement the project. The pandemic has increased many patients’ fear related to one-on-one interaction with their primary care providers. The primary investigator does not know if there is a possibility with the new variant (Delta-variant) if the project will be modified to virtual monitoring to minimize the participant’s risk of COVID-19 infection.
The second limitation is conducting the project (four weeks versus longer) (cross-sectional versus longitudinal). A cross-sectional project allows for a snapshot of a specific moment (Leedy & Ormrod, 2020). A longitudinal project would have allowed the primary investigator to provide a richness of data regarding the topic. The primary investigator could identify and convey the findings related to the participants’ behaviors, patterns of change, experiences, and reduce recall bias (Coolican, 2014). Furthermore, this type of project would allow the primary investigator to test whether the variables were casual or the result of other differences (Leedy & Ormrod, 2020).
Delimitations are choices the primary investigator made, describing the boundaries placed on the project. One project delimitation noted is the inclusion criteria of the participants. Patients with diabetes, ages 35 to 64, are included in the project. Since this project’s focus is to explore medication adherence among diabetes patients, which is a concern at the project site, it has narrowed the field to learn about other patients and their compliance issues. The second delimitation is where the project was conducted, an urban area located in the southeastern region of the United States, thereby impacting the generalizability of its findings.
Summary and Organization of the Remainder of the Project
The aging population is growing at an increasing rate in the United States, hence snowballing the number of individuals taking medications to manage their Type II diabetes. Kyarnstrom et al. (2018) emphasized that for Type II diabetics, it is essential that proper and effective medication adherence be maintained. For home healthcare patients, 45% of this population fail to maintain glycemic control < 7% (Polonsky & Henry, 2016). This is attributed to poor medication adherence (Polonsky & Henry, 2016). Healthcare providers are a critical component in making a difference by helping patients learn and maintain medication adherence.
The quality improvement project will use a quantitative methodology. The rationale for using this method is to collect numerical data that can be statistically analyzed. A quasi-experimental design will answer the clinical question to determine if the outcome impacted the medication adherence rates. The project will be guided by Orem’s self-care deficit theory and Roger’s diffusion of innovation model (Rogers, 2003).
Chapter 1 provided detailed support for utilizing the MAP resources to improve medication adherence among diabetic patients of the project site. A quantitative, quasi-experimental design was used to explore the impact of the MAP intervention on improving medication adherence among Type II diabetes patients of the selected project site. Other portions of the chapter included advancing scientific knowledge using Orem’s self-care deficit theory and Roger’s diffusion of innovation model. A detailed description was given related to the project’s significance, project’s methodology, and design. The last few sections of the chapter comprised the definition of terms, assumptions, limitations, delimitations, and a summarization of the chapter.
Chapter 2 presented a detailed summary of the literature collected related to the project’s clinical question. Information about the theoretical framework and change model is detailed. The chapter comprises five sections, which highlight information about literature obtained from 2016 to 2021. The information presented provides readers in-depth knowledge and the importance of each chosen section.
Chapter 3 offered research methodology details that the primary investigator employed. The information presented in the chapter included the selected research design, the target population, and the sample size. Furthermore, data collection tools (specifically the MAP’s resources) and data analysis procedures are discussed. The reliability and validity of the project instruments are detailed. Lastly, ethical considerations for collecting data are addressed.
Chapter 4 presented the project’s findings, which were analyzed using chi-square analysis. Results regarding the descriptive and inferential data analyses will be offered. Furthermore, a brief discussion of project-related findings is delivered. The information will be presented using graphics, figures, and tables. Chapter 5 delivered the conclusions and recommendations drawn from the project’s results. The impact of the findings, in terms of practical and theoretical knowledge, will be offered.
Chapter 2: Literature Review
Diabetes mellitus (DM) is a global epidemic in this era, and many diabetic patients comprise Type II diabetes mellitus (Rana et al., 2019). Medication adherence is a critical component and key determinant in obtaining therapeutic success and reducing diabetic complications (Rana et al., 2019). For Type II diabetic home health patients, this is vital in self-care and management of the disease. Unfortunately, approximately 30% to 50% of patients adhere to their medication regimen (Hennessey & Peters, 2019).
Diabetes is a lifestyle disease, which can be prevented or avoided by making lifestyle changes. Disease management can also occur through adhering to one’s prescribed medication regimen(s). Medication adherence is important since it can help to reduce the likelihood of diabetes-related challenges and complications. In the United States (U.S.), the problem is associated with increased morbidity and mortality rates, with approximately 125,000 deaths and 10% of hospitalizations annually (Hennessey & Peters, 2019). Furthermore, medication nonadherence costs the U.S. healthcare systems roughly $100 billion to $317 billion yearly (Kini & Ho, 2018). The purpose of this quantitative quasi-experimental project is to determine to what degree the implementation of the Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization located in urban Texas.
Chapter 2 reintroduced the project’s subject matter, background, theoretical framework, and change model. Other segments include a review of literature on previous and current empirical research related to medication adherence in Type II diabetic home health patients. The chapter’s themes are related to patient-related factors (non-pharmacological and pharmacological lifestyle changes, patient beliefs). Socio-economic factors (medication costs, health literacy, lack of social support), health system factors (trust in the healthcare provider, complicated medication regimen), and interventions (patient education, motivational interviewing, and MAP resources).
The primary investigator conducted a literature review utilizing peer-reviewed articles from 2016 to current. The inclusion criteria were articles written in English, topics specific to the project such as barriers to medication adherence, MAP resources, medication adherence, and Type II diabetes. The exclusion criteria were articles not written in English, more than six years, Type I diabetes, or involved children. Databases reviewed were PubMed, Google Scholar, CINAHL, Cochrane Library, EBSCOhost, and Grand Canyon University online library. The review revealed over 632,000 plus results; however, the primary investigator selected 30 articles for this chapter for this project.
One of the most problematic issues associated with home care for diabetes patients is adherence to medications. According to Bonney (2016), patients take their medication as prescribed only 50% of the time. Furthermore, patients are often reluctant to share medication compliance details, thereby resulting in health-related complications (Bonney, 2016). Type II diabetes mellitus is at an epidemic proportion globally (Centers for Diseases and Prevention Control, 2020). The incidence of the disease will continue to rise from 382 million individuals to 417 million by 2035 (Polonsky & Henry, 2016; Rana et al., 2019). Healthcare experts are becoming increasingly concerned because of the costs, morbidity, and mortality rates linked with the disease (Polonsky & Henry, 2016). One of the elements contributing to the problem is poor medication adherence (Rana et al., 2019). This is particularly true in-home health Type II diabetic patients. Medication adherence in adults with chronic conditions is roughly between 30% to 50% (Kini & Ho, 2018; Neiman et al., 2017). Furthermore, the healthcare system associated with medication non-adherence is costing the U.S. healthcare system $100 billion to $317 billion annually (Rana et al., 2019). (background)
As adults in this country age, many are afflicted with chronic diseases such as diabetes (Type II). It is one of the main reasons for admission to home health agencies (Sertbas et al., 2020; Wong et al., 2020). Home health agencies have been in existence for over 30 years (Choi et al., 2019). These organizations will continue to grow and impact medical advances and technology (Wong et al., 2020). Hence, there is a need for healthcare providers to become familiar with strategies and barriers linked with medication adherence for this population. Many home health patients have difficulty adhering to their medication regimens. They often express difficulty adhering to the regimens, which reinforces the critical role of home healthcare providers (Wong et al., 2020). This is partly due to them not having knowledge and education related to the disease and proper self-management (Wong et al., 2020).
Theoretical Foundation
Orem’s self-care deficit theory was selected to guide this quality improvement project. The theory was chosen because of its expectations that an individual must be self-reliant and responsible for their care (Orem, 1985). Dorothea Orem’s theory states self-care is an activity that a person engages in to maintain, restore, or enhance their health (Orem, 1985). The theory further states that nurses should not consider patients as inactive or sheer recipients of healthcare; instead, they should be considered reliable, responsible individuals who can make informed decisions and be active in their health care (Orem, 1985).
This theory describes nursing as an action between two or more individuals (RenpenningcN et al., 2003). Furthermore, it assumes that a successful patient with self-care understands it is a primary element in health prevention and illness (RenpenningcN et al., 2003). The theory fits the project because the healthcare providers are in supportive educational roles, which assists the patient when they are ready to learn or cannot complete a task without guidance (Orem, 1985). Also, the theory relates to healthcare providers assisting patients in their self-care and management to improve their function at a home level (RenpenningcN et al., 2003). The theory has been used in multiple studies regarding patients with chronic diseases (Afrasiabifar et al., 2016; Borji et al., 2017; Khademian et al., 2020).
The change model that will be used is the diffusion of innovation developed by Rogers (2003). There are five components of the theory are a) knowledge, b) persuasion, c) decision, d) implementation, and e) adoption (Rogers, 2003). The model is defined as a social process, which occurs among individuals in response to knowledge regarding a new strategy for improving their health (Dearing & Cox, 2018). It is a process communicated within a specific timeframe (for this project, four weeks) (Dearing & Cox, 2018). This change model can provide the primary investigator with methods to share and educate regarding a new diabetic prevention strategy (Lien & Jiang, 2016). The model has been utilized in various fields to help healthcare providers understand and translate new concepts, treatments, disease knowledge, and educational methods (De Civita & Dasgupta, 2007; Lien & Jiang, 2016). For this project, the primary investigator using the MAP resources provide the participants a new approach to be integrated into the daily practices to improve quality of life and diabetic outcomes. Utilizing these methods will help the project advance by helping the healthcare providers to implement a standardized method in evaluating the patient’s medication-taking behaviors.
Review of the Literature
Diabetes is prevalent in the United States and globally (Rana et al., 2019). It is one of the primary diagnoses for being admitted into home health care (Sertbas et al., 2019). Hence, the usage of home health services has become increasingly popular because it allows patients to remain in a comfortable atmosphere and decrease hospitalizations (Sertbas et al., 2019). There are many studies regarding older adults and diabetes, but minimum regarding home health care patients with diabetes (Sertbas et al., 2019). The review of literature is based on themes centered on patient-related factors, socioeconomic factors, and interventions.
Patient-related Factors
The World Health Organization (2017) stated patient related factors encompass an individual’s resources, knowledge levels, belief system, perspectives, and expectations. These factors can vary dependent on the non-pharmacologic and pharmacologic lifestyle changes that the person maintains (Nduaguba et al., 2017). Type II diabetes management involves not just medication adherence but observance to monitoring diet and exercise, follow-up, and self-care (Nduaguba et al., 2017).
Medication adherence.
Medication adherence is a term that refers to one taking medication as prescribed by their healthcare practitioner (Ahmed et al., 2018). Healthcare providers must ensure that the prescriptions provided to patients are suitable to the individual’s conditions.
While medication adherence is important, there is a plethora of literature available that expresses the prevalence of medication non-adherence among patients. Various factors continue to impact medication adherence, which includes, but are not limited to, fear, costs, misunderstanding, too many medications, lack of symptoms, mistrust, worry, and depression (American Medical Association [AMA], 2020). To prevent medication non-adherence, providers can seek to understand the needs of patients and provide them with resources that can aid in overcoming non-adherence.
Ahmed et al. (2018) emphasized that the quality of healthcare can be influenced by the body’s ability to respond to the treatment. A study conducted by Rana et al. (2019) was related to exploring medication adherence to prescribed treatments as a crucial factor for hospitalized Type II diabetic patients in a Bangladesh hospital. The quantitative, descriptive cross-sectional study involved 112 Type II diabetic patients recruited from medical and endocrinology wards. Much of the sample size age was 57.46, 60.7% were male and married. The patient’s medication adherence was measured using the 7-item MCQ scale modified by Ahmad et al. (2013). Data were analyzed using SPSS-21. Descriptive statistics were used to measure the participants’ demographics. An independent sample t-test and one-way ANOVA with post hoc comparisons were used to evaluate the relationships between the variables (p =.05).
The results from the Rana et al. (2019) study showed 72.3% of the participants forgot to take their medications, 96.4% chose not to take the medication or miss a dose when feeling better. Most of the patients, 81.3%, did not take their medications with them when traveling. The mean scores of the MCQ were 26.46 (SD =1.58). The study’s results concluded that the level of medication adherence among Type II diabetic patients was suboptimal (Rana et al., 2019). The authors recommended that more attention needed to be given to varied age groups related to medication adherence.
Lee et al. (2017a) conducted a quantitative study to determine the medication adherence among Type II diabetic patients in an Asian community. This cross-sectional study involved 382 Asian participants from a primary outpatient care clinic in Singapore. The patient’s medication adherence was measured using a five-item Medication adherence report scale (MARS-5). A low medication adherence score was <25. The sample size was predominately female, with a mean age of 62 years. Using univariate analysis, the results showed 57% of the participants had a low medication adherence score, which was attributed to them being married or widowed, taking fewer than four medications daily, and poor glucose control. The study concluded that younger patients were susceptible to low medication adherence scores (Lee et al., 2017).
Although the studies were conducted in different settings (primary care and hospital), the results demonstrated a need for healthcare providers to focus on different age groups and their reasons for not adhering to their medication regimen. The studies were cross-sectional, which indicated the authors were unable to evaluate the participant’s habits and trends. This could have changed if they could assist the patients with barriers they faced during the studies.
To handle the issue of medication adherence among the diabetic patients who have had an issue with adherence to medication needs to come up with a variety of strategies that have been attained from scholarly reviews as well as journals for purposes of well researched data on the concept. Appropriate types of medications are usually considered to be the identified cornerstone regarding the prevention as well as disease treatment yet according to numerous research carried out, there is solely about half of the individual patients who adhere to the instructions of their prescribed medication (Bosworth, 2015). This usually causes a common as well as costly public health-associated challenge especially for the healthcare system in the U.S.
This topic was chosen because inefficient medication adherence is complex, with a variety of contributing causes; hence, there is no universal solution (Rodriguez-Saldana, 2019). For a patient to succeed with medication adherence, the healthcare provider must understand the underlying reasons that are barriers that could be removed or diminished. Teaching the patient new strategies that are patient-centered will help them achieve the new normal.
Non-pharmacological indicators.
There are many medications used for the effective management of diabetes (Raveendran et al., 2018). Effective non-pharmacological therapy should be explored with all Type II diabetics. The measures could include nutrition and exercise. Nutrition interventions are critical in a person with diabetes maintaining an optimal glucose level (80-120mg). The dietary pattern that must be encouraged is consuming fruits, vegetables, low-fat dairy foods, whole grains, and minimal red meat (Asif, 2014). Khazrai et al. (2014) study emphasized that food intake is associated with obesity. However, it is not just the volume of food but the quality of one’s diet. High ingestion of red meat, sugary items, and fried foods contributes to insulin resistance and Type II diabetes (Khazrai et al., 2014). People with diabetes should be educated regarding consuming fruits and vegetables in protecting them since they are high in nutrients, fiber, antioxidants, and a protective barrier against diseases (Khazrai et al., 2014).
This topic was selected because educating Type II diabetic home healthcare patients regarding their dietary habits is an integral part of diabetes care. Failure to incorporate healthy eating habits along with medication adherence can lead to severe complications of the disease. Healthcare providers must teach home healthcare patients dietary guidelines according to their food selection, cultural, and personal preferences to change their eating patterns.
Pharmacological factors.
Type II diabetic patients typically take multiple medications for their condition and other comorbidities (Kirkman et al., 2015). Following one’s medication regimen and treatment improves patient outcomes, reduces healthcare costs, hospitalizations, and mortality (Kirkman et al., 2015). A retrospective study conducted by Kirkman et al. (2015) determined patient, medication, and prescriber factors that influenced diabetic patients and medication adherence. A sample size of 200,000 participants (from 50 states, including the Virgin Islands) was extracted from a pharmacy database (Medco Health Solutions). The participants’ eligibility was based on the medication, benefits, and prescription history. Each patient was followed for one year from the medication date to post-implementation of the study.
Medication adherence was described as a medication possession ratio > 0.8 (Kirkman et al., 2015). Logistic regression analyses were conducted to evaluate factors independently linked with adherence. The results demonstrated that 69% of the participants were adherent. Other findings illuminated that adherence was associated with one’s age (older), male, higher education and income, and the use of the mail order versus retail pharmacies. Individuals with a new diagnosis of diabetes were less likely to be compliant with their medication regimen.
The authors concluded that demographic, clinical, and system-level factors influenced the participants’ medication adherence regimen (Kirkman et al., 2015). The authors emphasized that younger individuals, newly diagnosed and had minimal medications to take, were at a higher risk for non-adherence. Individuals who used mail-order pharmacies resulted in higher medication adherence due to lower out-of-pocket costs (Kirkman et al., 2015).
Patient’s belief system.
One’s culture influences a patient’s beliefs regarding medications, which ultimately affects their medication adherence (Lemay et al., 2018). This remains a challenge for healthcare providers in helping patients to understand the significance of medication adherence (Shahin et al., 2019). A study conducted by Shahin et al. (2019) used a systematic review to determine the importance of an individual’s cultural belief influenced medication adherence. A total of 2,646 articles were selected from various databases such as PubMed, CINAHL, EMBASE, and PsychINFO. Twenty-five of them met the inclusion criteria. The studies focus on diabetes or hypertension.
The study results from Shahin et al. (2019) revealed personal and cultural factors linked with medication adherence. Ten articles (40%) demonstrated an individual’s perception of the illness, five (20%) were affiliated with health literacy, four (16%) cultural beliefs, three (12%) self-efficacy, and five (20%) knowledge illness (Shahin et al., 2019). Shahin et al. (2019) study concluded that one’s cultural influences affect their perception of the importance of medication adherence. Healthcare providers must understand their patients’ pre-existing perspectives of diabetes before offering new information. This is an opportunity for healthcare professionals and patients to have a dialogue to diffuse misconceptions related to the patient’s perceptions. The authors suggested that future research should identify the religious beliefs associated with disease knowledge and medication adherence.
Healthcare providers and the relationships with patients.
Patients usually consider their healthcare providers (HCPs) as the most dependable source of data regarding their health condition and treatment. Patients are highly likely to effectively follow the treatment plan when they are involved in having a good relationship with their HCP due to the confidence and trust that has been built over time. Relationship building in healthcare is a vital aspect in the day to day lives of healthcare practitioners due to the nature of their job, which necessitates that they maintain long-term relationships with their patients for enhanced medication and treatment outcomes (Heston, 2018).
Trust is critical to developing, specifically since patients can experience improve health-related outcomes when they value relationships with their HCPs. Patients who have trust in their HCP often believe that their provider has a high level of competence and truly cares about their health-related outcomes (Heston, 2018). Mistrust develops when the patients attain unrealistic, inconsiderate, or insensitive advice from their HCPs, as well as feel emotional distance from them.
Health literacy.
Health literacy is described as one’s ability to obtain, communicate, process, and comprehend basic health information and navigate health services to make an informed decision (Sawkin et al., 2015). Medication adherence is broadly identified as a patient’s ability to follow a prescribed medical treatment (Sawkin et al., 2015). Researchers Glanz et al. (2015) have explored the impact of low health literacy rates on patient compliance with medications and health-related advice. The authors stated that approximately 35% of American adults possess basic or below basic health literacy levels (Glanz et al., 2015). Chima et al. (2020) conducted a systematic review to evaluate the impact of health literacy and medication adherence. Literature searches were performed using Ovid Medline, CINAHL, EMBASE, Scopus, and PsycInfo. The inclusion criteria for the articles were conducted in the United States, 18 years or older with a diagnosis of Type I or II diabetes, medication adherence was an outcome variable, quantifiable measure reported, and was a full text journal article. Articles were graded using Joanna Briggs Institute Critical Appraisal Checklists, which is appropriate for the respective study designs identified. Thirteen articles were retained in the review, most of which used a cross-sectional design.
The results demonstrated four of the 11 studies found a positive association between health literacy and medication adherence (Chima et al., 2020). Two of the four studies had methodological shortcomings. The authors concluded there was some evidence that health literacy is linked with medication adherence among diabetic adults in the United States. Recommendation for future research to design and execute longitudinal studies to determine a deeper relationship between the variables (health literacy and medication adherence (Chima et al., 2020).
Given inadequate literacy rates, among members of the general population, world practitioners continue to create unique strategies that can be used to reduce lacking health adherence among patients with diabetes. Improved literacy is a theme that should be of the utmost priority, specifically since it creates the foundation for long-term sustained profitability. Furthermore, as patients can understand the importance of medication compliance, adherence to medication regimens improves (Glanz et al., 2015).
Using universally implemented and published resources that can improve medication adherence is important. Tools and resources can be utilized by HCPs to identify patients who are not taking their prescribed medications. Prescriptions need to be taken seriously for exceptional results and for the continued well-being of patients who have critical illnesses like diabetes.
The use of simple language by HCPs, as well as by medication manufacturers, can encourage providers to meet patients where they are and utilize teach-back techniques to ensure a patient’s understanding of his/her prescribed medication regimen. Teach-back methods have been utilized to enhance medication adherence among many types of non-adhering patients. Most of the time people opt to not take their medication as they cannot read all the instructions written on the medicine and are afraid that they will die, especially in the cases that they mistake those drugs for poison or some drug that may look like a famous poison causing death. This is a key issue that has left most of the people victims of non-adherence (National Academies of Sciences, Engineering, and Medicine, 2018).
Huang et al. (2020) conducted a cross-sectional study aimed to identify patient factors linked with diabetes medication adherence and health literacy levels. One hundred and seventy-five participants were involved in the study and recruited from two family medical clinics. All the participants were over the age of 20, diagnosed with Type II diabetes, taken one oral diabetic medication, and understood English. The authors evaluated the participants’ health literacy levels using the Newest Vital Sign, a six-item questionnaire, and an eight-item Morisky Medication Adherence Scale.
The results showed a self-reported status of (β = 0.17, p = 0.015) and medication self-efficacy (β = 0.53, p, 0.001), which were positively associated with diabetes and medication adherence (Huang et al., 2020). Health literacy was neither associated with diabetes medication adherence (β = −0.04, p = 0.586). The authors concluded that health literacy measured using the Newest Vital Sign did not correlate with medication adherence or glucose control among Type II diabetics. They recommended that healthcare clinics develop interventions to improve their patients’ self-efficacy of medication to improve the medication adherence rates (Huang et al., 2020).
Reading instructions and making a patient understand what is written on a medicine bottle or package should never be taken for granted as it is key for determining how patients will effectively or ineffectively adhere to the given drugs for treatment and disease control purposes. For the medical practitioner to be aware and sure that what they have explained to the patients has been delivered safely and appropriately, there is the need for a verification test. The patients as well as their identified support individuals need to be asked to explain in their own words stating what they have understood from everything the practitioner has told them regarding their health, along with drug management and intake. This teaching back method is vital in offering additional data on the key topic of interest; thus, it should be used often.
Concerns associated with the issues of side effects can be challenges to medication regimen adherence, especially when the given advantages associated with taking the medication are not properly comprehended. To minimize the potential concerns that are associated with the side effects of drugs, since this can be identified as one of the reasons why patients may opt to not adhere to medications in fear that they will experience the side effects and be greatly inconvenienced, there is the need for HCPs to offer the relevant data regarding the common types of side effects when they are in the prescription process.
There have been issues of people and patients dying or experiencing negative and disturbing side effects when it comes to them taking the medication prescribed by their doctors. These cases have always been used as examples to explain the reason why people have been reluctant to take medications for prolonged periods. When an individual has a critical illness, it is not uncommon that he/she needs to take the prescribed medication for a long period, as this can result in improved medication efficiency. Lacking understanding of medication-related details has caused patients to withdraw from their prescribed medication regimen, which is due to lacking knowledge and prolonged side effect issues that are associated with their medication (Institute of Medicine [IOM], 2011).
For example, when offering metformin, to enable adherence to the drug there is a need to inform patients that are suffering from diarrhea during their time of prescription to anticipate that the loose bowel issues will be over in about a week if the drug is continued. It is also vital to offer brief explanations about medication side effects and benefits due to time limitations. If a patient cannot have additional time with his/her provider, then other members of the health care team should aid in answering their questions and provide additional education. Education can be in the form of printed handouts, websites, or a teaching module that should be readily available for use with the identified patient.
Socioeconomic Factors
Socioeconomic-related factors that affect medication adherence include one’s location of residence, medical costs of treatment, and finances (Yeam et al., 2018). Other factors that could influence medication adherence are low health literacy, education level, lack of social support, living conditions, and medication costs (Hennessey & Peters, 2019). Health care providers must conduct a thorough assessment before providing a patient the prescription and consider any of the factors as mentioned above.
Medication costs.
Kang et al. (2018) conducted a quantitative, longitudinal study to examine factors that affected cost-related medication nonadherence. Cost-related medication nonadherence (CRMN) is defined as taking medication then indicated or prescribed due to costs (Kang et al., 2018). Unknown sample size noted, but the Behavioral Risk Factor Surveillance System data for 2013–2014 was used to identify individuals with diabetes and their CRMN. Weighted multivariable logistic regressions were used, and analyses were conducted using the Survey suite of programs in Stata SE version 14. The survey weights were used to obtain population-level estimates and subpopulation methods to estimate standard errors for the subgroup’s analyses (Kang et al., 2018).
The results demonstrated that CRMN among American adults was 16.5% (Kang et al., 2018). Individuals with an annual income of < $50k and without health insurance had the highest rates of CRMN. Insulin users had a 1.24 times higher risk of CRN than those not using insulin. Factors influencing CRMN were diabetes care and lifestyle factors, depression, arthritis, and asthma (Kang et al., 2018). Health insurance was the most significant factor for the participants < 65 years of age and depression for respondents > 65 years (Kang et al., 2018).
The authors (Kang et al., 2018) concluded that one’s annual income and health insurance status were the most significant factors for younger adults, while depression was for older adults > 65 years. When the younger and older groups were combined, it showed the largest impact of CRMN affecting individuals < 55years of age and having higher rates of non-medication adherence (Kang et al., 2018). Recommendations were for healthcare organizations to develop policies, resources, and support systems that address the factors to help improve CRMN.
Social Support.
Various factors impact medication adherence. However, Linni et al. (2015) emphasized that social support must be considered a core component in interventions that improve the management of Type II diabetic patients. The social support theory has three components a) subjective support (emotional experience and fulfillment of the individual being respected and understood; b) objective support (direct material help from the social network in the communities; c) support utilization (various support strategies from family, friends, and colleagues) (Linni et al., 2015; Shao et al., 2017).
A quantitative study conducted by Linni et al. (2015) determined whether social support was linked with medication adherence in patients with Type II diabetes. The study was conducted in a Beijing hospital with a random sampling of 412 participants with Type II diabetes. The adult patients’ assessment of their social support was retrieved from medical records and self-reported surveys (Social Support Rate Scale 14-item questionnaire). The support scale measured objective, subjective, and support utilization. The Chinese version of the Morisky Medication Adherence Scale, eight-item, was translated for the participants to complete. Three hundred and thirty participants completed the self-report measure medication adherence six months after the initial data collection.
A t-test demonstrated a significant difference in social support between the low and high medication adherence groups (t = -2.11, p= 0.036) (Linni et al., 2015). A regression analysis was used to determine the subscales of the support, which presented statistical significance and association with medication adherence (β = 0.29, p = 0.011), rather than another two subscales of subjective (β = −0.02, p = 0.80) and objective support (β = −0.04, p = 0.33) (Linni et al., 2015). The authors concluded that social support was a critical factor in improving medication adherence in diabetic patients. It must be impressed on this population to have open attitudes to receiving help from friends, family, and outside organizations.
A quantitative, longitudinal study conducted by Shao et al. (2017) determined the impact of social support and medication adherence among 532 Chinese patients from an outpatient and inpatient endocrine clinics. The authors used the ten-item Social Support Rating Scale for data collection related to social support. It measured the three components of social support (objective, subjective, and support utilization). A six-item self-efficacy scale was used to measure (emotional control, communication with physicians, symptom management, role function, and perceived adaptability to chronic diseases). Shao et al. (2017) developed a 13-item adherence scale that was divided into three subscales a) Do you take the medicine every day according to the doctor’s advice? b) Do you take the dosages according to the doctor’s advice? c) Do you take the medication on time?
Data were collected and entered into EpiData 3.1 software (Shao et al., 2017). A Pearson’s correlation coefficients were calculated to evaluate the pairwise associations between the social support scores, self-efficacy, and adherence (Shao et al., 2017). The descriptive data showed the participants were mostly older females. The coefficients for the three components were statistically significant demonstrated the goodness-of-fit indices (χ2 = 2 47, P = 0 12; GFI = 0 99; AGFi = 0 98; CFI = 0 98; and RMSEA = 0 05) (Shao et al., 2017).
Both studies, Linni et al. (2015) and Shao et al. (2017) utilized an adequate number of participants for their quantitative studies. They used the same support rating scale, which validated their findings. The key difference is that the studies were conducted in various settings (hospital and endocrine outpatient/inpatient clinics). In conclusion, the studies validated the role of social support in managing Type II diabetic patients. Hence, it must be considered as a key component in any intervention a healthcare provider develops to improve self-managing and glycemic control (Linni et al., 2015; Shao et al., 2017).
Interventions
Using tools and instruments that are considered effective and appropriate is vital in supporting adherence in different ways and in achieving self-efficacy among the various patients. Positive family and social support are vital aspects associated with adherence to the issue of diabetes management (Rodríguez-Saldana, 2019). The engagement of family members can enhance self-care activities for patients suffering from diabetes, including eating effective and healthy foods, keeping fit, monitoring blood glucose, and adhering to medication.
A web-based portal is an innovative resource that can be used to assist patients. This web-based portal can improve medication reconciliation processes among patients and providers. The web-based portal can help patients with various regimens navigate challenges. Furthermore, this medication information, available through the portal can help individuals understand medication requirements, as the portal often helps to clarify and verify inaccuracies. The web portal aims to enhance medication adherence and prevent the improved use of the medication (Forman & Shahidullah, 2018).
When patients can verify information in their electronic medical records to ensure proper medication adherence, this can enhance patient well-being. The EMR provides an accurate list of a patient’s medications and provides detailed medication information (e.g., type of drug, what the drug is used to treat, frequency of drug use, etc.). Also, the use of screening tests is vital in understanding how well patients are taking their drugs. If there is no consistency in medication-taking then motivation aspects should be utilized to enhance adherence (Eskola et al., 2017).
Medication Adherence Project (MAP).
The MAP resources were introduced, developed, and implemented by the New York City Department of Health and Mental Hygiene in response to clinicians and pharmacists working in primary care practices (Starr & Sacks, 2010). It serves patient populations impacted by several chronic diseases (Starr & Sacks, 2010). The resources provide practical tools to help practitioners communicate with patients related to medication adherence. It consists of a training course and toolkit that was piloted and assessed by doctors, nurses, pharmacists, medical assistants, nutritionists, and healthcare educators (Starr & Sacks, 2010).
The objectives of the tool are to acquaint healthcare providers with the obstacles associated with medication adherence with individuals who have chronic diseases:
Other aspects include a) evidence-based solutions that improve adherence, b) educate healthcare providers to engage in conversations regarding medication taking, c) help practitioners to combine the tool into the clinical practices and quality improvement methods, and d) help providers train their peers to use the resources effectively (Starr & Sacks, 2010).
Patient-Contentedness Care.
Patient-contentedness entails ensuring that all the identified interventions described in the first theme are focused on the individual patient who is being helped to effectively adhere to the given medication during home care settings. Patients who have been diagnosed with various critical illnesses and have been asked to go home for home-based care have been associated with poor adherence to the medications they are given when they are discharged from the hospital (Steinberg & Miller, 2015).
Practice recommendations, whether they are focused on evidence or expert opinion, are intended to offer the desired guidance on an overall approach to care (da Costa et al., 2018). The science, as well as the art associated with medicine, usually come together when the identified clinician is experiencing or has experienced some sort of situation whereby, they must make treatment recommendations for any patient who would be considered to not have effectively met the eligibility criteria for the studies on which the given guidelines were based.
Patient Advocacy.
Advocacy is a vital aspect in healthcare since it addresses the needs of the patient who need the utmost help and care, thereby allowing them to go back to their previous health state (D’Onofrio et al., 2018). Advocacy is an aspect that can be referred to as active support, as well as engagement, that aims to effectively develop a cause as well as a policy (Mollaoglu, 2018). Furthermore, advocacy is usually needed to enhance the lives of individuals suffering from diabetes. The various issues that diabetic patients experience, such as obesity, physical inactivity, and societal challenges reinforce the need for advocacy (Firstenberg & Stanislaw, 2017).
In summary, these topics were selected because they contributed to helping the healthcare provider understand the challenges noted for this population. This contributes significantly to the challenge’s healthcare providers face in caring for Type II diabetic patients.
Summary
The prevalence of Type II diabetes is affecting one in ten Americans (Ahmed et al., 2018). The disease is expected to continue rising higher by 2030 (Lin et al., 2018). Medication adherence for Type II diabetic home health patients is critical in decreasing the poor patient outcomes associated with the disease. Medication adherence with Type II diabetic patients remains a challenge for many healthcare professionals. Education for the healthcare providers and the patients can make a difference in this population’s lives.
Chapter 2 discussed reintroduced the topic and presented the theoretical framework and change model to guide the project. Other sections include the literature review related to patient-related, socio-economic, and health system factors.
A summary of the chapter was provided with an introductory sentence that previews Chapter 3.
Chapter 3 reinstated the selected topic. Other segments presented the project’s methodology, design, population, and sample selection. A description of the MAP resources and the electronic medical record (EPIC) are provided. The validity and reliability of the instrument was demonstrated along with the data collection and analysis procedures, potential bias. The last few sections discuss the ethical considerations, limitations, and a summary that leads into Chapter 4.
Chapter 3: Methodology
Medication adherence is a critical component in minimizing adverse patient-related outcomes among individuals with chronic illnesses (Type II diabetic patients). Ahmed et al. (2018) stated medication adherence for this quality improvement project refers to the extent to which a home healthcare patient can correctly take their medications in the absence of their health care providers. Medication adherence requires an individual to adhere and comply with all the medical instructions provided (Bellou et al., 2018).
Type II diabetes affects one in ten Americans (Ahmed et al., 2018). Furthermore, due to the increase in older-aged adults and the rising prevalence of the disease, it is expected to elevate higher by 2030 (Lin et al., 2018). The home health services continue to grow, hence illuminating the need for education regarding medication adherence. Roughly 45% of the patients cannot maintain their glucose levels (Polonsky & Henry, 2016). Poor medication adherence is associated with higher financial obligations for the patient, hospital, and insurance companies. Polonsky and Henry (2016) emphasized the adverse outcomes cause frequent hospitalizations and lower quality of life for patients and their families.
Chapter 3 reestablished the selected topic. Other sections of the chapter include the statement of the problem, clinical question, project methodology (quantitative), and project design (quasi-experimental). The chapter described the population and sample selection, the instrumentation (MAP resources), validity, reliability, and data collection procedures. The last few segments included the data analysis procedures, potential bias, ethical considerations, limitations, and a summary
Statement of the Problem
It is not known if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas. The targeted population is Type II diabetic patients in an urban healthcare facility in urban Texas. In collaboration with the stakeholders, it was noted that medication adherence among the patients was lacking. The information will be obtained from the electronic medical records (Cradle Solutions), which showed that ten percent of the diabetic patients were not adhering to their medication regimen.
Factors that influence poor medication adherence are numerous and include poor knowledge or awareness of the disease, medication costs, and lack of understanding of the medication treatment, which reinforced the project’s purpose (Heath, 2019; Sharma et al., 2020). Healthcare providers play an essential role in assisting patients with medication adherence. The primary investigator will introduce a standardized strategy for the facility’s healthcare providers to assess the patients’ medication adherence using MAP resources (Starr & Sacks, 2010).
Using a standardized method will help to solve the facility’s problem with medication adherence rates. It will also help improve the healthcare providers’ knowledge levels and awareness regarding the barriers associated with medication adherence. Complying with the new guidelines developed by the Centers for Disease Control and Prevention (2020) could help patients control their glucose levels, minimize healthcare costs, hospitalizations, and potential infections.
Clinical Question
The clinical question that will direct the primary investigator’s answer is: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks? The independent variable is the MAP resources. The dependent variables are the medication adherence rates. The data collection process will not begin before approval is received by Grand Canyon University IRB. The primary investigator developed informational flyers for the nurses to give their patients during their home health visits. The staff answered questions related to the project regarding risks, benefits, and purpose while instructing that participation is voluntary. A convenience sample will be used because of the easy access to the participants for the primary investigator.
The primary investigator will collect data retrospectively (four weeks) prior to implementation of the project. The data will be collected from the electronic medical records using Cradle Solutions for the impact of the MAP resources and medication adherence rates. In the first week, the primary investigator will educate the staff to use the MAP resources. Once the staff begins to implement the tool, post-medication rates will be assessed post-four weeks. The data will be inserted into a Microsoft Excel 2016 codebook developed by the primary investigator. It will then be exported into SPSS-27 and analyzed by using a chi-square test. The five-item demographic survey will collect the descriptive statistics of the home healthcare patients. The questionnaire comprises (age, gender, years with Type II diabetes, oral or insulin, and education).
Project Methodology
A quantitative methodology will be used for this quality improvement project. According to Creswell and Creswell (2018), a quantitative methodology is appropriate for projects that use data in its numerical form. For this project, the data will be presented using figures, graphs, charts, and tables. This will allow the readers to compare the medication adherence rates pre-implementation and post-implementation of the project.
A qualitative methodology was considered but not used, although they are beneficial. It explores the patient’s experiences, perspectives, and lived experiences regarding a phenomenon (Creswell & Creswell, 2018). Data collected using this methodology is semi-structured interviews, one-on-one interviews, and focus groups (Creswell & Creswell, 2018). The primary investigator aims not to understand the home health participants’ emotions, behaviors, or experiences related to medication adherence.
A quantitative methodology supports the project because it will permit the primary investigator to remain objective in providing the project’s findings (Leedy & Ormord, 2020). Furthermore, the methodology allows the primary investigator to summarize the data that could support generalizations for a larger or similar population. The methodology is less costly with easy replication for future quality improvement projects to obtain the same results.
Project Design
Quasi-experimental designs are utilized to compare data before and post-implementation of an intervention (Price et al., 2017). The design is frequently used in a controlled environment. For this project, the design was chosen because it is cost-effective versus an experimental project design (Schweizer et al., 2016). A quasi-experimental design allows the primary investigator to analyze the impact of MAP resources on medication adherence rates.
An experimental design was not considered because the primary investigator is not seeking to conduct the project under a controlled environment (Leedy & Ormrod, 2014). This design observes the independent variable (MAP resources) and the dependent variable (medication nonadherence rates). It is a simple test that is performed in various physical and natural settings (Leedy & Ormrod, 2014).
A correlational design was considered but not appropriate for the project because the primary investigator is not seeking to understand the relationships occurring among the variables (Creswell & Creswell, 2018). This design is typically descriptive relying on a hypothesis (Leedy & Ormord, 2014). The primary investigator will not seek the relationships between the independent variable (MAP resources and education intervention) and the dependent variable (medication adherence rates).
The targeted population are home health patients ages 35 to 64 years old. The selected site serves approximately 100 patients annually. The inclusion criteria are males and females diagnosed with Type II diabetes, oral medication or insulin, and home health patients. The exclusion criteria are individuals with language or cognitive deficits and diagnosed with Type I diabetes. Five registered nurses will help to implement the project. They are individuals who work full-time and have been employed over a year.
The data collection process will begin once approved by Grand Canyon University IRB. Recruitment will occur from informational flyers given to the patients during their home health visits with the providers. The nurses will answer any questions regarding the project’s risks, benefits, and purpose and be instructed that the participation is voluntary. The primary investigator will use a convenience sample because of the access to the participants.
Data will be collected retrospectively four weeks prior to project implementation from the electronic medical records (Cradle Solutions) (medication adherence rates). In the last portion of the first week, the primary investigator will educate the healthcare providers regarding using the MAP resources. The staff will begin implementing the tool, and the post medication adherence rates will be assessed four weeks post-implementation. The primary investigator will document the data in a Microsoft Excel 2016 codebook developed by the primary investigator. Once completed, it will be exported into the SPSS-27 and analyzed using a chi-square analysis. A five-item demographic questionnaire will be used for descriptive statistics of the population. The survey will include (age, gender, years with Type II diabetes, oral or insulin, and education).
Pre-intervention and post-intervention data will be obtained using the MAP resources. The questions that will be analyzed are: (1) “Have you experienced any increase in thirst?” (2) “How often do you urinate?” (3) “Do you often feel fatigued even when doing little tasks?” and (4) “Do you experience blurred vision?” In addition to the questions, home healthcare providers will ask the patient “Are you taking your medications?” Any information attained from the question and due to probing, observation of patient’s medications, and patient-related medication adherence will be documented in the project site’s EHR. The data will be analyzed using an independent t-test to determine the statistical significance.
The electronic medical record that will be used to collect data is Cradle Solutions a software for home health companies. It serves the specialized needs of home health care providers that give a web-based point-of-contact information entry and management (Cradle Solutions, 2021). It is compliant with HIPPA security features for billing, reporting, administrating, and managing patient information (Cradle Solutions, 2021). Liss et al. (2020) emphasized that electronic health records can be used for quality measures as a snapshot or calendar year. The primary investigator will obtain the measurement of the medication adherence rates and align it with new protocols and guidelines developed by the facility.
Population and Sample Selection
The specific population that will be addressed are home health patients ages 35 to 64 years old. The selected site serves approximately 100 patients annually, and 30 patients are diagnosed with Type II diabetes. A G* power analysis was conducted using version 3.1.9.2, the alpha measure of 0.05, effect size of 0.5, power of 80% to calculate the lowest sample size needed, which was (n=34). The inclusion criteria are males and females diagnosed with Type II diabetes, oral medication or insulin, and home health patients. The exclusion criteria are individuals with language or cognitive deficits and diagnosed with Type I diabetes. Five staff nurses will help to implement the quality improvement project. They are individuals who are registered nurses, work full-time, and have been employed with the facility over one year, and have access to Cradle Solutions EHR system.
The geographical location of the project is in a metropolitan area of Houston, Texas. The County statistics show that approximately 17.6% of the population have Type II diabetes (Houston, 2021). During 2016-2018, 20.2% of the population was hospitalized due to diabetic complications (Houston, 2021). There are over 700 000 Medicare participants in a three-county radius, which is higher than the national average (Understanding Houston, 2021). Data further showed that preventable hospital stays occur in older adults 65 and above (Understanding Houston, 2021). This suggested a trend to overuse the hospitals as a primary source of care (Understanding Houston, 2021).
The informed consent process will consist of the nurses explaining the project’s purpose, risks, and benefits. The participants will be informed that participation is voluntary and can withdraw without repercussions to their professional or personal lives. No compensation will be provided to the participants in the project. The participants’ identities and privacy will be protected throughout the project by the primary investigator not using their names or other identifiable information. The participants will be assigned a random number for security purposes. The primary investigator will abide by the University’s IRB guidelines and the Belmont Report (justice, respect for persons, and beneficence) (U.S. Department of Health & Human Services, 2018).
Hard copies of the data will be stored on a flash drive and kept in the primary investigator’s home office (in a locked file cabinet). The data files will be kept on the primary investigator’s laptop, which is digitally protected. The data will be stored for three years according to Grand Canyon University procedures (June 2023). Once the project is completed and the requirements met, the primary investigator will destroy the information using Iron Mountain shredding services and software ERASER on the laptop.
Instrumentation or Sources of Data
The instruments to be used in the project are the MAP Toolkit and Training Guide resources, which includes (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list. The questions to ask poster encourages patients to ask the provider about their medication. For this project, the nurses will review the medications with the Type II diabetic patients. Six questions will be asked (1) Why do I need to take this medicine, (2) Is there a less expensive medicine that would work as well, (3) What are the side-effects and how can I deal with them, (4) Can I stop taking any of my medicines, (5) Is it okay to take my medicine with over the counter drugs, herbs, or vitamins, and (6) How can I remember to take my medicine?
The second section, the Adherence assessment pad, explores answers the barriers to the patient’s maintaining medication adherence. The questions include (1) makes me feel sick, (2) I cannot remember, (3) too many pills, (4) costs, (5) nothing, and (6) other.
The third component is my medication list. It provides detailed information in chart form, which is discussed between the patient and the healthcare provider. It comprises of (1) name and doses of my medicine, (2) this medication is for my diabetes, (3) when do I take and how much (options include: morning, noon, evening, or bedtime), and (4) I will remember to take my medicine (a blank that will be filled in).
The source of data for this project is the electronic medical record. The facility uses Cradle Solutions, software for home health companies. It serves the specialized needs of home health care providers that give a web-based point-of-contact information entry and management (Cradle Solution, 2021). It is compliant with HIPPA security features for billing, reporting, administrating, and managing patient information (Cradle Solution, 2021). Liss et al. (2020) emphasized that electronic health records can be used for quality measures as a snapshot or calendar year. The primary investigator will measure the medication adherence rates and align them with new protocols and guidelines developed by the facility.
Validity
Validity conveys how accurately a method is measured (Creswell & Creswell, 2017). If the method measures what it should and the findings correspond closely, it is considered valid. There are four types of validity are constructs, content, face, and criterion (Creswell & Creswell, 2018). For this project, construct and face validity is applicable to the instrument. A group of professionals developed the tool, which consisted of physicians, pharmacists, nurses, and medical assistants (Starr & Sacks, 2010). It was based on their years of work experience in their perspective fields. The toolkit’s improvements were adjusted and in alignment with the CDC and other healthcare governing bodies.
Reliability
Reliability refers to the consistency of instrument measuring something (Creswell & Creswell, 2018). If the same results occur regularly by using the same procedures under the same conditions, the measurement is reliable (Creswell & Creswell, 2018). For this project, the MAP toolkit reliability was confirmed by inter-rater reliability (Starr & Sacks, 2010). The observers noted the same results associated with using the instrument, which aligned with the literature findings regarding collecting data for medication adherence rates.
A study conducted by Harrell (2017), occurred over 90 days, where weekly medication adherence rates were assessed. Seventy-eight percent of the patients prior to the study’s implementation did not adhere to their prescribed medication regimen. Post three-months of the project, 56% of the patients improved regarding medication adherence rates. For this project, test-rest reliability will be noted, because the nurses will be using the MAP toolkit over time (two different times) (Creswell & Creswell, 2018).
Data Collection Procedures
The data collection process will begin once approved by Grand Canyon University IRB. Recruitment will occur from informational flyers given to the patients during their home health visits with the providers. The nurses will answer any questions regarding the project’s risks, benefits, and purpose and be instructed that the participation is voluntary. The primary investigator will use a convenience sample because of the accessibility to the participants. The goal is to achieve approximately 34 participants.
Five home healthcare nurses will be trained to implement the project. Training sessions will be offered twice so that the nurses working on the weekends can participate. The primary investigator will offer two 60-minute Zoom training sessions. During these sessions, the primary investigator will provide information regarding using the MAP toolkit and resources. A 10-minute PowerPoint presentation will be included during the 45-minute training session, along with a MAP toolkit binder for each participant.
The participants will be educated by the nurses regarding the purpose of the informed consent and its contents. The participants will be informed regarding the benefits, risks (minimal), and purpose of the project. The potential risk (minimal) is related to emotional circumstances such as the stigma of the disease, anxiety, or depression. The participants will be instructed that if they felt increased anxiety, depression, or embarrassment during the project, they can withdraw without any reason, or the project will end for them immediately. They will be directed to a primary care physician or professional who will further help them. There is a slight chance that the hard copies (demographic and MAP surveys could be lost. To ensure that this does not occur, the primary investigator will use a digitally password-protected laptop to protect their privacy. The participants will be informed that the data will be kept in a password-protected folder on the laptop accessible only to the primary investigator. The nurses will collect the signed informed consents and return them to the primary investigator after their visits. The primary investigator will collect them daily during the first week of the project.
The participants’ rights and well-being will be ensured by the primary investigator upholding the Belmont ‘s report principles a) justice, b) respect for a person, and c) beneficence. Furthermore, the primary investigator will adhere to Grand Canyon University’s IRB guidelines. The primary investigator will uphold justice by delivering fair treatment to all the participants. The participants will not exploit this population or manipulate their situation or disease. Respect for persons will be shown by treating the participants as autonomous individuals. All the participants will be treated using ethical conduct by respecting their answers and decision, thus protecting them from harm. Hence, this allows the primary investigator to abide by the beneficence guidelines.
The primary investigator will work with the information technology department, who will ensure that the three MAP resources are inserted into the Cradle Solution documentation software. During week one, the nurses will provide the patients with informed consent, answer questions related to the project, a five-item demographic survey, and a pre-MAP survey. The second to fourth week, the nurses will examine the patient’s medication list and adherence (ten minutes). Each week the nurses will record the medication adherence information in the patient’s electronic medical record.
Week four, all input by the nursing staff will be completed. If the patient expresses, they have not adhered to the medication regimen; it will be recorded in the system. Post scores will be collected by the primary investigator regarding the medication adherence rates. The results will be entered into the Microsoft Excel 2016 codebook developed by the primary investigator. The data will be exported into SPSS-27 be analyzed using a chi-square test.
The procedures adopted to maintain data security are the hard copies of the demographic and MAP surveys will be kept in a locked file cabinet in the primary investigator’s home, not accessible to anyone else. The Microsoft Excel 2016 codebook and SPSS results will be saved on the primary investigator’s digitally password-protected laptop. To ensure additional security, the primary investigator will install an encryption program (TrueCrypt) to prevent accidental access to the information. Per Grand Canyon University IRB guidelines, the data will be kept for three years (June 2024). At that time, the primary investigator will erase the information from the laptop using ERASER (computer software) and Iron Mountain shredding services to eliminate the data correctly.
Data Analysis Procedures
This quality improvement project is being conducted to address the issue noted of medication adherence among Type II diabetic patients in the home healthcare population. The information will be obtained from the electronic medical records (Cradle Solutions), which showed that ten percent of the diabetic patients were not adhering to their medication regimen. Data for the comparative and implementation patients will collected at the culmination of the four-week implementation period from the EMR and will be given to the primary investigator in a PDF report. The dependent variable (medication adherence rate) will be manually entered into a secure Microsoft Excel file (2016) for the comparative and implementation patients. All data collected will be in numerical values. Each patient will be given a unique identifier to organized data according to everyone.
The medication adherence rate is a nominal-level variable with two mutually exclusive options (adherent or non-adherent) for each patient and will be analyzed using a chi-square test as that is the most appropriate test for comparing two independent groups on a dependent categorical variable (Schober & Vetter, 2019). The patient groups are independent as patients in the comparative group (four weeks before implementation) were not matched for the implementation group. The project analysis will use a chi-square test, which is aligned to the project design as the test compares group differences when the dependent variable is measured at a nominal/categorical level (Schober & Vetter, 2019).
The clinical question that is guiding the project is: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks?
To address this question, the medication adherence rate for 30-days before and 30-days after the implementation of MAP resources will be compared. To answer the clinical question, a chi-square test will be conducted. The chi-square test will allow for a comparison of the medication adherence rate for patients 30 days before and 30 days after the implementation, thereby answering the clinical question. The level of significance will be set to .05, indicating a p-value of less than .05 would reveal statistical significance.
Raw data will be organized using a Microsoft Excel (2016) file with a unique identifier for each patient. Data on medication adherence rate for each patient in the 30-day comparative period and 30-day implementation period will be collected from quality department in a report and then manually entered into the Excel file as a categorical variable with numeric codes represented as 0 for non-adherent and 1 for adherent. After data entry in Microsoft Excel is completed, data will be exported to IBM SPSS version 27. To ensure data will be prepared for analysis, a preliminary analysis of all variables will be conducted to determine if the dataset has missing data or inaccurate entries. This will include frequency counts for variables to check for missing data and values outside of the possible range of 0 to 1 for the medication adherence rates.
Potential Bias and Mitigation
The internal validity is related to the extent the primary investigator can be confident that the cause-and-effect relationship found cannot be explained by other factors (Leedy & Ormrod, 2020). This makes the project’s conclusions credible and trustworthy (Leedy & Ormrod, 2020). Two factors that affect the internal validity of the project are the participants’ maturation and the instrument (MAP resources). The participants’ maturation could be affected by their recollection, poor memory, or follow-thru. The outcomes of the project would vary over time, affecting the results. One way to decrease this occurrence is to have the participant take the survey during the best time for them and productivity. For example, if an individual is a morning person (have them take the survey in the morning versus the afternoon or late evening). The second factor is the instrumentation process (MAP resources). The primary investigator will educate the nurses regarding the purpose of providing the participants the same time (30 minutes) to ensure the same measures are used during the pre-implementation and post-implementation phases. For example, the pre-implementation test cannot be given for 15 minutes, while the post-implementation test is given for 30 minutes.
Bias is described as any tendency that prevents impartial consideration of a clinical question (Pannucci & Wilkins, 2010). It can occur at any stage of the research, study design, data collection or analysis, and publication (Pannucci & Wilkins, 2010). One potential bias is related to the selection process. The primary investigator will avoid bias by selecting individuals and using strict inclusion and exclusion criteria previously developed for the project. The participants will originate from the specified population.
The second bias is related to recall bias, a systematic error that occurs when the participants do not remember prior events or experiences accurately (Creswell & Creswell, 2018). The project could be affected because the participants are self-reporting to the nurses using the MAP resources. To avoid this type of bias, the nurses will be trained to carefully train each participant using the same method, which will prevent influencing their responses (Creswell & Creswell, 2018).
Ethical Considerations
The primary investigator will abide by the University’s IRB and Belmont report guidelines while conducting the project. The three principles to be followed are respect for participants, justice, and beneficence (Belmont, 1979). The primary investigator and the nurses will show the participants respect by listening, validating their feelings, and answering the questions regarding the education or project. The primary investigator will occasionally monitor the nurse’s interaction with the participants throughout the project. The participants will be instructed that there are no repercussions to their personal or professional lives upon withdrawing from the project. The primary investigator and the nurses will always protect the participants’ privacy and confidentiality by not discussing the project, the participants, or its findings with anyone not involved in the project or without the participant’s permission.
Beneficence will be shown to the participants by informing the participants that the primary investigator or the nurses will stop the questioning immediately if they feel emotionally harmed. A psychological resource will be provided to participants who feel affected by the questions or project. All participants will be informed of the risks, benefits, and minimal harm that can occur to them, such as loss of data, social or emotional conflict with family and friends, and anxiety or depression.
The Belmont Report (1979) states justice is the “distribution of the burden.” During this project, it is possible that the participants could perceive unwanted stigma from the colleagues, family members, or friends. Each participant will be treated uniformly following their wishes, so it will not affect the project’s findings. There could be a potential conflict of interest with the project since the primary investigator works at the facility. To minimize the conflict, the primary investigator will not interact with the participants.
Limitations
The limitations of the project are self-reporting of medication adherence by the patients. To minimize this limitation, the primary investigator has validated the self-reporting instrument (MAP resources) before utilizing it for data collection (Althubaiti, 2016). Furthermore, the patient’s self-reporting will be compared to their fasting blood glucose levels, medical records, or reports from family and friends (Althubaiti, 2016).
The second limitation is the healthcare organization being impacted by the COVID-19 pandemic. The new COVID-19 guidelines have affected the current healthcare delivery model. The pandemic has caused the primary investigator to redirect resources and halt in-person training sessions for the nurses. The recruitment process has been limited to Zoom meetings and telephone calls. The third limitation is the location of the project and its setting. The project findings cannot be generalized to other home healthcare agencies of similar populations. The fourth limitation is the time to conduct the project (four weeks). A longer timeframe would help the primary investigator analyze the site’s challenges, trends, and sustainability.
Summary
Medication adherence among Type II diabetic home health patients remains a critical factor in their quality of life. The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks. A quasi-experimental design will allow the primary investigator to evaluate the impact of the MAP resources and educational intervention on the dependent variable (medication adherence rates). The medication adherence rates, and weekly glucose levels will be collected before and after project implementation (four weeks). Data will be collected by the primary investigator and stored on the digitally protected laptop and hard copies will be locked in a secured file cabinet at the residence. Chapter 4 provided a summary of the topic, along with descriptive data of the participants. Other sections consisted of the data analysis procedure, project findings, and summary.
Chapter 4: Data Analysis and Results
It is not known if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas. The stakeholders have cited that medication adherence among diabetic patients is lacking. According to data obtained from the site’s electronic health record (EHR), home healthcare providers documented that ten percent of diabetic home healthcare patients are not adhering to their medication regimens.
A quantitative quasi-experimental project will be conducted to address the clinical question: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks? Data on medication adherence will be collected for the comparative group and compared to an implementation patient group.
Chapter 4 presented the descriptive data for the patient sample. The data analysis procedures are outlined, and the results are presented using narrative and chart format. The chapter concluded with a summary of the findings regarding the clinical question and the significance of the data analysis.
Descriptive Data
The quality improvement project will use a quantitative, quasi-experimental approach for data collection. The targeted population for the project is from a home health care facility in urban Texas. The primary investigator used a G* power version 3.1.9.7, effect size 0.3, power 0.95, and df 0.5 to calculate the sample size needed for the project (N=220) for a significant level. The participants will complete a five-item demographic questionnaire comprised of (age, gender, education level, type of medication (oral or insulin), years as Type II diabetic).
A total of XX patients will be included in the project, n= XX in the comparative group and n= XX in the implementation group. The descriptive data will be displayed in Table 1. It shows X males (xx.x%) and x females (xx.x%) in the comparative group and x males (xx.x%) and x females (xx.x%) in the implementation group. The mean age of the participants was xx.xx (SD= xx.xx) with a range from x-to-x years of age for the comparative group and the mean age of the implementation group with a range from x to x years of age (SD = xx.xx). The educational level of the comparative and implementation patients x (xx.xx%) graduated from high school, x (x.xx%), did not graduate from high school, x (x.xx%), had some college but did not finish x (x.xx%), Associate degree, x (x.xx%), Bachelor’s degree, x (x.xx%), and higher-level doctorate, PhD, MD, or JD. A total of x participants (xx%) took insulin and x (x.xx%) are on oral medications.
Table 1
Descriptive Data for Comparative and Implementation Patients (N = XX)
Variable
Comparative
(n = xx)
Implementation
(n = xx)
Gender
Male
X
x.xx
X
x.xx
Female
X
x.xx
X
x.xx
Did not Graduate High School
Graduate High School
X
x.xx
X
x.xx
Some College
X
x.xx
X
x.xx
Associate Degree
X
x.xx
X
x.xx
Bachelor’s degree
X
x.xx
X
x.xx
Doctorate
X
x.xx
X
x.xx
Oral or Insulin
Oral
X
x.xx
X
x.xx
Insulin
x
x.xx
x
x.xx
M
SD
M
SD
Age
xx.xx
xx.xx
xx.xx
xx.xx
Years with Type II Diabetes
xx.xx
xx.xx
xx.xx
xx.xx
Data Analysis Procedures
The data analysis procedures will include evaluating de-identified data of medication adherence rates four weeks prior and four weeks post-implementation of the project. The primary investigator will abstract a PDF report of the medication adherence rates for both the comparative and implementation groups. Raw data will be input into a Microsoft Excel (2016) file (codebook). The independent variable is the MAP resource implementation (categorical), and the dependent variable is the medication adherence rates (yes/no). After data entry in Microsoft Excel is completed, data will be exported to IBM SPSS version 27.
To ensure data will be prepared for analysis, a preliminary analysis of all variables was conducted to determine if the dataset has missing data or inaccurate entries. If data is missing, it will be assigned a -99. If 50% of the questionnaire is not completed, the data will not be used in the project. This included frequency counts for variables to check for missing data and values outside of the possible range of 0= no medication adherence and 1= medication adherence. A chi-square test will be conducted, and the results discussed to answer the clinical question. The chi-square test will compare the association between two independent categorical variables (Schober & Vetter, 2019), which will compare the medication adherence rate for patients 30 days before and 30 days after the implementation, thereby answering the clinical question. The significance level will be set to .05, indicating a p-value of less than .05 would reveal statistical significance.
The patient outcome-dependent variable will be collected from the electronic medical records (Cradle Solutions) within the project site. Electronic medical records are considered a reliable and valid source for data collection. A study conducted by McGinnis et al. (2009) examined EMR and written records. The results demonstrated the EMR-based data validity was shown to be moderate to excellent, with Pearson r correlations ranging from .875 to .99 for EMR and documentation records (McGinnis et al., 2009). Electronic medical records are considered a reliable source of data, as emphasized by Goulet et al. (2007), found strong agreement (Kappa between .86 and .99) and high sensitivity and specificity (≥.95) for quality measures based on electronically abstracted structured data compared with manual review.
One identified potential error is related to the data is coverage error, which results in a difference between the sample size and the population measured (Qualtrics, 2020). To reduce the chances of this occurring, the primary investigator will utilize a recruitment method accessible to all potential participants (such as word of mouth, text messages, and emails). The random error related to the quality improvement project is the measurements (Leedy & Ormrod, 2020). The error could occur after the primary investigator collects the data while being processed (Leedy & Ormrod, 2020). To minimize the chances of errors, the primary investigator has hired a statistician to interpret the data patterns using statistical tests and perform data cleaning (Leedy & Ormrod, 2020).
Results
A chi-square test will be conducted to answer the clinical question: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks? The results are displayed in Table 2. There was an increase in medication adherence from the comparative (n = X, XX.X%) to the implementation group (n = X, XX.X%), X2 (1, N = xx) = x.xx, p =. xxx. The p-value was [less] than .05, which indicates that the increase in medication adherence was statistically significant.
Table 2
Medication Adherence Rates in the Comparative and Implementation Groups
Variable
Comparative
(n = xx)
Implementation
(n = xx)
X2
p-value
n
%
n
%
Medication Adherence
x
xx.x
x
xx.x
x.xx
.xxx
The results of the chi-square test analysis support the implementation of MAP resources to improve medication adherence as compared to current practice among Type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization. The rate increases in the implementation group and the p-value is less than .05 indicating (statistical or no statistical significance). Given these findings, the data analysis supports statistical and clinical significance of implementation of the MAP resources for improving medication adherence rates.
Summary
The purpose of this quantitative quasi-experimental project was to evaluate the impact of the Medication Adherence Project (MAP) resources on patient medication adherence rates for home health Type II diabetics. Data on medication adherence will be collected from the site’s EMR for four weeks before the SBAR intervention and for four weeks after the intervention. A total of XX patients were included in the study (n = xx in the comparative group and n = xx in the implementation group). The medication adherence rate was compared between the comparative and implementation patient groups using a chi-square test to address the project’s clinical question. There was an increased in medication errors from the comparative (n = X, XX.X%) to the implementation group (n = X, XX.X%), X2 (1, N = xx) = x.xx, p =. xxx. These results (showed or not showed) statistically significant increase in medication adherence after the MAP resource intervention compared to the comparative group and support the use of the MAP to improve medication adherence for adult home health patients with Type II diabetes.
Chapter 5 offered a summation of the results and conclusions based on the findings showing increased medication adherence after the MAP resource implementation. The theoretical and practical implications of the results will be summarized. The chapter concluded with recommendations for future projects, including adult home health patients with Type II diabetes, concerning the project findings that support MAP resources to improve medication adherence rates.
Chapter 5: Summary, Conclusions, and Recommendations
Diabetes impacts approximately one in ten Americans (Centers for Disease Control and Prevention, 2020). The prevalence of the disease continues to rise and is expected to grow by 0.3% annually until 2030 (Lin et al., 2018). This particularly troublesome for Type II home healthcare patients diagnosed with the disease. Polonsky and Henry (2016) emphasized that roughly 45% of this population fail in sustaining a normal glucose level. Poor medication adherence is associated with increased morbidity and mortality rates, finances, hospital readmissions, and diminished quality of life (Polonsky & Henry, 2016).
This quality improvement project was developed to address a standardized method for healthcare providers to assess their patients’ medication adherence. A quantitative, quasi-experimental design contributed to the participants promoting self-reliance and increased knowledge levels in maintaining healthier glucose levels. Furthermore, the project improved the practitioner’s awareness of the need to evaluate their patient regarding medication adherence frequently. The project provided current information related to Type II diabetic home health patients and medication adherence, which validated other studies such as Heath (2019) and Sharma et al. (2020).
Chapter 5 summarized the project related to Type II diabetic home health patients and medication adherence. Other segments comprised of the summary of the project’s findings and conclusions. The theoretical (Orem’s self-care deficit theory and Roger’s diffusion of innovation model), practical, and future implications were discussed. The last section consisted of recommendations for future projects and clinical practices.
Summary of the Project
The clinical question that directed the project was: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks? A chi-square test was conducted for a comparison of the medication adherence rates for the patients 30 days prior and 30 days post-implementation. A level of significance was set to .05, which indicated a p-value of less than.05 would reveal statistical or non-statistical significance.
A convenience sampling was used to recruit N=XX participants for the comparative group and N=XX for the implementation group. The nurses (XX) were educated regarding the use of the MAP resources. A retrospective chart audit (n=XX) was done to evaluate the medication adherence rates before the project implementation. The chi-square test was utilized to determine the variations among the two groups for statistical difference.
Summary of Findings and Conclusion
A sample size of N=XX participants was compared utilizing a chi-square test with the significance level at p <.05. Two groups were compared comparative (n=XX) and implementation (n=XX). The number of medication adherence rates were evaluated four weeks pre-implementation and post-implementation of the project. The clinical question that was answered using the chi-square analysis was: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks? There was an increase or decrease in medication errors from the comparative group (n= XX%) to the implementation (n=XX%), X2 [1, N=XX] = X.XXX, p= X. XX. These results (showed or not showed) statistical significance increase in medication adherence rates after the MAP resource intervention compared to the comparative group. It demonstrated the need for consistent use and the importance of healthcare providers to evaluate their diabetic patients frequently for medication adherence with each home health visit.
Implications
Nursing is a practice discipline, therefore when a quality improvement project is conducted it should focus on issues that directly affected the nursing practice (Polit & Beck, 2018). In this project, the emphasis is on patient care and offering the potential clinical consequences that impacted the findings (Polit & Beck, 2018). The theoretical, practical, and future implications are based on the data from the project and the literature preceding it.
Theoretical Implications
Orem’s self-care deficit theory was selected because it aligned appropriately with the clinical question that directed the project. The theory assisted the primary investigator and the staff nurses to implement the project solely based on the self-care requirements of the home health Type II diabetic patients. The theory helped build a foundation for the project by integrating strategies that aided the participants to understand their disease and sustain self-care management. Orem’s self-care deficit theory is comprised of three components: theory of self-care, self-care deficit, and the nursing system (RenpenningcN et al., 2003). The services designed were focused on the a) abilities and actions related to medication adherence of the participant, b) staff nurses coordinating resources for the diabetic patients, monitoring the disease, assessing the patient’s medication adherence using a patient-centered approach (Orem, 1985).
The strength of Orem’s self-care deficit theory allowed the primary investigator to provide the nurses an increased awareness in understanding their patients while addressing barriers that could impact them from understanding and maintaining medication adherence. In Chapter 2, the literature review examined how patients could effectively manage medication adherence while contributing to previous literature that utilized the theory on Type II diabetic patients (Borji et al., 2017; Ebrahimi, 2015; Ghafourifard & Shahbaz et al., 2016). One strength noted in the project was the increased curiosity and desire to learn exhibited by the patients. This was related to the nursing staff using a patient-centered approach in addressing their medication adherence. The patients verbalized that they appreciated the extra time that the nurses spent with them regarding how to maneuver the chronic disease.
The weakness of the project was teaching the nurses to become familiar with Orem’s self-care deficit theory, which was the foundation for the project. Orem’s theory can be utilized and implemented in other projects related to Type II diabetic home healthcare patients, since the findings cannot be generalized. A second weakness noted was the time restrictions to conduct the project (four weeks). A longer time frame would have allowed the primary investigator to observe the nurses and patient interactions, trends, and analyze obstacles that prevented an individual from maintaining medication adherence procedures.
Practical Implications
One practical implication included the agency evaluating and developing medication adherence guideline patient-specific using the MAP resources and Orem’s theory. Many of the nurses suggested that one of the monthly home visits should be dedicated solely to the patient’s current medication list and medication adherence. Another suggestion was to incorporate a text-messaging component from the primary nurse via the patient’s cell phone to remind them to take their medications. The last practical implication was related to the nursing staff not confronting the patient regarding their medication adherence status; instead, develop interventions tailored to their needs Sansbury et al., 2014). Using strategies such as goal setting, behavior contracts, or having an accountability partner could decrease the challenges in medication adherence (Sansbury et al., 2014).
Future Implications
One future implication related to the project is for other quality improvement projects to examine medication adherence rates among teenagers in the home healthcare settings. This should utilize medication adherence strategies specific to their age group. A second implication is related to diabetic medications, home health patients should be encouraged to participate in phase three trials for new diabetic products that would enhance medication adherence. These products are becoming available and provided to the participants at monthly or longer intervals. This would address some of the short-term barriers to sustaining medication adherence (Polonsky & Henry, 2016).
The second future implication is for the nurses to implement strategies for medication adherence based on the participant’s demographic characteristics (race, gender, age, personal preferences, culture, and social determinants) (Williams et al., 2014). The factors that affect the patient should be identified and addressed as they appear to allow greater control of the disease (Williams et al., 2014). A systems approach towards medication adherence would help achieve higher effectiveness, adherence, healthcare outcomes, and decrease healthcare costs (Williams et al., 2014).
Recommendations
Recommendations provide a firm foundation for the nursing workforce by ensuring they are adequately educated and prepared to implement the practice fully (Institute of Medicine, 2011). They are needed to meet their patients’ future health care needs and lead as change agents within the healthcare arena (Institute of Medicine, 2011). For this home health agency implementing and sustaining the recommendations will take time, finances, resources, and commitment from the staff. In the following few paragraphs, the primary investigator addressed recommendations for future projects and clinical practices.
Recommendations for Future Projects
The first recommendation is for those projects to utilize a standardized assessment strategy to evaluate their patient’s medication adherence behaviors and practices. Inaccurate medical records and inadequate medication assessment result in poor healthcare outcomes and minimum patient engagement in the decision-making. Educating the diabetic patients regarding the need for medication adherence would help them remain compliant. The best determinant for medication adherence is for patients to demonstrate via their behavior the change.
The second recommendation is to conduct the project use a larger population size focused on the caregivers of diabetic patients. Focusing the attention on this sector would emphasize the emotional and family support to help the patient remain compliant. Since many Type 2 diabetic patients have friends, family, or caregivers in their circle, it would be significant to include them in the discussion and the importance of medication adherence. This would allow a greater understanding of the subject and generalization of the project findings on this populace.
The next steps in moving this type of project forward are for the home health agency to implement and sustain the MAP resources for maximum impact on the patients. The continued use of the assess tool would help decrease frequent hospitalizations, financial expenses, and increased quality of health. Adopting the project should be specific to the home health agency’s specific needs and demands, which would enhance the project’s sustainability.
Recommendations for Practice
One recommendation for current practices is for home health nurses to offer other options to help their patients remain medication adherence compliant. Kirkman et al. (2015) suggested via their project findings that encouraging patients to use mail-order pharmacies increases the patient’s chance for medication adherence. An analysis conducted by Medicare Part D showed an increase in medication adherence by diabetic patients (Kirkman et al., 2015). Another suggestion is the use of a medication events monitoring system to evaluate the patient’s medication adherence. The device would be incorporated into the patient’s packaging of the prescription medication (Lam & Fresco, 2015). It records the dosing events and stores the information with audiovisual reminders. The last option is to receive automated electronic reminders such as (text messages) using REMIND software from the visiting home health nurse.
The second recommendation is for future clinic practices to establish and educate the nursing staff on cultural competency care. This type of nurse-patient relationship allows a stronger connection with the patient who feels comfortable expressing the concerns and knowledge deficits because of a non-judgmental environment that helps them maintain medication adherence behaviors. Effective communication restores and improves patients’ capability to cope with Type II diabetes and improve their patient outcomes (Aloudah et al., 2018).
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Appendix A
The 10 Strategic Points
Broad Topic Area
1. Broad Topic Area/Title of Project:
Improving Medication Adherence among Type II Home Healthcare Diabetic Patients
Literature Review
2. Literature Review:
a. Background of the Problem/Gap:
· Medication adherence is defined as how well patients in home-based care adhere to their medication regimen in the absence of health practitioners.
· Medication adherence incorporates total adherence and compliance with the medical instructions that patients are given.
· Proper medication adherence can significantly improve patient-related healthcare outcomes.
· In the United States, alone, the number of patients who have been diagnosed with type II diabetes cannot be accommodated by hospital settings (Brown & Bussell, 2018). Therefore, to prevent overflowing hospitals, home healthcare programs have been created.
b. Theoretical Foundations (models and theories to be the foundation for the project):
a. Attachment theory: In accordance with Hunter and Maunder (2016), there are two key reasons why the attachment theory is considered effective for the following DPI. First, the theory acts as a solid foundation for the enhanced comprehension regarding the identified development of ineffective coping techniques, as well as the underlying dynamics associated with the emotional difficulties of the person. Clinicians can help people who have attachment anxiety and fail to comprehend past experiences. Through the involvement of caregivers and/or significant others, individuals can help to reshape their coping patterns.
b. Social cognitive theory: The social cognitive theory (SCT) is a critical theory that will be utilized during this DPI project. The SCT is utilized to explain the manner in which human behavior is associated with dynamic, reciprocal, and progressive types of interactions that exist between the person and his/her given surrounding (Bosworth, 2015). Therefore, the SCT is famous because it often proposes that identified behavior aspects are an outcome of the cognitive processes that individuals usually develop. Cognitive processes are developed through social knowledge acquisition.
c. Review of Literature with Key Organizing Themes and sub-themes (Identify at least two themes, with three sub-themes per theme)
a. Theme 1: Medication Adherence – To handle the issue of medication adherence among the diabetic patients who have had an issue with the adherence to medication needs, various strategic should be utilized. The primary focus of this review of literature is to ensure that drug adherence, though understanding why lacking adherence occurs, is improved upon.
i. Drug Adherence: This is the art of sticking to the drug prescription as being presented by the doctors. There are many reasons why home care patients might fail to take drugs as prescribed. For instance, when there is no person to remind them of what is supposed to be taken and at what time (Brown & Bussell, 2018). Some patients go ahead of suffering conditions that make it difficult for them to progress in life.
b. Theme 2: Enhancing Adherence through Understanding
i. Patient-Centered Communication Approach: This approach will incorporate the interests and preferences of the patients. It will also serve to determine the possible barriers that patients might be facing related to their medication adherence (Voortman et al., 2017). To address components associated with the patient-centered approach, the following MAP resources will be used: Questions to Ask Poster and an Adherence Assessment Pad.
ii. Chronic Care Models:It is important to understand that patients need care when they are dealing with a chronic illness. Therefore, to ensure that proper care resources are provided, the My Medications List will be used.
c. Summary
i. Prior studies: Prior studies have revealed that medical adherence among home healthcare-based patients is lacking and has been a smooth process. In fact, up to 14% of diabetic patients (nationally) do not adhere to their prescribed medication regimen; however, other sources note that this lacking adherence is much higher than 14%, thereby contributing an issue that must be addressed.
ii. Quantitative application: The WHO reports numerical data about medication adherence among home healthcare patients. Furthermore, researchers have cited that medication adherence is often impacted by lacking literacy, poor understanding/knowledge about the importance of one’s medication, etc., thereby resulting in inflated adherence rates.
iii. Significance: Using the MAP resources and providing patient-specific care, medical adherence among type II diabetes patients will likely improve, thereby resulting in enhanced health-related outcomes.
Problem Statement
3. Problem Statement:
It is not known if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization located in urban Texas.
Clinical/ PICOT Questions
4. Clinical/PICOT Questions:
To what degree does the implementation of Medication Adherence Project resources, which include the Questions to Ask Pad, the Questions to Ask Poster, an Adherence Assessment Pad, and the My Medications List impact medication adherence among Type II diabetic home healthcare patients, ages 35 to 64, of a home healthcare organization located in urban Texas over a period of four weeks? The following clinical question will guide this quantitative project:
Q1: Does using the MAP resources improve medication adherence among home health diabetic patients?
Sample
5. Sample (and Location):
a. Location: The location of this project is in urban Texas. The project site provides a larger percentage of patients with healthcare services who reside in the urban area as compared to the rural area.
b. At the selected project site, approximately 30 patients have been diagnosed with type II diabetes, though this census changes each month. Patients between the ages of 35 to 64, with no cognitive limitation, who speak English, will be invited to participate in this project.
c. Inclusion Criteria
i. 35 to 64 years of age
ii. Type II diabetes diagnosis
iii. English speakers
iv. Cognitively abled
d. Exclusion Criteria
· Younger than 35 and older than 64 years of age
· Not diagnosed with type II diabetes
· Non-English speakers
· Cognitively disabled/delayed
Define Variables
6. Define Variables and Level of Measurement:
a. Intervention: Use of the MAP resources, by nursing staff members, which will be implemented upon the completion of an educational training session. Starr and Sacks’s (2010) MAP Toolkit and Training Guide resources, include: (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List.
b. Outcome: Enhanced medication adherence.
c. Variables: Medication adherence, which is the dependent variable explored in this project, will be measured using data attained through the project site’s EHR. The MAP resources, which serve as the independent variables explored in this project, include (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List.
Methodology and Design
Methodology and Design:
A quantitative methodology, which employs a quasi-experimental design, will be used to examine medication adherence rates pre-project implementation and post-project implementation. Statistical analyses will be used to compare pre-and post-project data. Demographic data will be collected because the prevalence of non-adherence is often high among certain groups (e.g., impacted by socioeconomic status, gender, age, etc.).
Purpose Statement
Purpose Statement:
The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization located in urban Texas.
Data Collection Approach
Data Collection Approach:
The source of data for this project is the electronic medical record. Each week, nursing staff members will record medication adherence information in the patient’s EMR. If the patient expresses that he/she has not adhered to the medication regiment, during the previous week, lacking adherence information will be recorded in the system. Upon the completion of the four-week project, all information, input by nursing staff members into the EMR, will be assessed. The PI will compare pre-project implementation medication adherence rates to post-project implementation medication adherence rates. In addition to exploring medication adherence rates after the implementation of this project, pre-project implementation adherence rates will be explored over four weeks from April 1, 2021 to April 30, 2021.
Once pre-project implementation data and post-project implementation data are obtained, the results will be statistically analyzed. The PI will work with a statistician, who will assist in the data analysis process. Data will be compared analyze using various statistical techniques.
Data Analysis Approach
Data Analysis Approach: The facility uses Cradle Solutions, software for home health companies. It serves the specialized needs of home health care providers that give a web-based point-of-contact information entry and management.
The data will be collected using the project site’s EHR and will be presented to the PI by the secretary in a Microsoft Excel document. Data will be input into SPSS version 28 and analyzed using a t-test with a p-value of 0.05.
References
Bosworth, H. B. (2015). Enhancing medication adherence: The public health dilemma. Philadelphia, PA: Springer Healthcare.
Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO Cares? Mayo Clinic Proceedings, 86(4), 304-314. Retrieved from /orders/doi.org/10.4065/mcp.2010.0575
Hunter, J., & Maunder, R. (2016). Improving patient treatment with attachment theory: A guide for primary care practitioners and specialists. Switzerland: Springer International Publishing.
Starr, B., & Sacks, R. (2010). Improving outcomes for patients with chronic diseases: The Medication Adherence Project (MAP). NYC Health. Retrieved from /orders/www.hfproviders.org/documents/root/pdf_9a3a46fa03.pdf
Voortman, T., Kiefte-de Jong, J., Ikram, M. A., Stricker, B. H., van Rooij, F. J. A., Lahousse, L., … Schoufour, J. D. (2017). Adherence to the 2015 Dutch dietary guidelines and risk of non-communicable diseases and mortality in the Rotterdam Study. European Journal of Epidemiology, 32(11), 993-1005. /orders/doi.org/10.1007/s10654-017-0295-2
Appendix B
MAP Resources
Appendix C
Permission to Use the MAP Resources
Per the website of Starr and Sacks (2010), the MAP tools are available free of charge. Tools can be downloaded from
THIS IS NOT PART OF THE PAPER JUST A REFERENCE FOR THE LEARNER
Appendix C
Power Analysis Using G Power
Note: Public source G-Power Software available /orders/www.psychologie.hhu.de/arbeitsgruppen/allgemeine-psychologie-und-arbeitspsychologie/gpower.html
Appendix D
Example SPSS Dataset & Variable View
The SPSS database is set up with all variables coded to compare between or within the comparison groups. A comparison may be made within the same individual and it coded 1 for before and 2 after the intervention. Or if measuring between individuals, the data would be coded the same 1 for before and 2 after as noted in the Group Column. Software supplied by Grand Canyon University.
Appendix E
How to Make APA Format Tables and Figures Using Microsoft Word
Tables vs. Figures
0. See APA Publication Manual, Chapter 7 for additional details (APA, 2019).
0. Tables consist of words and numbers where spatial relationships usually do not indicate any numerical information.
0. Tables should be used to present information that would be too wordy, repetitive, or difficult to read as text.
0. Figures typically communicate numerical information using spatial relations. For example, as you move up the Y axis of bar graph the scores usually go up.
1. Examples of APA Tables
A. Descriptive table
Table 1
Characteristics of Variables
Variable
Variable Type
Level of Measurement
Group, Intervention or Tool
Independent
Nominal
Rates or events
Dependent
Nominal
Socio Economic Status or Categories in an order
Dependent
Ordinal
Time, Temperature
Dependent
Interval
Age, height, Scores of tests
Dependent
Ratio
Note. Add notes here = (Provide any reference, 2019).
Table 1
Number of Handoff Per Groups
Group
# of Handoffs (%)
Pre-Intervention Group (Baseline)
150 (50%)
SBAR Group
150 (50%)
Note. SBAR handoff was defined as …. (IHI, 2020)
Table 1
Number of Hours Per Week Spent in Various Activities
Group
Baseline
(n = 30)
Post Intervention (n = 30)
Total Sample
(n = 60)
M (SD)
M (SD)
M (SD)
Schoolwork
18.23 (7.79)
16.23 (3.99)
17.63 (1.2)
Physical activities
19.54 (3.63)
14.23 (2.84)*
18.67 (1.0)
Socializing
16.23 (3.99)
17.63 (1.2)
18.23 (7.79)
Watching television
14.23 (2.84)
18.67 (1.0)
19.54 (3.63)
Extracurricular activities
19.54 (3.63)
18.23 (7.79)
19.22 (5.45)
Note. Schoolwork was defined as time spent doing class work outside of regular class time.
*statistically significant at p <.05
B. Chi-Square example (Group IV x Group DV)
Table 1
Crosstabulation of Gender and Chronic Pain
Chronic
Pain
Gender
Female
Male
χ2
Φ
Yes
2
(-2.7)
8
(2.7)
7.20**
,60
No
8
(2.7)
2
(-2.7)
Note. Adjusted standardized residuals appear in parentheses below group frequencies.
**= p< .01.
C. t-Test Example (Dichotomous Group IV x Score DV) –Notice two separate t-test results have been reported.
Table 1
Chronic Paint Score and Exercise time for Males and Females
Gender
Female
Male
T
df
Pain Score
3.33
(1.70)
3.75
(1.79)
-2.20*
175
Exercise Time
4.28
(.7509)
3.87
(.9280)
4.2**
176
Note. Standard Deviations appear in parentheses below means.
* = p < .05, *** = p < .001.
D. One Way ANOVA with 3 Groups Example (Group IV x Score DV)
Remember with an ANOVA, you have to report paired comparisons associated with post hoc or planned comparisons) for significant analyses. The results of paired comparisons are indicated by the subscripts on the means within rows. Also, notice in this table that we report the results of four separate analyses. This is the real power of tables: we can convey a large amount of information very concisely.
Table 1
Analysis of Variance for Sleep Times and Experimental Groups
Experimental Group
Aerobic Exercise
Weight Lifting
No Exercise
F
η2
Total Sleep Time
8.23a
(.55)
7.93b
(.90)
7.73ab
(.55)
3.98***
.18
Total Wake Time
3.58a
(.70)
3.62a
(.55)
3.54a
(.90)
.03
.00
Total Light Sleep
3.19c
(.73)
2.80a
(.72)
3.02b
(.49)
2.95*
.06
Total Deep Sleep
3.21b
(.19)
3.10a
(.28)
3.30a
(.19)
.20
.01
Standard deviations appear in parentheses bellow means. Means with differing subscripts within rows are significantly different at the p< .05 based on Fisher’s LSD post hoc paired comparisons.
* = p < .05, *** = p < .001.
E. Factorial ANOVA Example 2 x 3 between subject’s design.
Notice that two tables are used here. The first table reports the overall results for the 2×3 factorial ANOVA, which includes the Main Effects for the two IV’s and the Interaction Effect for the two IV’s. The second table reports the means and simple effects tests for the significant interaction effect.
Table 1
Experimental Group x Sex Factorial Analysis of Variance for Sleep Scores
Source
Df
F
η2
p
Experimental Group
2
7.93
.17
.001
Sex
1
31.41
.34
.001
Group x Sex (interaction)
2
7.85
.17
.002
Error (within groups)
30
Table 1
Analysis of Sleep Scores for Experimental Groups by Gender
Aerobic Exercise
Weightlifting
No Exercise
Simple Effects:
F df (2, 30)
Males
10.37a
(2.50)
10.30a
(2.34)
10.33a
(1.63)
.04
Females
4.83a
(1.60)
10.50b
(2.59)
4.50a
(1.52)
15.74**
Simple Effects:
F df (1, 30)
23.56**
.00
23.56**
Note. Standard deviations appear in parentheses bellow means. Means with differing subscripts within rows are significantly different at the p< .05 based on Fisher’s LSD post hoc paired comparisons.
** = p < .01
Notice that the simple effect comparing the 3 experiment groups only for females, requires follow up tests in order to determine which groups are significantly different. In this case, Fisher’s LSD test was used, and the results are represented with the different subscripts for each mean. In this case, female participants in the Aerobic exercise group did not differ from the no exercise group so they are given the same subscript (a). However, women in the control group and women in the Weightlifting group significantly differed from the Aerobic watching group and so the Weightlifting group was labeled with a different subscript (b). The male subjects did not differ from one another, so they all share the same subscript (a).
F. Correlations (Scores IV x Scores IV)
Table 1
Pearson’s Product Moment Correlations for Chronic Pain Score, Exercise Attitude Scores and Physical Activity
Demographic Influences on Exercise
Weight
Age
Chronic Pain Score
Pain Level
.39***
-.07
Pain Intensity
.15
.22*
Physical Exercise
Type of Exercise
-.26**
-.19†
Time of Exercise
-.13
-.21*
Intent to Exercise
.02
-.10
Note.N = 96 for all analyses.
† = p < .10, *= p < .05, **= p < .01, ***= p < .001.
1. Examples of APA Figures
Generally, the same features apply to figures as have been previously provided for tables: They should be easy to read and interpret, consistent throughout the document when presenting the same type of figure, kept on one page if possible, and supplement the accompanying text or table.
Figure 1
Graph of Scores Before and After
If the figure is not your own work, note the source or reference where you found the figure. Write, “Reprinted from” or “Adapted from,” followed by the title of the book, article, or website where you found the figure. Include the page number where you found the figure as well if you are citing a figure from a book. If you are citing a figure from a website, you may write, “Reprinted from The Huffington Post.” Or include the author’s first and second initial as well as their surname. Use the author’s first and second initial, if available, rather than the author’s full first name. Note their last name as well.
References:
American Psychological Association [APA]. (2019). Publication manual of the American Psychological Association. (7th ed.). Washington, DC; Author
Microsoft Word ®. (2019). Retrieved from /orders/products.office.com/
Appendix F
Writing up your statistical results
Identify the analysis technique.
In the results section (Chapter 4), your goal is to report the results of the data analyses used to answer your project question. To do this, you need to identify your data analysis technique, report your test statistic, and provide some interpretation of the results. Each analysis you run should be related to your clinical question or PICOT. If you analyze data that is exploratory or outside your clinical question, you need to indicate this in the results.
Format test statistics.
Test statistics and p values should be rounded to two decimal places (If you are providing precise p-values for future use in meta-analyses, 3 decimal places are acceptable). All statistical symbols (sample statistics) that are not Greek letters should be italicized (M, SD, t, p, etc.).
Indicate the direction of the significant difference.
When reporting a significant difference between two conditions, indicate the direction of this difference, i.e. which condition was more/less/higher/lower than the other condition(s). Assume that your audience has a professional knowledge of statistics. Do not explain how or why you used a certain test unless it is unusual (i.e., such as a non-parametric test).
How to report p values.
Report the exact p value (this is the preferred option if you want to make your data convenient for individuals conducting a meta-analysis on the topic).
Example: t(33) = 2.10, p = .03.
If your exact p value is less than .001, it is conventional to state merely p < .001. If you report exact p values, state early in the results section the alpha level used as a significance criterion for your tests. For example: “We used an alpha level of .05 for all statistical tests.”
If your results are in the predicted direction but are not significant, you can say your results were marginally significant. Example: Results indicated a marginally significant preference for pie (M = 3.45, SD = 1.11) over cake (M = 3.00, SD = .80), t(5) = 1.25, p = .08.
If your p-value is over .10, you can say your results revealed a non-significant trend in the predicted direction. Example: Results indicated a non-significant trending in the predicted direction indicating a preference for pie (M = 4.25, SD = 2.21) over cake (M = 3.25, SD = 2.60), t(5) = 1.75, p = .26.
Descriptive Statistics
Mean and Standard Deviation are most clearly presented in parentheses:
The sample as a whole was relatively young (M = 19.22, SD = 3.45).
The average age of students was 19.22 years (SD = 3.45).
Percentages are also most clearly displayed in parentheses with no decimal places:
Nearly half (49%) of the sample was married.
Frequencies or rates are reported including the range, mode, or median.
t-tests
There are several different designs that utilize a t-test for the statistical inference testing. The differences between one-sample t-tests, related measures t-tests, and independent samples t tests are clear to the knowledgeable reader so eliminate any elaboration of which type of t-test has been used. Additionally, the descriptive statistics provided will identify which variation was employed. It is important to note that we assume that all p values represent two-tailed tests unless otherwise noted and that independent samples t-tests use the pooled variance approach (based on an equal variances assumption) unless otherwise noted:
There was a significant effect for gender, t(54) = 5.43, p < .001, with men receiving
higher scores than women.
Results indicate a significant preference for pie (M = 3.45, SD = 1.11) over cake (M = 3.00, SD = .80), t(15) = 4.00, p = .001.
The 36 study participants had a mean age of 27.4 (SD = 12.6) were significantly older
than the university norm of 21.2 years, t(35) = 2.95, p = .01.
Students taking statistics courses in psychology at the University of Washington reported studying more hours for tests (M = 121, SD = 14.2) than did UW college students in general, t(33) = 2.10, p = .034.
The 25 participants had an average difference from pre-test to post-test anxiety scores of -4.8 (SD = 5.5), indicating the anxiety treatment resulted in a significant decrease in
anxiety levels, t(24) = -4.36, p = .005 (one-tailed).
The 36 participants in the treatment group (M = 14.8, SD = 2.0) and the 25 participants in the control group (M = 16.6, SD = 2.5), demonstrated a significance difference in
performance (t[59] = -3.12, p = .01); as expected, the visual priming treatment inhibited
performance on the phoneme recognition task.
UW students taking statistics courses in Psychology had higher IQ scores (M = 121, SD = 14.2) than did those taking statistics courses in Statistics (M = 117, SD = 10.3), t(44) =
1.23, p = .09.
Over a two-day period, participants drank significantly fewer drinks in the experimental group (M= 0.667, SD = 1.15) than did those in the wait-list control group (M= 8.00, SD= 2.00), t(4) = -5.51, p=.005.
ANOVA and post hoc tests.
ANOVAs are reported like the t test, but there are two degrees-of-freedom numbers to report. First report the between-groups degrees of freedom, then report the within-groups degrees of freedom (separated by a comma). After that report the F statistic (rounded off to two decimal places) and the significance level.
One-way ANOVA:
The 12 participants in the high dosage group had an average reaction time of 12.3.
seconds (SD = 4.1); the 9 participants in the moderate dosage group had an average
reaction time of 7.4 seconds (SD = 2.3), and the 8 participants in the control group had a
mean of 6.6 (SD = 3.1). The effect of dosage, therefore, was significant, F(2,26) = 8.76,
p=.012.
A one-way analysis of variance showed that the effect of noise was significant, F(3,27) = 5.94, p = .007. Post hoc analyses using the Scheffé post hoc criterion for significance indicated that the average number of errors was significantly lower in the white noise condition (M = 12.4, SD = 2.26) than in the other two noise conditions (traffic and industrial) combined (M = 13.62, SD = 5.56), F(3, 27) = 7.77, p = .042.
Tests of the four a priori hypotheses were conducted using Bonferroni adjusted alpha
levels of .0125 per test (.05/4). Results indicated that the average number of errors was
significantly lower in the silence condition (M = 8.11, SD = 4.32) than were those in both
the white noise condition (M = 12.4, SD = 2.26), F(1, 27) = 8.90, p =.011 and in the
industrial noise condition (M = 15.28, SD = 3.30), F (1, 27) = 10.22, p = .007. The
pairwise comparison of the traffic noise condition with the silence condition was nonsignificant.
The average number of errors in all noise conditions combined (M = 15.2, SD
= 6.32) was significantly higher than those in the silence condition (M = 8.11, SD = 3.30),
F(1, 27) = 8.66, p = .009.
Multiple Factor (Independent Variable) ANOVA
There was a significant main effect for treatment, F(1, 145) = 5.43, p < .01, and a
significant interaction, F(2, 145) = 3.13, p < .05.
The cell sizes, means, and standard deviations for the 3×4 factorial design are presented
in Table 1. The main effect of Dosage was marginally significant (F[2,17] = 3.23, p =
.067), as was the main effect of diagnosis category, F(3,17) = 2.87, p = .097. The
interaction of dosage and diagnosis, however, has significant, F(6,17) = 14.2, p = .0005.
Attitude change scores were subjected to a two-way analysis of variance having two
levels of message discrepancy (small, large) and two levels of source expertise (high,
low). All effects were statistically significant at the .05 significance level. The main
effect of message discrepancy yielded an F ratio of F(1, 24) = 44.4, p < .001, indicating
that the mean change score was significantly greater for large-discrepancy messages (M =
4.78, SD = 1.99) than for small-discrepancy messages (M = 2.17, SD = 1.25). The main
effect of source expertise yielded an F ratio of F(1, 24) = 25.4, p < .01, indicating that the
mean change score was significantly higher in the high-expertise message source (M =
5.49, SD = 2.25) than in the low-expertise message source (M = 0.88, SD = 1.21). The
interaction effect was non-significant, F(1, 24) = 1.22, p > .05.
A two-way analysis of variance yielded a main effect for the diner’s gender, F(1,108) =
3.93, p < .05, such that the average tip was significantly higher for men (M = 15.3%, SD
= 4.44) than for women (M = 12.6%, SD = 6.18). The main effect of touch was nonsignificant, F(1, 108) = 2.24, p > .05. However, the interaction effect was significant,
F(1, 108) = 5.55, p < .05, indicating that the gender effect was greater in the touch
condition than in the non-touch condition.
Chi Square
Chi-Square statistics are reported with degrees of freedom and sample size in parentheses, the Pearson chi-square value (rounded to two decimal places), and the significance level:
The percentage of participants that were married did not differ by gender, X2(1, N = 90) = 0.89, p > .05.
The sample included 30 respondents who had never married, 54 who were married, 26
who reported being separated or divorced, and 16 who were widowed. These frequencies
were significantly different, X2 (3, N = 126) = 10.1, p = .017.
As can be seen by the frequencies cross tabulated in Table xx, there is a significant
relationship between marital status and depression, X2 (3, N = 126) = 24.7, p < .001.
The relation between these variables was significant, X2 (2, N = 170) = 14.14, p < .01.
Catholic teens were less likely to show an interest in attending college than were
Protestant teens.
Preference for the three sodas was not equally distributed in the population, X2 (2, N =
55) = 4.53, p < .05.
Correlations
Correlations are reported with the degrees of freedom (which is N-2) in parentheses and the significance level:
The two variables were strongly correlated, r(55) = .49, p < .01.
Regression analyses
Regression results are often best presented in a table. A
PA doesn’t say much about how to report regression results in the text, but if you would like to report the regression in the text of your Results section, you should at least present the standardized slope (beta) along with the t-test and the corresponding significance level. (Degrees of freedom for the t-test is N-k-1 where k equals the number of predictor variables.) It is also customary to report the percentage of variance explained along with the corresponding F test.
Social support significantly predicted depression scores, b = -.34, t(225) = 6.53, p < .01. Social support also explained a significant proportion of variance in depression scores, R2 = .12, F(1, 225) = 42.64, p < .01.
Tables
Add a table or figure.
Adding a table of figure can be helpful to the reader. See the current APA Publication manual for examples. In reporting the results of statistical tests, report the descriptive statistics, such as means and standard deviations, as well as the test statistic, degrees of freedom, obtained value of the test, and the probability of the result occurring by chance (p value).
•APA style tables do not contain any vertical lines
•There are no periods used after the table number or title.
•When using columns with decimal numbers, make the decimal points line up.
•Use MS Word tables to create tables
American Psychological Association [APA].(2019). Publication manual of the American Psychological Association (7th ed.). Washington, DC: Author.
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Improving Medication Adherence among Type II Home Healthcare Diabetic Patients
by
Bola Odusola-Stephen
has been approved.
April 6, 2021
APPROVED:
Maria Thomas., DNP., DPI Project Chairperson
Bamidele Jokodola., DNP., DPI Project Mentor
ACCEPTED AND SIGNED:
________________________________________
Lisa Smith, PhD, RN, CNE
Dean and Professor, College of Nursing and Health Care Professions
_________________________________________
Date
Abstract
Medication adherence is essential in controlling chronic health conditions such as Type II diabetes in home health patients. At the project site, there was no standardized process for identifying and addressing the patient’s medication adherence. The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks. The nursing theory and change model that will guide this project is Orem’s Self-Care Deficit Theory and Diffusion of Innovation Model. Data extrapolated from Cradle Solutions and analyzed utilizing a chi-square analysis to determine the statistical significance. The clinical significance could be noted with the nurses using the tool consistently and performing the medication adherence screenings on each visit to help the patient remain compliant. The findings suggested that implementing the medication adherence program could improve patient compliance rates. A future recommendation is to conduct the project using larger populations of home health patients for a longer timeframe.
Keywords: diabetes mellitus type II, Diffusion of innovation model, home-based care, medication adherence, MAP resources, Orem’s self-care deficit theory
Dedication
An optional dedication may be included here. While a practice improvement project is an objective, scientific document, this is the place to use the first person and to be subjective. The dedication page is numbered with a Roman numeral, but the page number does not appear in the Table of Contents. It is only included in the final practice improvement project and is not part of the proposal. If this page is not to be included, delete the heading, the body text, and the page break below.
Acknowledgments
An optional acknowledgements page can be included here. This is another place to use the first person. If it applies, acknowledge and identify grants and other means of financial support. Also acknowledge supportive colleagues who rendered assistance. The acknowledgments page is numbered with a Roman numeral, but the page number does not appear in the Table of Contents. This page provides a formal opportunity to thank family, friends, and faculty members who have been helpful and supportive. The acknowledgements page is only included in the final practice improvement project and is not part of the proposal. If this page is not to be included, delete the heading, the body text, and the page break below. If you cannot see the page break, click on the Show/Hide button (go to the Home tab and then to the Paragraph toolbar).
Chapter 1: Introduction to the Project
According to the Centers for Disease Control and Prevention (2020), diabetes impacts one in ten Americans. Furthermore, the prevalence of diabetes continues to rise and is projected to increase by 0.3% per year until 2030 (Lin et al., 2018). For individuals with Type II diabetes, proper and effective medication adherence is critical (Kvarnström et al., 2018). This is particularly significant among healthcare patients because diabetes is one of the leading diagnoses for admission into a home health care facility (Sertbas et al., 2019). In this population, approximately 45% of the patients fail to maintain glycemic control (HgbA1c < 7%) (Polonsky & Henry, 2016). Poor medication adherence is linked with increased morbidity and mortality rates, increased financial expenses for the patient, hospital, and insurance companies, frequent hospitalizations, and lower quality of life (Polonsky & Henry, 2016).
At the project site, the primary investigator, in collaboration with the stakeholders, noted that the healthcare providers documented ten percent of the patients were not adhering to their medication regimen. This prompted frequent hospitalizations, infections, and other diabetic complications. In further investigation, it was found that there was not a standardized method for the healthcare providers to evaluate the patients regarding medication adherence. Hence, the introduction of the MAP resources and education intervention will be implemented.
The project is worth conducting because the primary investigator focuses on diabetic home health patients who are not the focal point of many literature reviews. Furthermore, little information is noted regarding the impact the healthcare team plays in addressing this population’s lack of medication adherence. The primary investigator aims to introduce a standardized method of addressing patient’s medication adherence using the MAP resources and education to minimize frequent hospitalizations, infections and increase their quality of life (Starr & Sacks, 2010). For this project’s purpose, the primary investigator (PI) will examine the impact/role healthcare team members play in addressing patient-related factors that affect medication adherence among home healthcare diabetic patients.
Chapter 1 introduces the project, background, and problem statements. Other segments include the purpose of the project, clinical question, advancing scientific knowledge, and project significance. The last sections consist of the rationale for using a quantitative method and quasi-experimental design, definition of operational terms, assumptions, limitations, and delimitations. The last few sentences are transitional ones providing a preview into Chapter 2.
Background of the Project
Home-based healthcare has existed since 1909 (Choi et al., 2019). Present-day, home-based healthcare is often selected due to an individual’s personal preferences. While home-based healthcare is not appropriate for all patients, Szanton et al. (2016) noted that this care option is best when an individual’s condition can be managed without admission to a hospital. Patients who have diabetes or hypertension are often recipients of home-based healthcare (Wong et al., 2020).
Adhering to diabetes medication regimen requirements can be complex. Raoufi et al. (2018) conducted a study using a multi-stage stratified cluster sampling method to recruit its participants. Two thousand one-hundred eight three diabetic patients participated in the study. Of the participants, 51.4% tested their glucose level more than once a month (Raoufi et al., 2018). The authors also noted that 10% of the participants did not monitor the glucose levels correctly or adhere to the medication requirements.
Patients with diabetes often express difficulties adhering to medication regimens, thereby reinforcing the critical role of receiving education from home healthcare providers (Wong et al., 2020). This is in part to the patients not having sufficient knowledge and education regarding diabetes and proper management of the disease (Wong et al., 2020). With diabetes being one of the leading diagnoses for patients needing home health services, healthcare agencies must educate their staff to evaluate the factors prohibiting patients from adhering to their medication regimen.
Problem Statement
It is not known if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas. The population affected are home health Type II diabetic patients in an urban healthcare agency in Texas. At the project site, nursing administration and staff cited that medication adherence among diabetic patients is lacking. According to data obtained from the site’s electronic health record (EHR), home healthcare providers documented that ten percent of diabetic home healthcare patients are not adhering to their medication regimen. Although this percentage four to six percent lower than other percentages cited in the literature for medication non-adherence, in terms of chronic disease management, various researchers have noted the implications associated with lacking adherence to medication regimens (Camacho et al., 2020; Hamrahian, 2020; Misquitta, 2020).
The lack of medication adherence can be attributed to inadequate drug-related knowledge, medication costs, poor understanding of medication regimen, etc., reinforcing the need for this quality improvement project (Heath, 2019; Sharma et al., 2020). Kvarnström et al. (2017) emphasized healthcare providers play a critical role in ensuring medication adherence. To promote medication adherence among patients of a home healthcare facility, the primary investigator will introduce a standardized method for the healthcare providers to assess the patient’s medication adherence. The staff will achieve greater insight by using MAP resources and an education intervention created by Starr and Sacks (2010). The tools utilized in this study, which are from Starr and Sacks’s (2010) MAP Toolkit and Training Guide resources, include: (1) the questions to ask poster, (2) an adherence assessment pad, and (3) my medications list.
The project contributes to solving the problem by introducing a standardized method of evaluating the patient’s medication adherence. It will improve the healthcare provider’s knowledge and awareness regarding the obstacles or factors the patient may face in maintaining a medication regimen. This would help the facility adhere to the current Centers for Disease Control and Prevention (2020a) guidelines in the participants maintaining their normal daily glucose levels, deter healthcare costs, frequent hospitalizations, and infections.
Purpose of the Project
The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks. The independent variable is the MAP resources and educational intervention. The dependent variable is medication adherence rates. A quantitative methodology will be used for the project to learn about this population (home health patients) (Allen, 2017).
The specific population that will be addressed are adult home health patients ages 35 to 64 years old. The primary investigator chose this population because of the prevalence of Type II diabetes rising in children, adolescents, and young adults in the United States (12:100000) (Centers for Disease Control and Prevention, 2020; Kao & Sabin, 2016; Reinehr, 2013). The selected site serves approximately 100 patients annually, and 30 patients are diagnosed with Type II diabetes. The inclusion criteria are males and females diagnosed with Type II diabetes, oral medication or insulin, and home health patients. The exclusion criteria are individuals with language or cognitive deficits and diagnosed with Type I diabetes. Five female staff nurses will be trained to help implement the quality improvement project. They are individuals who are registered nurses, work full-time, and have been employed with the facility for over one year.
The geographic location of the project is in an urban area of Houston, Texas. The County statistics show that approximately 17.6% of the population have Type II diabetes (Houston, 2021). During 2016-2018, 20.2% of the population was hospitalized due to diabetic complications (Houston, 2021). There are over 700 000 Medicare participants in a three-county radius, which is higher than the national average (Understanding Houston, 2021). Data further showed that preventable hospital stays occur in older adults 65 and above (Understanding Houston, 2021). This suggested a trend to overuse the hospitals as a primary source of care (Understanding Houston, 2021).
The project contributes to the nursing field by increasing the healthcare providers’ knowledge and awareness of the obstacles and other risk factors involved in a patient not adhering to their medication regimen. Furthermore, it would help increase dialogue between the provider and patient in sharing the details of their behavior (Bussell et al., 2017). This creates a positive, blame-free atmosphere allowing the patients to discuss their medication-taking behavior (Bussell et al., 2017).
Clinical Question
A well-developed clinical question must be related and relevant to patient care. This helps the primary investigator search for evidence-based answers. The clinical question that will direct this quality improvement project is: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks?
The independent variable is the MAP resources. The dependent variables are the medication adherence rates.
To address the clinical question, the medication adherence rate for 30-days before and 30-days after the implementation of MAP resources will be compared using a chi-square test. The chi-square test will allow for a comparison of the medication adherence rate for patients 30 days before and 30 days after the implementation, thereby answering the clinical question. The level of significance will be set to .05, indicating a p-value of less than .05 would reveal statistical significance.
Advancing Scientific Knowledge
This direct practice improvement project seeks to enhance medication adherence among diabetic home healthcare patients using the MAP resources. Various researchers have cited the benefits associated with patient-provider engagement and collaboration to improve medication adherence (Ong et al., 2018; Polonsky & Henry, 2016; Wong et al., 2020). The advancement of a small step forward at the clinical site is that by improving medication adherence rates among diabetic patients’ positive patient-related outcomes will likely occur using the MAP protocol. This will add to the current literature and address the gap found regarding non-medication factors among home health diabetic patients.
The theoretical framework that will be used in this quality improvement project is Orem’s self-care deficit theory (1995) was developed to improve patient health outcomes in in the context of nursing contribution (Yip, 2021). The theory is comprised of three related sections: theory of self-care, self-care deficit, and the nursing system (RenpenningcN et al., 2003). It fits the project because it includes healthcare providers assisting patients in their self-care and management to improve their function at a home level (RenpenningcN et al., 2003). The patients cannot effectively manage medication adherence for diabetes, which affects their quality of life and health Orem’s self-care deficit theory advances the project by contributing to previous research conducted on Type II diabetic patients using the theory (Borji et al., 2017; Ghafourifard & Ebrahimi, 2015; Shahbaz et al., 2016). This project, the theory, helps to advances the clinical practice by improving the participant’s quality of life by providing a self-care program as a solution using the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources. The theory guides the primary investigator to increase the patient’s awareness about their disease and minimize their non-compliance with their regimen (Borji et al., 2017). The theory helps to identify the educational needs of home healthcare patients, which is more needed than the proper treatment (Borji et al., 2017). Implementing Orem’s self-care deficit theory is recommended to increase a patient’s knowledge level and adherence to self-care behaviors (Shahbaz et al., 2016).
The change model that will be used in this quality improvement project is the Diffusion of Innovation Model developed by Rogers (2003). There are five stages: a) knowledge or awareness, b) persuasion or interest, c) decision or evaluation, d) implementation or trial, e) confirmation or adoption (Rogers, 2003). Diffusion is defined as a social process, which occurs among individuals in response to knowledge regarding a new strategy for improving their health (Dearing & Cox, 2018). It is also the process communicated within a specific timeframe (four weeks) (Dearing & Cox, 2018). This change model can provide the primary investigator with methods to share and educate regarding a new diabetic prevention strategy (Lien & Jiang, 2016). The model has been utilized in various fields to help healthcare providers understand and translate new concepts, treatments, disease knowledge, and educational methods (De Civita & Dasgupta, 2007; Lien & Jiang, 2016). For this project, the primary investigator using the MAP resources provide the participants a new approach to be integrated into the daily practices to improve quality of life and diabetic outcomes. Utilizing these methods will help the project advance by helping the healthcare providers to implement a standardized method in evaluating the patient’s medication-taking behaviors.
Significance of the Project
The significance of the project is that there continues to be a steady rise in chronic diseases has resulted in more patient care options (Polonsky & Henry, 2016). To meet various population groups’ unique needs, home-based care has gained popularity (Holly, 2020). Type II diabetes patients who qualify for home-based care options must demonstrate their willingness to work with the home healthcare agency at the selected project site. When patients who receive home-based care fail to adhere to the care requirements set forth, adverse outcomes can ensue (Polonsky & Henry, 2016).
The possible results based on the clinical question and problem statement should increase patient compliance related to medication adherence. The project also helps to empower healthcare providers to adequately address medication questions and patient concerns and ensure the patients keep track of their medication regimen, resulting in a reduction in adverse events. Holecki et al. (2018), when the MAP resources were utilized, medication adherence increased significantly.
The findings noted by Holecki et al. (2018) reinforce the beneficial nature of implementing the MAP resources, as this can improve the quality of patient care received. For this quality improvement project, it fits within helping to correct the gap noted in the literature (regarding medication adherence) for this population. Furthermore, it contributes to the clinical site by helping the patients maintain their medication regimen. Hence, decreasing potential infections, hospitalizations, and incurring financial costs to (patients and the facility).
Rationale for Methodology
The methodology chosen for this quality improvement project is quantitative.
Creswell and Creswell (2018) noted a quantitative methodology is best suited for projects that require data in numerical form. In this project, the numerical data will be presented using charts and graphs. These charts and graphs will allow readers to compare medication adherence rates pre-project implementation and post-project implementation.
While qualitative research studies are beneficial, they examine experiences, perspectives, and beliefs about a specific issue (Creswell & Creswell, 2018). The data collection used in this type of methodology is interviews (semi-structured, one-on-one, and focus groups). For this project, the primary investigator is not seeking to understand the participants’ feelings, behaviors, or lived experiences related to medication adherence.
A quantitative methodology supports the project because it will permit the primary investigator to remain objective in providing the project’s findings (Leedy & Ormord, 2020). Furthermore, the methodology allows the primary investigator to summarize the data that could support generalizations for a larger or similar population. The methodology is less costly with easy replication for future quality improvement projects to obtain the same results.
Nature of the Project Design
A quasi-experimental design will be used for this project. Quasi-experimental designs are used to compare data before and after the implementation of an initiative/intervention. Price et al. (2017) state in a pretest-posttest design, the dependent variable is measured once before the treatment is implemented after it is implemented. Often, these designs are used when research occurs in a controlled environment. While this project will not be conducted in a controlled environment, the primary investigator selected a quasi-experimental design because it is more cost-effective than an experimental project design (Schweizer et al., 2016). Furthermore, since data pre-project implementation and post-project implementation need to be collected and analyzed to explore the intervention’s impact, a quasi-experimental design is most appropriate.
A correlational design was considered but not appropriate for the project because the primary investigator is not seeking to understand the relationships occurring among the variables (Creswell & Creswell, 2018). This design is typically descriptive relying on a hypothesis (Leedy & Ormord, 2020). The primary investigator will not seek the relationships between the independent variable (MAP resources and education intervention) and the dependent variable (medication adherence rates).
The targeted population are home health patients ages 35 to 64 years old. The selected site serves approximately 100 patients annually, and 30 patients are diagnosed with Type II diabetes. The inclusion criteria are males and females diagnosed with Type II diabetes, oral medication or insulin, and home health patients. The exclusion criteria are individuals with language or cognitive deficits and diagnosed with Type I diabetes.
The data collection process will begin once approved by Grand Canyon University Institutional Review Board (IRB). Recruitment will occur from informational flyers given to the patients during their home health visits with the providers. The nurses will answer any questions regarding the project’s risks, benefits, and purpose and be instructed that the participation is voluntary. The primary investigator will use a convenience sample because of the access to the participants.
Data will be collected retrospectively four weeks prior to project implementation from the electronic medical records (Cradle Solutions software) (medication adherence rates) (Cradle Solutions, 2021). In the last three days of the first week the primary investigator will educate the healthcare providers regarding using the MAP resources. The staff will begin implementing the tool, and the post medication adherence rates will be assessed four weeks post-implementation. The primary investigator will document the data in a Microsoft Excel 2016 codebook developed by the primary investigator. Once completed, it will be exported into the SPSS-27 and analyzed using an independent t-test. A five-item demographic questionnaire will be used for descriptive statistics of the population. The survey will include (age, gender, years with Type II diabetes, oral or insulin, and education).
Pre-intervention and post-intervention data will be obtained via the project site’s EHR. The questions that will be analyzed are: (1) “Have you experienced any increase in thirst?” (2) “How often do you urinate?” (3) “Do you often feel fatigued even when doing little tasks?” and (4) “Do you experience blurred vision?” In addition to the questions, home healthcare providers will ask the patient “Are you taking your medications?” Any information attained from the question and due to probing, observation of patient’s medications, and patient-related medication adherence will be documented in the project site’s EHR. The data will be analyzed using an independent t-test to determine the statistical significance.
Definition of Terms
The following operational terms will be used interchangeably throughout the manuscript:
Adherence Assessment Pad.
The Adherence Assessment Pad is part of the MAP resources that explores answers via the patient perspectives. Using the Adherence Assessment Pad, nursing staff members will be able to explore the concerns of patients and adjust, pending further project team review, to the patient’s medication regimen (Starr & Sacks, 2010).
Home-based Healthcare.
The term home-based healthcare or home healthcare references the medical care that is provided to patients in the comfort of the patient’s home (Polonsky & Henry, 2016). Home-based healthcare services differ depending on a patient’s needs, diagnosis, and other factors.
Medication Adherence.
The term medication adherence references the extent to which a patient, caregiver, or home nurse follows the recommended guidelines on managing a medical condition (Ahmed et al., 2018).
My Medications List.
Is a list that provides a breakdown of the patient’s medications, in an easy-to-follow chart format, thereby improving patient medication adherence (Starr & Sacks, 2010).
Questions to Ask Poster.
Is a part of the MAP toolkit, which will be utilized during this project. When using the Questions to Ask Poster, home healthcare providers answer six questions to patients about medication adherence and medication knowledge. The questions that providers will answer include: (1) “Why do I need to take this medicine?,” (2) “Is there a less expensive medicine that would work was well?,” (3) “What are the side-effects and how can I deal with them?,” (4) “Can I stop taking any of my other medicines?,” (5) “Is it okay to take my medicine with over-the-counter drugs, herbs, or vitamins?,” and (6) “How can I remember to take my medicine?” Providers must answer all the questions and should assume that individuals have no medication knowledge, thereby confirming that patients know and understand these critical answers (Starr & Sacks, 2010).
Type II Diabetes.
For this project, Type II diabetes is the topic of exploration. It is described as an impairment of the body regulating and using glucose as a fuel source. Type II diabetes is a chronic condition where an excess amount of sugar is circulating in the blood stream (Mayo Clinic, 2019).
Assumptions, Limitations, Delimitations
As with all practice improvement projects, assumptions, limitations, and delimitations must be addressed. Assumptions are considered self-evident truth (Grand Canyon University, 2021). They are statements that are deemed plausible by other individuals and peers who read the project. The first assumption is that the participants will self-report honestly to the best of their recollection. To minimize social-desirability bias, the primary investigator will compare the participant’s answers with other data (laboratory values for glucose levels) (Leedy & Ormrod, 2020).
The second assumption is that the primary investigator will provide an accurate description of the current situation at the project site. To ensure that fabrication and falsification of the project findings do not occur, the primary investigator will observe the nurses during the patient visit to monitor the interactions. The primary investigator will use an outside source as a statistician so that the project results are not skewed.
Leedy and Ormrod (2020) stated that limitations are factors that the primary investigator has no control over. The first limitation is the primary investigator’s lack of control over the environment related to the novel coronavirus pandemic (COVID-19). The pandemic has affected the method in which the project will be implemented. The primary investigator will not interact with the participants during the project. Instead, five registered nurses were educated to implement the project. The pandemic has increased many patients’ fear related to one-on-one interaction with their primary care providers. The primary investigator does not know if there is a possibility with the new variant (Delta-variant) if the project will be modified to virtual monitoring to minimize the participant’s risk of COVID-19 infection.
The second limitation is conducting the project (four weeks versus longer) (cross-sectional versus longitudinal). A cross-sectional project allows for a snapshot of a specific moment (Leedy & Ormrod, 2020). A longitudinal project would have allowed the primary investigator to provide a richness of data regarding the topic. The primary investigator could identify and convey the findings related to the participants’ behaviors, patterns of change, experiences, and reduce recall bias (Coolican, 2014). Furthermore, this type of project would allow the primary investigator to test whether the variables were casual or the result of other differences (Leedy & Ormrod, 2020).
Delimitations are choices the primary investigator made, describing the boundaries placed on the project. One project delimitation noted is the inclusion criteria of the participants. Patients with diabetes, ages 35 to 64, are included in the project. Since this project’s focus is to explore medication adherence among diabetes patients, which is a concern at the project site, it has narrowed the field to learn about other patients and their compliance issues. The second delimitation is where the project was conducted, an urban area located in the southeastern region of the United States, thereby impacting the generalizability of its findings.
Summary and Organization of the Remainder of the Project
The aging population is growing at an increasing rate in the United States, hence snowballing the number of individuals taking medications to manage their Type II diabetes. Kyarnstrom et al. (2018) emphasized that for Type II diabetics, it is essential that proper and effective medication adherence be maintained. For home healthcare patients, 45% of this population fail to maintain glycemic control < 7% (Polonsky & Henry, 2016). This is attributed to poor medication adherence (Polonsky & Henry, 2016). Healthcare providers are a critical component in making a difference by helping patients learn and maintain medication adherence.
The quality improvement project will use a quantitative methodology. The rationale for using this method is to collect numerical data that can be statistically analyzed. A quasi-experimental design will answer the clinical question to determine if the outcome impacted the medication adherence rates. The project will be guided by Orem’s self-care deficit theory and Roger’s diffusion of innovation model (Rogers, 2003).
Chapter 1 provided detailed support for utilizing the MAP resources to improve medication adherence among diabetic patients of the project site. A quantitative, quasi-experimental design was used to explore the impact of the MAP intervention on improving medication adherence among Type II diabetes patients of the selected project site. Other portions of the chapter included advancing scientific knowledge using Orem’s self-care deficit theory and Roger’s diffusion of innovation model. A detailed description was given related to the project’s significance, project’s methodology, and design. The last few sections of the chapter comprised the definition of terms, assumptions, limitations, delimitations, and a summarization of the chapter.
Chapter 2 presented a detailed summary of the literature collected related to the project’s clinical question. Information about the theoretical framework and change model is detailed. The chapter comprises five sections, which highlight information about literature obtained from 2016 to 2021. The information presented provides readers in-depth knowledge and the importance of each chosen section.
Chapter 3 offered research methodology details that the primary investigator employed. The information presented in the chapter included the selected research design, the target population, and the sample size. Furthermore, data collection tools (specifically the MAP’s resources) and data analysis procedures are discussed. The reliability and validity of the project instruments are detailed. Lastly, ethical considerations for collecting data are addressed.
Chapter 4 presented the project’s findings, which were analyzed using chi-square analysis. Results regarding the descriptive and inferential data analyses will be offered. Furthermore, a brief discussion of project-related findings is delivered. The information will be presented using graphics, figures, and tables. Chapter 5 delivered the conclusions and recommendations drawn from the project’s results. The impact of the findings, in terms of practical and theoretical knowledge, will be offered.
Chapter 2: Literature Review
Diabetes mellitus (DM) is a global epidemic in this era, and many diabetic patients comprise Type II diabetes mellitus (Rana et al., 2019). Medication adherence is a critical component and key determinant in obtaining therapeutic success and reducing diabetic complications (Rana et al., 2019). For Type II diabetic home health patients, this is vital in self-care and management of the disease. Unfortunately, approximately 30% to 50% of patients adhere to their medication regimen (Hennessey & Peters, 2019).
Diabetes is a lifestyle disease, which can be prevented or avoided by making lifestyle changes. Disease management can also occur through adhering to one’s prescribed medication regimen(s). Medication adherence is important since it can help to reduce the likelihood of diabetes-related challenges and complications. In the United States (U.S.), the problem is associated with increased morbidity and mortality rates, with approximately 125,000 deaths and 10% of hospitalizations annually (Hennessey & Peters, 2019). Furthermore, medication nonadherence costs the U.S. healthcare systems roughly $100 billion to $317 billion yearly (Kini & Ho, 2018). The purpose of this quantitative quasi-experimental project is to determine to what degree the implementation of the Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization located in urban Texas.
Chapter 2 reintroduced the project’s subject matter, background, theoretical framework, and change model. Other segments include a review of literature on previous and current empirical research related to medication adherence in Type II diabetic home health patients. The chapter’s themes are related to patient-related factors (non-pharmacological and pharmacological lifestyle changes, patient beliefs). Socio-economic factors (medication costs, health literacy, lack of social support), health system factors (trust in the healthcare provider, complicated medication regimen), and interventions (patient education, motivational interviewing, and MAP resources).
The primary investigator conducted a literature review utilizing peer-reviewed articles from 2016 to current. The inclusion criteria were articles written in English, topics specific to the project such as barriers to medication adherence, MAP resources, medication adherence, and Type II diabetes. The exclusion criteria were articles not written in English, more than six years, Type I diabetes, or involved children. Databases reviewed were PubMed, Google Scholar, CINAHL, Cochrane Library, EBSCOhost, and Grand Canyon University online library. The review revealed over 632,000 plus results; however, the primary investigator selected 30 articles for this chapter for this project.
One of the most problematic issues associated with home care for diabetes patients is adherence to medications. According to Bonney (2016), patients take their medication as prescribed only 50% of the time. Furthermore, patients are often reluctant to share medication compliance details, thereby resulting in health-related complications (Bonney, 2016). Type II diabetes mellitus is at an epidemic proportion globally (Centers for Diseases and Prevention Control, 2020). The incidence of the disease will continue to rise from 382 million individuals to 417 million by 2035 (Polonsky & Henry, 2016; Rana et al., 2019). Healthcare experts are becoming increasingly concerned because of the costs, morbidity, and mortality rates linked with the disease (Polonsky & Henry, 2016). One of the elements contributing to the problem is poor medication adherence (Rana et al., 2019). This is particularly true in-home health Type II diabetic patients. Medication adherence in adults with chronic conditions is roughly between 30% to 50% (Kini & Ho, 2018; Neiman et al., 2017). Furthermore, the healthcare system associated with medication non-adherence is costing the U.S. healthcare system $100 billion to $317 billion annually (Rana et al., 2019). (background)
As adults in this country age, many are afflicted with chronic diseases such as diabetes (Type II). It is one of the main reasons for admission to home health agencies (Sertbas et al., 2020; Wong et al., 2020). Home health agencies have been in existence for over 30 years (Choi et al., 2019). These organizations will continue to grow and impact medical advances and technology (Wong et al., 2020). Hence, there is a need for healthcare providers to become familiar with strategies and barriers linked with medication adherence for this population. Many home health patients have difficulty adhering to their medication regimens. They often express difficulty adhering to the regimens, which reinforces the critical role of home healthcare providers (Wong et al., 2020). This is partly due to them not having knowledge and education related to the disease and proper self-management (Wong et al., 2020).
Theoretical Foundation
Orem’s self-care deficit theory was selected to guide this quality improvement project. The theory was chosen because of its expectations that an individual must be self-reliant and responsible for their care (Orem, 1985). Dorothea Orem’s theory states self-care is an activity that a person engages in to maintain, restore, or enhance their health (Orem, 1985). The theory further states that nurses should not consider patients as inactive or sheer recipients of healthcare; instead, they should be considered reliable, responsible individuals who can make informed decisions and be active in their health care (Orem, 1985).
This theory describes nursing as an action between two or more individuals (RenpenningcN et al., 2003). Furthermore, it assumes that a successful patient with self-care understands it is a primary element in health prevention and illness (RenpenningcN et al., 2003). The theory fits the project because the healthcare providers are in supportive educational roles, which assists the patient when they are ready to learn or cannot complete a task without guidance (Orem, 1985). Also, the theory relates to healthcare providers assisting patients in their self-care and management to improve their function at a home level (RenpenningcN et al., 2003). The theory has been used in multiple studies regarding patients with chronic diseases (Afrasiabifar et al., 2016; Borji et al., 2017; Khademian et al., 2020).
The change model that will be used is the diffusion of innovation developed by Rogers (2003). There are five components of the theory are a) knowledge, b) persuasion, c) decision, d) implementation, and e) adoption (Rogers, 2003). The model is defined as a social process, which occurs among individuals in response to knowledge regarding a new strategy for improving their health (Dearing & Cox, 2018). It is a process communicated within a specific timeframe (for this project, four weeks) (Dearing & Cox, 2018). This change model can provide the primary investigator with methods to share and educate regarding a new diabetic prevention strategy (Lien & Jiang, 2016). The model has been utilized in various fields to help healthcare providers understand and translate new concepts, treatments, disease knowledge, and educational methods (De Civita & Dasgupta, 2007; Lien & Jiang, 2016). For this project, the primary investigator using the MAP resources provide the participants a new approach to be integrated into the daily practices to improve quality of life and diabetic outcomes. Utilizing these methods will help the project advance by helping the healthcare providers to implement a standardized method in evaluating the patient’s medication-taking behaviors.
Review of the Literature
Diabetes is prevalent in the United States and globally (Rana et al., 2019). It is one of the primary diagnoses for being admitted into home health care (Sertbas et al., 2019). Hence, the usage of home health services has become increasingly popular because it allows patients to remain in a comfortable atmosphere and decrease hospitalizations (Sertbas et al., 2019). There are many studies regarding older adults and diabetes, but minimum regarding home health care patients with diabetes (Sertbas et al., 2019). The review of literature is based on themes centered on patient-related factors, socioeconomic factors, and interventions.
Patient-related Factors
The World Health Organization (2017) stated patient related factors encompass an individual’s resources, knowledge levels, belief system, perspectives, and expectations. These factors can vary dependent on the non-pharmacologic and pharmacologic lifestyle changes that the person maintains (Nduaguba et al., 2017). Type II diabetes management involves not just medication adherence but observance to monitoring diet and exercise, follow-up, and self-care (Nduaguba et al., 2017).
Medication adherence.
Medication adherence is a term that refers to one taking medication as prescribed by their healthcare practitioner (Ahmed et al., 2018). Healthcare providers must ensure that the prescriptions provided to patients are suitable to the individual’s conditions.
While medication adherence is important, there is a plethora of literature available that expresses the prevalence of medication non-adherence among patients. Various factors continue to impact medication adherence, which includes, but are not limited to, fear, costs, misunderstanding, too many medications, lack of symptoms, mistrust, worry, and depression (American Medical Association [AMA], 2020). To prevent medication non-adherence, providers can seek to understand the needs of patients and provide them with resources that can aid in overcoming non-adherence.
Ahmed et al. (2018) emphasized that the quality of healthcare can be influenced by the body’s ability to respond to the treatment. A study conducted by Rana et al. (2019) was related to exploring medication adherence to prescribed treatments as a crucial factor for hospitalized Type II diabetic patients in a Bangladesh hospital. The quantitative, descriptive cross-sectional study involved 112 Type II diabetic patients recruited from medical and endocrinology wards. Much of the sample size age was 57.46, 60.7% were male and married. The patient’s medication adherence was measured using the 7-item MCQ scale modified by Ahmad et al. (2013). Data were analyzed using SPSS-21. Descriptive statistics were used to measure the participants’ demographics. An independent sample t-test and one-way ANOVA with post hoc comparisons were used to evaluate the relationships between the variables (p =.05).
The results from the Rana et al. (2019) study showed 72.3% of the participants forgot to take their medications, 96.4% chose not to take the medication or miss a dose when feeling better. Most of the patients, 81.3%, did not take their medications with them when traveling. The mean scores of the MCQ were 26.46 (SD =1.58). The study’s results concluded that the level of medication adherence among Type II diabetic patients was suboptimal (Rana et al., 2019). The authors recommended that more attention needed to be given to varied age groups related to medication adherence.
Lee et al. (2017a) conducted a quantitative study to determine the medication adherence among Type II diabetic patients in an Asian community. This cross-sectional study involved 382 Asian participants from a primary outpatient care clinic in Singapore. The patient’s medication adherence was measured using a five-item Medication adherence report scale (MARS-5). A low medication adherence score was <25. The sample size was predominately female, with a mean age of 62 years. Using univariate analysis, the results showed 57% of the participants had a low medication adherence score, which was attributed to them being married or widowed, taking fewer than four medications daily, and poor glucose control. The study concluded that younger patients were susceptible to low medication adherence scores (Lee et al., 2017).
Although the studies were conducted in different settings (primary care and hospital), the results demonstrated a need for healthcare providers to focus on different age groups and their reasons for not adhering to their medication regimen. The studies were cross-sectional, which indicated the authors were unable to evaluate the participant’s habits and trends. This could have changed if they could assist the patients with barriers they faced during the studies.
To handle the issue of medication adherence among the diabetic patients who have had an issue with adherence to medication needs to come up with a variety of strategies that have been attained from scholarly reviews as well as journals for purposes of well researched data on the concept. Appropriate types of medications are usually considered to be the identified cornerstone regarding the prevention as well as disease treatment yet according to numerous research carried out, there is solely about half of the individual patients who adhere to the instructions of their prescribed medication (Bosworth, 2015). This usually causes a common as well as costly public health-associated challenge especially for the healthcare system in the U.S.
This topic was chosen because inefficient medication adherence is complex, with a variety of contributing causes; hence, there is no universal solution (Rodriguez-Saldana, 2019). For a patient to succeed with medication adherence, the healthcare provider must understand the underlying reasons that are barriers that could be removed or diminished. Teaching the patient new strategies that are patient-centered will help them achieve the new normal.
Non-pharmacological indicators.
There are many medications used for the effective management of diabetes (Raveendran et al., 2018). Effective non-pharmacological therapy should be explored with all Type II diabetics. The measures could include nutrition and exercise. Nutrition interventions are critical in a person with diabetes maintaining an optimal glucose level (80-120mg). The dietary pattern that must be encouraged is consuming fruits, vegetables, low-fat dairy foods, whole grains, and minimal red meat (Asif, 2014). Khazrai et al. (2014) study emphasized that food intake is associated with obesity. However, it is not just the volume of food but the quality of one’s diet. High ingestion of red meat, sugary items, and fried foods contributes to insulin resistance and Type II diabetes (Khazrai et al., 2014). People with diabetes should be educated regarding consuming fruits and vegetables in protecting them since they are high in nutrients, fiber, antioxidants, and a protective barrier against diseases (Khazrai et al., 2014).
This topic was selected because educating Type II diabetic home healthcare patients regarding their dietary habits is an integral part of diabetes care. Failure to incorporate healthy eating habits along with medication adherence can lead to severe complications of the disease. Healthcare providers must teach home healthcare patients dietary guidelines according to their food selection, cultural, and personal preferences to change their eating patterns.
Pharmacological factors.
Type II diabetic patients typically take multiple medications for their condition and other comorbidities (Kirkman et al., 2015). Following one’s medication regimen and treatment improves patient outcomes, reduces healthcare costs, hospitalizations, and mortality (Kirkman et al., 2015). A retrospective study conducted by Kirkman et al. (2015) determined patient, medication, and prescriber factors that influenced diabetic patients and medication adherence. A sample size of 200,000 participants (from 50 states, including the Virgin Islands) was extracted from a pharmacy database (Medco Health Solutions). The participants’ eligibility was based on the medication, benefits, and prescription history. Each patient was followed for one year from the medication date to post-implementation of the study.
Medication adherence was described as a medication possession ratio > 0.8 (Kirkman et al., 2015). Logistic regression analyses were conducted to evaluate factors independently linked with adherence. The results demonstrated that 69% of the participants were adherent. Other findings illuminated that adherence was associated with one’s age (older), male, higher education and income, and the use of the mail order versus retail pharmacies. Individuals with a new diagnosis of diabetes were less likely to be compliant with their medication regimen.
The authors concluded that demographic, clinical, and system-level factors influenced the participants’ medication adherence regimen (Kirkman et al., 2015). The authors emphasized that younger individuals, newly diagnosed and had minimal medications to take, were at a higher risk for non-adherence. Individuals who used mail-order pharmacies resulted in higher medication adherence due to lower out-of-pocket costs (Kirkman et al., 2015).
Patient’s belief system.
One’s culture influences a patient’s beliefs regarding medications, which ultimately affects their medication adherence (Lemay et al., 2018). This remains a challenge for healthcare providers in helping patients to understand the significance of medication adherence (Shahin et al., 2019). A study conducted by Shahin et al. (2019) used a systematic review to determine the importance of an individual’s cultural belief influenced medication adherence. A total of 2,646 articles were selected from various databases such as PubMed, CINAHL, EMBASE, and PsychINFO. Twenty-five of them met the inclusion criteria. The studies focus on diabetes or hypertension.
The study results from Shahin et al. (2019) revealed personal and cultural factors linked with medication adherence. Ten articles (40%) demonstrated an individual’s perception of the illness, five (20%) were affiliated with health literacy, four (16%) cultural beliefs, three (12%) self-efficacy, and five (20%) knowledge illness (Shahin et al., 2019). Shahin et al. (2019) study concluded that one’s cultural influences affect their perception of the importance of medication adherence. Healthcare providers must understand their patients’ pre-existing perspectives of diabetes before offering new information. This is an opportunity for healthcare professionals and patients to have a dialogue to diffuse misconceptions related to the patient’s perceptions. The authors suggested that future research should identify the religious beliefs associated with disease knowledge and medication adherence.
Healthcare providers and the relationships with patients.
Patients usually consider their healthcare providers (HCPs) as the most dependable source of data regarding their health condition and treatment. Patients are highly likely to effectively follow the treatment plan when they are involved in having a good relationship with their HCP due to the confidence and trust that has been built over time. Relationship building in healthcare is a vital aspect in the day to day lives of healthcare practitioners due to the nature of their job, which necessitates that they maintain long-term relationships with their patients for enhanced medication and treatment outcomes (Heston, 2018).
Trust is critical to developing, specifically since patients can experience improve health-related outcomes when they value relationships with their HCPs. Patients who have trust in their HCP often believe that their provider has a high level of competence and truly cares about their health-related outcomes (Heston, 2018). Mistrust develops when the patients attain unrealistic, inconsiderate, or insensitive advice from their HCPs, as well as feel emotional distance from them.
Health literacy.
Health literacy is described as one’s ability to obtain, communicate, process, and comprehend basic health information and navigate health services to make an informed decision (Sawkin et al., 2015). Medication adherence is broadly identified as a patient’s ability to follow a prescribed medical treatment (Sawkin et al., 2015). Researchers Glanz et al. (2015) have explored the impact of low health literacy rates on patient compliance with medications and health-related advice. The authors stated that approximately 35% of American adults possess basic or below basic health literacy levels (Glanz et al., 2015). Chima et al. (2020) conducted a systematic review to evaluate the impact of health literacy and medication adherence. Literature searches were performed using Ovid Medline, CINAHL, EMBASE, Scopus, and PsycInfo. The inclusion criteria for the articles were conducted in the United States, 18 years or older with a diagnosis of Type I or II diabetes, medication adherence was an outcome variable, quantifiable measure reported, and was a full text journal article. Articles were graded using Joanna Briggs Institute Critical Appraisal Checklists, which is appropriate for the respective study designs identified. Thirteen articles were retained in the review, most of which used a cross-sectional design.
The results demonstrated four of the 11 studies found a positive association between health literacy and medication adherence (Chima et al., 2020). Two of the four studies had methodological shortcomings. The authors concluded there was some evidence that health literacy is linked with medication adherence among diabetic adults in the United States. Recommendation for future research to design and execute longitudinal studies to determine a deeper relationship between the variables (health literacy and medication adherence (Chima et al., 2020).
Given inadequate literacy rates, among members of the general population, world practitioners continue to create unique strategies that can be used to reduce lacking health adherence among patients with diabetes. Improved literacy is a theme that should be of the utmost priority, specifically since it creates the foundation for long-term sustained profitability. Furthermore, as patients can understand the importance of medication compliance, adherence to medication regimens improves (Glanz et al., 2015).
Using universally implemented and published resources that can improve medication adherence is important. Tools and resources can be utilized by HCPs to identify patients who are not taking their prescribed medications. Prescriptions need to be taken seriously for exceptional results and for the continued well-being of patients who have critical illnesses like diabetes.
The use of simple language by HCPs, as well as by medication manufacturers, can encourage providers to meet patients where they are and utilize teach-back techniques to ensure a patient’s understanding of his/her prescribed medication regimen. Teach-back methods have been utilized to enhance medication adherence among many types of non-adhering patients. Most of the time people opt to not take their medication as they cannot read all the instructions written on the medicine and are afraid that they will die, especially in the cases that they mistake those drugs for poison or some drug that may look like a famous poison causing death. This is a key issue that has left most of the people victims of non-adherence (National Academies of Sciences, Engineering, and Medicine, 2018).
Huang et al. (2020) conducted a cross-sectional study aimed to identify patient factors linked with diabetes medication adherence and health literacy levels. One hundred and seventy-five participants were involved in the study and recruited from two family medical clinics. All the participants were over the age of 20, diagnosed with Type II diabetes, taken one oral diabetic medication, and understood English. The authors evaluated the participants’ health literacy levels using the Newest Vital Sign, a six-item questionnaire, and an eight-item Morisky Medication Adherence Scale.
The results showed a self-reported status of (β = 0.17, p = 0.015) and medication self-efficacy (β = 0.53, p, 0.001), which were positively associated with diabetes and medication adherence (Huang et al., 2020). Health literacy was neither associated with diabetes medication adherence (β = −0.04, p = 0.586). The authors concluded that health literacy measured using the Newest Vital Sign did not correlate with medication adherence or glucose control among Type II diabetics. They recommended that healthcare clinics develop interventions to improve their patients’ self-efficacy of medication to improve the medication adherence rates (Huang et al., 2020).
Reading instructions and making a patient understand what is written on a medicine bottle or package should never be taken for granted as it is key for determining how patients will effectively or ineffectively adhere to the given drugs for treatment and disease control purposes. For the medical practitioner to be aware and sure that what they have explained to the patients has been delivered safely and appropriately, there is the need for a verification test. The patients as well as their identified support individuals need to be asked to explain in their own words stating what they have understood from everything the practitioner has told them regarding their health, along with drug management and intake. This teaching back method is vital in offering additional data on the key topic of interest; thus, it should be used often.
Concerns associated with the issues of side effects can be challenges to medication regimen adherence, especially when the given advantages associated with taking the medication are not properly comprehended. To minimize the potential concerns that are associated with the side effects of drugs, since this can be identified as one of the reasons why patients may opt to not adhere to medications in fear that they will experience the side effects and be greatly inconvenienced, there is the need for HCPs to offer the relevant data regarding the common types of side effects when they are in the prescription process.
There have been issues of people and patients dying or experiencing negative and disturbing side effects when it comes to them taking the medication prescribed by their doctors. These cases have always been used as examples to explain the reason why people have been reluctant to take medications for prolonged periods. When an individual has a critical illness, it is not uncommon that he/she needs to take the prescribed medication for a long period, as this can result in improved medication efficiency. Lacking understanding of medication-related details has caused patients to withdraw from their prescribed medication regimen, which is due to lacking knowledge and prolonged side effect issues that are associated with their medication (Institute of Medicine [IOM], 2011).
For example, when offering metformin, to enable adherence to the drug there is a need to inform patients that are suffering from diarrhea during their time of prescription to anticipate that the loose bowel issues will be over in about a week if the drug is continued. It is also vital to offer brief explanations about medication side effects and benefits due to time limitations. If a patient cannot have additional time with his/her provider, then other members of the health care team should aid in answering their questions and provide additional education. Education can be in the form of printed handouts, websites, or a teaching module that should be readily available for use with the identified patient.
Socioeconomic Factors
Socioeconomic-related factors that affect medication adherence include one’s location of residence, medical costs of treatment, and finances (Yeam et al., 2018). Other factors that could influence medication adherence are low health literacy, education level, lack of social support, living conditions, and medication costs (Hennessey & Peters, 2019). Health care providers must conduct a thorough assessment before providing a patient the prescription and consider any of the factors as mentioned above.
Medication costs.
Kang et al. (2018) conducted a quantitative, longitudinal study to examine factors that affected cost-related medication nonadherence. Cost-related medication nonadherence (CRMN) is defined as taking medication then indicated or prescribed due to costs (Kang et al., 2018). Unknown sample size noted, but the Behavioral Risk Factor Surveillance System data for 2013–2014 was used to identify individuals with diabetes and their CRMN. Weighted multivariable logistic regressions were used, and analyses were conducted using the Survey suite of programs in Stata SE version 14. The survey weights were used to obtain population-level estimates and subpopulation methods to estimate standard errors for the subgroup’s analyses (Kang et al., 2018).
The results demonstrated that CRMN among American adults was 16.5% (Kang et al., 2018). Individuals with an annual income of < $50k and without health insurance had the highest rates of CRMN. Insulin users had a 1.24 times higher risk of CRN than those not using insulin. Factors influencing CRMN were diabetes care and lifestyle factors, depression, arthritis, and asthma (Kang et al., 2018). Health insurance was the most significant factor for the participants < 65 years of age and depression for respondents > 65 years (Kang et al., 2018).
The authors (Kang et al., 2018) concluded that one’s annual income and health insurance status were the most significant factors for younger adults, while depression was for older adults > 65 years. When the younger and older groups were combined, it showed the largest impact of CRMN affecting individuals < 55years of age and having higher rates of non-medication adherence (Kang et al., 2018). Recommendations were for healthcare organizations to develop policies, resources, and support systems that address the factors to help improve CRMN.
Social Support.
Various factors impact medication adherence. However, Linni et al. (2015) emphasized that social support must be considered a core component in interventions that improve the management of Type II diabetic patients. The social support theory has three components a) subjective support (emotional experience and fulfillment of the individual being respected and understood; b) objective support (direct material help from the social network in the communities; c) support utilization (various support strategies from family, friends, and colleagues) (Linni et al., 2015; Shao et al., 2017).
A quantitative study conducted by Linni et al. (2015) determined whether social support was linked with medication adherence in patients with Type II diabetes. The study was conducted in a Beijing hospital with a random sampling of 412 participants with Type II diabetes. The adult patients’ assessment of their social support was retrieved from medical records and self-reported surveys (Social Support Rate Scale 14-item questionnaire). The support scale measured objective, subjective, and support utilization. The Chinese version of the Morisky Medication Adherence Scale, eight-item, was translated for the participants to complete. Three hundred and thirty participants completed the self-report measure medication adherence six months after the initial data collection.
A t-test demonstrated a significant difference in social support between the low and high medication adherence groups (t = -2.11, p= 0.036) (Linni et al., 2015). A regression analysis was used to determine the subscales of the support, which presented statistical significance and association with medication adherence (β = 0.29, p = 0.011), rather than another two subscales of subjective (β = −0.02, p = 0.80) and objective support (β = −0.04, p = 0.33) (Linni et al., 2015). The authors concluded that social support was a critical factor in improving medication adherence in diabetic patients. It must be impressed on this population to have open attitudes to receiving help from friends, family, and outside organizations.
A quantitative, longitudinal study conducted by Shao et al. (2017) determined the impact of social support and medication adherence among 532 Chinese patients from an outpatient and inpatient endocrine clinics. The authors used the ten-item Social Support Rating Scale for data collection related to social support. It measured the three components of social support (objective, subjective, and support utilization). A six-item self-efficacy scale was used to measure (emotional control, communication with physicians, symptom management, role function, and perceived adaptability to chronic diseases). Shao et al. (2017) developed a 13-item adherence scale that was divided into three subscales a) Do you take the medicine every day according to the doctor’s advice? b) Do you take the dosages according to the doctor’s advice? c) Do you take the medication on time?
Data were collected and entered into EpiData 3.1 software (Shao et al., 2017). A Pearson’s correlation coefficients were calculated to evaluate the pairwise associations between the social support scores, self-efficacy, and adherence (Shao et al., 2017). The descriptive data showed the participants were mostly older females. The coefficients for the three components were statistically significant demonstrated the goodness-of-fit indices (χ2 = 2 47, P = 0 12; GFI = 0 99; AGFi = 0 98; CFI = 0 98; and RMSEA = 0 05) (Shao et al., 2017).
Both studies, Linni et al. (2015) and Shao et al. (2017) utilized an adequate number of participants for their quantitative studies. They used the same support rating scale, which validated their findings. The key difference is that the studies were conducted in various settings (hospital and endocrine outpatient/inpatient clinics). In conclusion, the studies validated the role of social support in managing Type II diabetic patients. Hence, it must be considered as a key component in any intervention a healthcare provider develops to improve self-managing and glycemic control (Linni et al., 2015; Shao et al., 2017).
Interventions
Using tools and instruments that are considered effective and appropriate is vital in supporting adherence in different ways and in achieving self-efficacy among the various patients. Positive family and social support are vital aspects associated with adherence to the issue of diabetes management (Rodríguez-Saldana, 2019). The engagement of family members can enhance self-care activities for patients suffering from diabetes, including eating effective and healthy foods, keeping fit, monitoring blood glucose, and adhering to medication.
A web-based portal is an innovative resource that can be used to assist patients. This web-based portal can improve medication reconciliation processes among patients and providers. The web-based portal can help patients with various regimens navigate challenges. Furthermore, this medication information, available through the portal can help individuals understand medication requirements, as the portal often helps to clarify and verify inaccuracies. The web portal aims to enhance medication adherence and prevent the improved use of the medication (Forman & Shahidullah, 2018).
When patients can verify information in their electronic medical records to ensure proper medication adherence, this can enhance patient well-being. The EMR provides an accurate list of a patient’s medications and provides detailed medication information (e.g., type of drug, what the drug is used to treat, frequency of drug use, etc.). Also, the use of screening tests is vital in understanding how well patients are taking their drugs. If there is no consistency in medication-taking then motivation aspects should be utilized to enhance adherence (Eskola et al., 2017).
Medication Adherence Project (MAP).
The MAP resources were introduced, developed, and implemented by the New York City Department of Health and Mental Hygiene in response to clinicians and pharmacists working in primary care practices (Starr & Sacks, 2010). It serves patient populations impacted by several chronic diseases (Starr & Sacks, 2010). The resources provide practical tools to help practitioners communicate with patients related to medication adherence. It consists of a training course and toolkit that was piloted and assessed by doctors, nurses, pharmacists, medical assistants, nutritionists, and healthcare educators (Starr & Sacks, 2010).
The objectives of the tool are to acquaint healthcare providers with the obstacles associated with medication adherence with individuals who have chronic diseases:
Other aspects include a) evidence-based solutions that improve adherence, b) educate healthcare providers to engage in conversations regarding medication taking, c) help practitioners to combine the tool into the clinical practices and quality improvement methods, and d) help providers train their peers to use the resources effectively (Starr & Sacks, 2010).
Patient-Contentedness Care.
Patient-contentedness entails ensuring that all the identified interventions described in the first theme are focused on the individual patient who is being helped to effectively adhere to the given medication during home care settings. Patients who have been diagnosed with various critical illnesses and have been asked to go home for home-based care have been associated with poor adherence to the medications they are given when they are discharged from the hospital (Steinberg & Miller, 2015).
Practice recommendations, whether they are focused on evidence or expert opinion, are intended to offer the desired guidance on an overall approach to care (da Costa et al., 2018). The science, as well as the art associated with medicine, usually come together when the identified clinician is experiencing or has experienced some sort of situation whereby, they must make treatment recommendations for any patient who would be considered to not have effectively met the eligibility criteria for the studies on which the given guidelines were based.
Patient Advocacy.
Advocacy is a vital aspect in healthcare since it addresses the needs of the patient who need the utmost help and care, thereby allowing them to go back to their previous health state (D’Onofrio et al., 2018). Advocacy is an aspect that can be referred to as active support, as well as engagement, that aims to effectively develop a cause as well as a policy (Mollaoglu, 2018). Furthermore, advocacy is usually needed to enhance the lives of individuals suffering from diabetes. The various issues that diabetic patients experience, such as obesity, physical inactivity, and societal challenges reinforce the need for advocacy (Firstenberg & Stanislaw, 2017).
In summary, these topics were selected because they contributed to helping the healthcare provider understand the challenges noted for this population. This contributes significantly to the challenge’s healthcare providers face in caring for Type II diabetic patients.
Summary
The prevalence of Type II diabetes is affecting one in ten Americans (Ahmed et al., 2018). The disease is expected to continue rising higher by 2030 (Lin et al., 2018). Medication adherence for Type II diabetic home health patients is critical in decreasing the poor patient outcomes associated with the disease. Medication adherence with Type II diabetic patients remains a challenge for many healthcare professionals. Education for the healthcare providers and the patients can make a difference in this population’s lives.
Chapter 2 discussed reintroduced the topic and presented the theoretical framework and change model to guide the project. Other sections include the literature review related to patient-related, socio-economic, and health system factors.
A summary of the chapter was provided with an introductory sentence that previews Chapter 3.
Chapter 3 reinstated the selected topic. Other segments presented the project’s methodology, design, population, and sample selection. A description of the MAP resources and the electronic medical record (EPIC) are provided. The validity and reliability of the instrument was demonstrated along with the data collection and analysis procedures, potential bias. The last few sections discuss the ethical considerations, limitations, and a summary that leads into Chapter 4.
Chapter 3: Methodology
Medication adherence is a critical component in minimizing adverse patient-related outcomes among individuals with chronic illnesses (Type II diabetic patients). Ahmed et al. (2018) stated medication adherence for this quality improvement project refers to the extent to which a home healthcare patient can correctly take their medications in the absence of their health care providers. Medication adherence requires an individual to adhere and comply with all the medical instructions provided (Bellou et al., 2018).
Type II diabetes affects one in ten Americans (Ahmed et al., 2018). Furthermore, due to the increase in older-aged adults and the rising prevalence of the disease, it is expected to elevate higher by 2030 (Lin et al., 2018). The home health services continue to grow, hence illuminating the need for education regarding medication adherence. Roughly 45% of the patients cannot maintain their glucose levels (Polonsky & Henry, 2016). Poor medication adherence is associated with higher financial obligations for the patient, hospital, and insurance companies. Polonsky and Henry (2016) emphasized the adverse outcomes cause frequent hospitalizations and lower quality of life for patients and their families.
Chapter 3 reestablished the selected topic. Other sections of the chapter include the statement of the problem, clinical question, project methodology (quantitative), and project design (quasi-experimental). The chapter described the population and sample selection, the instrumentation (MAP resources), validity, reliability, and data collection procedures. The last few segments included the data analysis procedures, potential bias, ethical considerations, limitations, and a summary
Statement of the Problem
It is not known if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas. The targeted population is Type II diabetic patients in an urban healthcare facility in urban Texas. In collaboration with the stakeholders, it was noted that medication adherence among the patients was lacking. The information will be obtained from the electronic medical records (Cradle Solutions), which showed that ten percent of the diabetic patients were not adhering to their medication regimen.
Factors that influence poor medication adherence are numerous and include poor knowledge or awareness of the disease, medication costs, and lack of understanding of the medication treatment, which reinforced the project’s purpose (Heath, 2019; Sharma et al., 2020). Healthcare providers play an essential role in assisting patients with medication adherence. The primary investigator will introduce a standardized strategy for the facility’s healthcare providers to assess the patients’ medication adherence using MAP resources (Starr & Sacks, 2010).
Using a standardized method will help to solve the facility’s problem with medication adherence rates. It will also help improve the healthcare providers’ knowledge levels and awareness regarding the barriers associated with medication adherence. Complying with the new guidelines developed by the Centers for Disease Control and Prevention (2020) could help patients control their glucose levels, minimize healthcare costs, hospitalizations, and potential infections.
Clinical Question
The clinical question that will direct the primary investigator’s answer is: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks? The independent variable is the MAP resources. The dependent variables are the medication adherence rates. The data collection process will not begin before approval is received by Grand Canyon University IRB. The primary investigator developed informational flyers for the nurses to give their patients during their home health visits. The staff answered questions related to the project regarding risks, benefits, and purpose while instructing that participation is voluntary. A convenience sample will be used because of the easy access to the participants for the primary investigator.
The primary investigator will collect data retrospectively (four weeks) prior to implementation of the project. The data will be collected from the electronic medical records using Cradle Solutions for the impact of the MAP resources and medication adherence rates. In the first week, the primary investigator will educate the staff to use the MAP resources. Once the staff begins to implement the tool, post-medication rates will be assessed post-four weeks. The data will be inserted into a Microsoft Excel 2016 codebook developed by the primary investigator. It will then be exported into SPSS-27 and analyzed by using a chi-square test. The five-item demographic survey will collect the descriptive statistics of the home healthcare patients. The questionnaire comprises (age, gender, years with Type II diabetes, oral or insulin, and education).
Project Methodology
A quantitative methodology will be used for this quality improvement project. According to Creswell and Creswell (2018), a quantitative methodology is appropriate for projects that use data in its numerical form. For this project, the data will be presented using figures, graphs, charts, and tables. This will allow the readers to compare the medication adherence rates pre-implementation and post-implementation of the project.
A qualitative methodology was considered but not used, although they are beneficial. It explores the patient’s experiences, perspectives, and lived experiences regarding a phenomenon (Creswell & Creswell, 2018). Data collected using this methodology is semi-structured interviews, one-on-one interviews, and focus groups (Creswell & Creswell, 2018). The primary investigator aims not to understand the home health participants’ emotions, behaviors, or experiences related to medication adherence.
A quantitative methodology supports the project because it will permit the primary investigator to remain objective in providing the project’s findings (Leedy & Ormord, 2020). Furthermore, the methodology allows the primary investigator to summarize the data that could support generalizations for a larger or similar population. The methodology is less costly with easy replication for future quality improvement projects to obtain the same results.
Project Design
Quasi-experimental designs are utilized to compare data before and post-implementation of an intervention (Price et al., 2017). The design is frequently used in a controlled environment. For this project, the design was chosen because it is cost-effective versus an experimental project design (Schweizer et al., 2016). A quasi-experimental design allows the primary investigator to analyze the impact of MAP resources on medication adherence rates.
An experimental design was not considered because the primary investigator is not seeking to conduct the project under a controlled environment (Leedy & Ormrod, 2014). This design observes the independent variable (MAP resources) and the dependent variable (medication nonadherence rates). It is a simple test that is performed in various physical and natural settings (Leedy & Ormrod, 2014).
A correlational design was considered but not appropriate for the project because the primary investigator is not seeking to understand the relationships occurring among the variables (Creswell & Creswell, 2018). This design is typically descriptive relying on a hypothesis (Leedy & Ormord, 2014). The primary investigator will not seek the relationships between the independent variable (MAP resources and education intervention) and the dependent variable (medication adherence rates).
The targeted population are home health patients ages 35 to 64 years old. The selected site serves approximately 100 patients annually. The inclusion criteria are males and females diagnosed with Type II diabetes, oral medication or insulin, and home health patients. The exclusion criteria are individuals with language or cognitive deficits and diagnosed with Type I diabetes. Five registered nurses will help to implement the project. They are individuals who work full-time and have been employed over a year.
The data collection process will begin once approved by Grand Canyon University IRB. Recruitment will occur from informational flyers given to the patients during their home health visits with the providers. The nurses will answer any questions regarding the project’s risks, benefits, and purpose and be instructed that the participation is voluntary. The primary investigator will use a convenience sample because of the access to the participants.
Data will be collected retrospectively four weeks prior to project implementation from the electronic medical records (Cradle Solutions) (medication adherence rates). In the last portion of the first week, the primary investigator will educate the healthcare providers regarding using the MAP resources. The staff will begin implementing the tool, and the post medication adherence rates will be assessed four weeks post-implementation. The primary investigator will document the data in a Microsoft Excel 2016 codebook developed by the primary investigator. Once completed, it will be exported into the SPSS-27 and analyzed using a chi-square analysis. A five-item demographic questionnaire will be used for descriptive statistics of the population. The survey will include (age, gender, years with Type II diabetes, oral or insulin, and education).
Pre-intervention and post-intervention data will be obtained using the MAP resources. The questions that will be analyzed are: (1) “Have you experienced any increase in thirst?” (2) “How often do you urinate?” (3) “Do you often feel fatigued even when doing little tasks?” and (4) “Do you experience blurred vision?” In addition to the questions, home healthcare providers will ask the patient “Are you taking your medications?” Any information attained from the question and due to probing, observation of patient’s medications, and patient-related medication adherence will be documented in the project site’s EHR. The data will be analyzed using an independent t-test to determine the statistical significance.
The electronic medical record that will be used to collect data is Cradle Solutions a software for home health companies. It serves the specialized needs of home health care providers that give a web-based point-of-contact information entry and management (Cradle Solutions, 2021). It is compliant with HIPPA security features for billing, reporting, administrating, and managing patient information (Cradle Solutions, 2021). Liss et al. (2020) emphasized that electronic health records can be used for quality measures as a snapshot or calendar year. The primary investigator will obtain the measurement of the medication adherence rates and align it with new protocols and guidelines developed by the facility.
Population and Sample Selection
The specific population that will be addressed are home health patients ages 35 to 64 years old. The selected site serves approximately 100 patients annually, and 30 patients are diagnosed with Type II diabetes. A G* power analysis was conducted using version 3.1.9.2, the alpha measure of 0.05, effect size of 0.5, power of 80% to calculate the lowest sample size needed, which was (n=34). The inclusion criteria are males and females diagnosed with Type II diabetes, oral medication or insulin, and home health patients. The exclusion criteria are individuals with language or cognitive deficits and diagnosed with Type I diabetes. Five staff nurses will help to implement the quality improvement project. They are individuals who are registered nurses, work full-time, and have been employed with the facility over one year, and have access to Cradle Solutions EHR system.
The geographical location of the project is in a metropolitan area of Houston, Texas. The County statistics show that approximately 17.6% of the population have Type II diabetes (Houston, 2021). During 2016-2018, 20.2% of the population was hospitalized due to diabetic complications (Houston, 2021). There are over 700 000 Medicare participants in a three-county radius, which is higher than the national average (Understanding Houston, 2021). Data further showed that preventable hospital stays occur in older adults 65 and above (Understanding Houston, 2021). This suggested a trend to overuse the hospitals as a primary source of care (Understanding Houston, 2021).
The informed consent process will consist of the nurses explaining the project’s purpose, risks, and benefits. The participants will be informed that participation is voluntary and can withdraw without repercussions to their professional or personal lives. No compensation will be provided to the participants in the project. The participants’ identities and privacy will be protected throughout the project by the primary investigator not using their names or other identifiable information. The participants will be assigned a random number for security purposes. The primary investigator will abide by the University’s IRB guidelines and the Belmont Report (justice, respect for persons, and beneficence) (U.S. Department of Health & Human Services, 2018).
Hard copies of the data will be stored on a flash drive and kept in the primary investigator’s home office (in a locked file cabinet). The data files will be kept on the primary investigator’s laptop, which is digitally protected. The data will be stored for three years according to Grand Canyon University procedures (June 2023). Once the project is completed and the requirements met, the primary investigator will destroy the information using Iron Mountain shredding services and software ERASER on the laptop.
Instrumentation or Sources of Data
The instruments to be used in the project are the MAP Toolkit and Training Guide resources, which includes (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list. The questions to ask poster encourages patients to ask the provider about their medication. For this project, the nurses will review the medications with the Type II diabetic patients. Six questions will be asked (1) Why do I need to take this medicine, (2) Is there a less expensive medicine that would work as well, (3) What are the side-effects and how can I deal with them, (4) Can I stop taking any of my medicines, (5) Is it okay to take my medicine with over the counter drugs, herbs, or vitamins, and (6) How can I remember to take my medicine?
The second section, the Adherence assessment pad, explores answers the barriers to the patient’s maintaining medication adherence. The questions include (1) makes me feel sick, (2) I cannot remember, (3) too many pills, (4) costs, (5) nothing, and (6) other.
The third component is my medication list. It provides detailed information in chart form, which is discussed between the patient and the healthcare provider. It comprises of (1) name and doses of my medicine, (2) this medication is for my diabetes, (3) when do I take and how much (options include: morning, noon, evening, or bedtime), and (4) I will remember to take my medicine (a blank that will be filled in).
The source of data for this project is the electronic medical record. The facility uses Cradle Solutions, software for home health companies. It serves the specialized needs of home health care providers that give a web-based point-of-contact information entry and management (Cradle Solution, 2021). It is compliant with HIPPA security features for billing, reporting, administrating, and managing patient information (Cradle Solution, 2021). Liss et al. (2020) emphasized that electronic health records can be used for quality measures as a snapshot or calendar year. The primary investigator will measure the medication adherence rates and align them with new protocols and guidelines developed by the facility.
Validity
Validity conveys how accurately a method is measured (Creswell & Creswell, 2017). If the method measures what it should and the findings correspond closely, it is considered valid. There are four types of validity are constructs, content, face, and criterion (Creswell & Creswell, 2018). For this project, construct and face validity is applicable to the instrument. A group of professionals developed the tool, which consisted of physicians, pharmacists, nurses, and medical assistants (Starr & Sacks, 2010). It was based on their years of work experience in their perspective fields. The toolkit’s improvements were adjusted and in alignment with the CDC and other healthcare governing bodies.
Reliability
Reliability refers to the consistency of instrument measuring something (Creswell & Creswell, 2018). If the same results occur regularly by using the same procedures under the same conditions, the measurement is reliable (Creswell & Creswell, 2018). For this project, the MAP toolkit reliability was confirmed by inter-rater reliability (Starr & Sacks, 2010). The observers noted the same results associated with using the instrument, which aligned with the literature findings regarding collecting data for medication adherence rates.
A study conducted by Harrell (2017), occurred over 90 days, where weekly medication adherence rates were assessed. Seventy-eight percent of the patients prior to the study’s implementation did not adhere to their prescribed medication regimen. Post three-months of the project, 56% of the patients improved regarding medication adherence rates. For this project, test-rest reliability will be noted, because the nurses will be using the MAP toolkit over time (two different times) (Creswell & Creswell, 2018).
Data Collection Procedures
The data collection process will begin once approved by Grand Canyon University IRB. Recruitment will occur from informational flyers given to the patients during their home health visits with the providers. The nurses will answer any questions regarding the project’s risks, benefits, and purpose and be instructed that the participation is voluntary. The primary investigator will use a convenience sample because of the accessibility to the participants. The goal is to achieve approximately 34 participants.
Five home healthcare nurses will be trained to implement the project. Training sessions will be offered twice so that the nurses working on the weekends can participate. The primary investigator will offer two 60-minute Zoom training sessions. During these sessions, the primary investigator will provide information regarding using the MAP toolkit and resources. A 10-minute PowerPoint presentation will be included during the 45-minute training session, along with a MAP toolkit binder for each participant.
The participants will be educated by the nurses regarding the purpose of the informed consent and its contents. The participants will be informed regarding the benefits, risks (minimal), and purpose of the project. The potential risk (minimal) is related to emotional circumstances such as the stigma of the disease, anxiety, or depression. The participants will be instructed that if they felt increased anxiety, depression, or embarrassment during the project, they can withdraw without any reason, or the project will end for them immediately. They will be directed to a primary care physician or professional who will further help them. There is a slight chance that the hard copies (demographic and MAP surveys could be lost. To ensure that this does not occur, the primary investigator will use a digitally password-protected laptop to protect their privacy. The participants will be informed that the data will be kept in a password-protected folder on the laptop accessible only to the primary investigator. The nurses will collect the signed informed consents and return them to the primary investigator after their visits. The primary investigator will collect them daily during the first week of the project.
The participants’ rights and well-being will be ensured by the primary investigator upholding the Belmont ‘s report principles a) justice, b) respect for a person, and c) beneficence. Furthermore, the primary investigator will adhere to Grand Canyon University’s IRB guidelines. The primary investigator will uphold justice by delivering fair treatment to all the participants. The participants will not exploit this population or manipulate their situation or disease. Respect for persons will be shown by treating the participants as autonomous individuals. All the participants will be treated using ethical conduct by respecting their answers and decision, thus protecting them from harm. Hence, this allows the primary investigator to abide by the beneficence guidelines.
The primary investigator will work with the information technology department, who will ensure that the three MAP resources are inserted into the Cradle Solution documentation software. During week one, the nurses will provide the patients with informed consent, answer questions related to the project, a five-item demographic survey, and a pre-MAP survey. The second to fourth week, the nurses will examine the patient’s medication list and adherence (ten minutes). Each week the nurses will record the medication adherence information in the patient’s electronic medical record.
Week four, all input by the nursing staff will be completed. If the patient expresses, they have not adhered to the medication regimen; it will be recorded in the system. Post scores will be collected by the primary investigator regarding the medication adherence rates. The results will be entered into the Microsoft Excel 2016 codebook developed by the primary investigator. The data will be exported into SPSS-27 be analyzed using a chi-square test.
The procedures adopted to maintain data security are the hard copies of the demographic and MAP surveys will be kept in a locked file cabinet in the primary investigator’s home, not accessible to anyone else. The Microsoft Excel 2016 codebook and SPSS results will be saved on the primary investigator’s digitally password-protected laptop. To ensure additional security, the primary investigator will install an encryption program (TrueCrypt) to prevent accidental access to the information. Per Grand Canyon University IRB guidelines, the data will be kept for three years (June 2024). At that time, the primary investigator will erase the information from the laptop using ERASER (computer software) and Iron Mountain shredding services to eliminate the data correctly.
Data Analysis Procedures
This quality improvement project is being conducted to address the issue noted of medication adherence among Type II diabetic patients in the home healthcare population. The information will be obtained from the electronic medical records (Cradle Solutions), which showed that ten percent of the diabetic patients were not adhering to their medication regimen. Data for the comparative and implementation patients will collected at the culmination of the four-week implementation period from the EMR and will be given to the primary investigator in a PDF report. The dependent variable (medication adherence rate) will be manually entered into a secure Microsoft Excel file (2016) for the comparative and implementation patients. All data collected will be in numerical values. Each patient will be given a unique identifier to organized data according to everyone.
The medication adherence rate is a nominal-level variable with two mutually exclusive options (adherent or non-adherent) for each patient and will be analyzed using a chi-square test as that is the most appropriate test for comparing two independent groups on a dependent categorical variable (Schober & Vetter, 2019). The patient groups are independent as patients in the comparative group (four weeks before implementation) were not matched for the implementation group. The project analysis will use a chi-square test, which is aligned to the project design as the test compares group differences when the dependent variable is measured at a nominal/categorical level (Schober & Vetter, 2019).
The clinical question that is guiding the project is: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks?
To address this question, the medication adherence rate for 30-days before and 30-days after the implementation of MAP resources will be compared. To answer the clinical question, a chi-square test will be conducted. The chi-square test will allow for a comparison of the medication adherence rate for patients 30 days before and 30 days after the implementation, thereby answering the clinical question. The level of significance will be set to .05, indicating a p-value of less than .05 would reveal statistical significance.
Raw data will be organized using a Microsoft Excel (2016) file with a unique identifier for each patient. Data on medication adherence rate for each patient in the 30-day comparative period and 30-day implementation period will be collected from quality department in a report and then manually entered into the Excel file as a categorical variable with numeric codes represented as 0 for non-adherent and 1 for adherent. After data entry in Microsoft Excel is completed, data will be exported to IBM SPSS version 27. To ensure data will be prepared for analysis, a preliminary analysis of all variables will be conducted to determine if the dataset has missing data or inaccurate entries. This will include frequency counts for variables to check for missing data and values outside of the possible range of 0 to 1 for the medication adherence rates.
Potential Bias and Mitigation
The internal validity is related to the extent the primary investigator can be confident that the cause-and-effect relationship found cannot be explained by other factors (Leedy & Ormrod, 2020). This makes the project’s conclusions credible and trustworthy (Leedy & Ormrod, 2020). Two factors that affect the internal validity of the project are the participants’ maturation and the instrument (MAP resources). The participants’ maturation could be affected by their recollection, poor memory, or follow-thru. The outcomes of the project would vary over time, affecting the results. One way to decrease this occurrence is to have the participant take the survey during the best time for them and productivity. For example, if an individual is a morning person (have them take the survey in the morning versus the afternoon or late evening). The second factor is the instrumentation process (MAP resources). The primary investigator will educate the nurses regarding the purpose of providing the participants the same time (30 minutes) to ensure the same measures are used during the pre-implementation and post-implementation phases. For example, the pre-implementation test cannot be given for 15 minutes, while the post-implementation test is given for 30 minutes.
Bias is described as any tendency that prevents impartial consideration of a clinical question (Pannucci & Wilkins, 2010). It can occur at any stage of the research, study design, data collection or analysis, and publication (Pannucci & Wilkins, 2010). One potential bias is related to the selection process. The primary investigator will avoid bias by selecting individuals and using strict inclusion and exclusion criteria previously developed for the project. The participants will originate from the specified population.
The second bias is related to recall bias, a systematic error that occurs when the participants do not remember prior events or experiences accurately (Creswell & Creswell, 2018). The project could be affected because the participants are self-reporting to the nurses using the MAP resources. To avoid this type of bias, the nurses will be trained to carefully train each participant using the same method, which will prevent influencing their responses (Creswell & Creswell, 2018).
Ethical Considerations
The primary investigator will abide by the University’s IRB and Belmont report guidelines while conducting the project. The three principles to be followed are respect for participants, justice, and beneficence (Belmont, 1979). The primary investigator and the nurses will show the participants respect by listening, validating their feelings, and answering the questions regarding the education or project. The primary investigator will occasionally monitor the nurse’s interaction with the participants throughout the project. The participants will be instructed that there are no repercussions to their personal or professional lives upon withdrawing from the project. The primary investigator and the nurses will always protect the participants’ privacy and confidentiality by not discussing the project, the participants, or its findings with anyone not involved in the project or without the participant’s permission.
Beneficence will be shown to the participants by informing the participants that the primary investigator or the nurses will stop the questioning immediately if they feel emotionally harmed. A psychological resource will be provided to participants who feel affected by the questions or project. All participants will be informed of the risks, benefits, and minimal harm that can occur to them, such as loss of data, social or emotional conflict with family and friends, and anxiety or depression.
The Belmont Report (1979) states justice is the “distribution of the burden.” During this project, it is possible that the participants could perceive unwanted stigma from the colleagues, family members, or friends. Each participant will be treated uniformly following their wishes, so it will not affect the project’s findings. There could be a potential conflict of interest with the project since the primary investigator works at the facility. To minimize the conflict, the primary investigator will not interact with the participants.
Limitations
The limitations of the project are self-reporting of medication adherence by the patients. To minimize this limitation, the primary investigator has validated the self-reporting instrument (MAP resources) before utilizing it for data collection (Althubaiti, 2016). Furthermore, the patient’s self-reporting will be compared to their fasting blood glucose levels, medical records, or reports from family and friends (Althubaiti, 2016).
The second limitation is the healthcare organization being impacted by the COVID-19 pandemic. The new COVID-19 guidelines have affected the current healthcare delivery model. The pandemic has caused the primary investigator to redirect resources and halt in-person training sessions for the nurses. The recruitment process has been limited to Zoom meetings and telephone calls. The third limitation is the location of the project and its setting. The project findings cannot be generalized to other home healthcare agencies of similar populations. The fourth limitation is the time to conduct the project (four weeks). A longer timeframe would help the primary investigator analyze the site’s challenges, trends, and sustainability.
Summary
Medication adherence among Type II diabetic home health patients remains a critical factor in their quality of life. The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks. A quasi-experimental design will allow the primary investigator to evaluate the impact of the MAP resources and educational intervention on the dependent variable (medication adherence rates). The medication adherence rates, and weekly glucose levels will be collected before and after project implementation (four weeks). Data will be collected by the primary investigator and stored on the digitally protected laptop and hard copies will be locked in a secured file cabinet at the residence. Chapter 4 provided a summary of the topic, along with descriptive data of the participants. Other sections consisted of the data analysis procedure, project findings, and summary.
Chapter 4: Data Analysis and Results
It is not known if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas. The stakeholders have cited that medication adherence among diabetic patients is lacking. According to data obtained from the site’s electronic health record (EHR), home healthcare providers documented that ten percent of diabetic home healthcare patients are not adhering to their medication regimens.
A quantitative quasi-experimental project will be conducted to address the clinical question: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks? Data on medication adherence will be collected for the comparative group and compared to an implementation patient group.
Chapter 4 presented the descriptive data for the patient sample. The data analysis procedures are outlined, and the results are presented using narrative and chart format. The chapter concluded with a summary of the findings regarding the clinical question and the significance of the data analysis.
Descriptive Data
The quality improvement project will use a quantitative, quasi-experimental approach for data collection. The targeted population for the project is from a home health care facility in urban Texas. The primary investigator used a G* power version 3.1.9.7, effect size 0.3, power 0.95, and df 0.5 to calculate the sample size needed for the project (N=220) for a significant level. The participants will complete a five-item demographic questionnaire comprised of (age, gender, education level, type of medication (oral or insulin), years as Type II diabetic).
A total of XX patients will be included in the project, n= XX in the comparative group and n= XX in the implementation group. The descriptive data will be displayed in Table 1. It shows X males (xx.x%) and x females (xx.x%) in the comparative group and x males (xx.x%) and x females (xx.x%) in the implementation group. The mean age of the participants was xx.xx (SD= xx.xx) with a range from x-to-x years of age for the comparative group and the mean age of the implementation group with a range from x to x years of age (SD = xx.xx). The educational level of the comparative and implementation patients x (xx.xx%) graduated from high school, x (x.xx%), did not graduate from high school, x (x.xx%), had some college but did not finish x (x.xx%), Associate degree, x (x.xx%), Bachelor’s degree, x (x.xx%), and higher-level doctorate, PhD, MD, or JD. A total of x participants (xx%) took insulin and x (x.xx%) are on oral medications.
Table 1
Descriptive Data for Comparative and Implementation Patients (N = XX)
Variable
Comparative
(n = xx)
Implementation
(n = xx)
Gender
Male
X
x.xx
X
x.xx
Female
X
x.xx
X
x.xx
Did not Graduate High School
Graduate High School
X
x.xx
X
x.xx
Some College
X
x.xx
X
x.xx
Associate Degree
X
x.xx
X
x.xx
Bachelor’s degree
X
x.xx
X
x.xx
Doctorate
X
x.xx
X
x.xx
Oral or Insulin
Oral
X
x.xx
X
x.xx
Insulin
x
x.xx
x
x.xx
M
SD
M
SD
Age
xx.xx
xx.xx
xx.xx
xx.xx
Years with Type II Diabetes
xx.xx
xx.xx
xx.xx
xx.xx
Data Analysis Procedures
The data analysis procedures will include evaluating de-identified data of medication adherence rates four weeks prior and four weeks post-implementation of the project. The primary investigator will abstract a PDF report of the medication adherence rates for both the comparative and implementation groups. Raw data will be input into a Microsoft Excel (2016) file (codebook). The independent variable is the MAP resource implementation (categorical), and the dependent variable is the medication adherence rates (yes/no). After data entry in Microsoft Excel is completed, data will be exported to IBM SPSS version 27.
To ensure data will be prepared for analysis, a preliminary analysis of all variables was conducted to determine if the dataset has missing data or inaccurate entries. If data is missing, it will be assigned a -99. If 50% of the questionnaire is not completed, the data will not be used in the project. This included frequency counts for variables to check for missing data and values outside of the possible range of 0= no medication adherence and 1= medication adherence. A chi-square test will be conducted, and the results discussed to answer the clinical question. The chi-square test will compare the association between two independent categorical variables (Schober & Vetter, 2019), which will compare the medication adherence rate for patients 30 days before and 30 days after the implementation, thereby answering the clinical question. The significance level will be set to .05, indicating a p-value of less than .05 would reveal statistical significance.
The patient outcome-dependent variable will be collected from the electronic medical records (Cradle Solutions) within the project site. Electronic medical records are considered a reliable and valid source for data collection. A study conducted by McGinnis et al. (2009) examined EMR and written records. The results demonstrated the EMR-based data validity was shown to be moderate to excellent, with Pearson r correlations ranging from .875 to .99 for EMR and documentation records (McGinnis et al., 2009). Electronic medical records are considered a reliable source of data, as emphasized by Goulet et al. (2007), found strong agreement (Kappa between .86 and .99) and high sensitivity and specificity (≥.95) for quality measures based on electronically abstracted structured data compared with manual review.
One identified potential error is related to the data is coverage error, which results in a difference between the sample size and the population measured (Qualtrics, 2020). To reduce the chances of this occurring, the primary investigator will utilize a recruitment method accessible to all potential participants (such as word of mouth, text messages, and emails). The random error related to the quality improvement project is the measurements (Leedy & Ormrod, 2020). The error could occur after the primary investigator collects the data while being processed (Leedy & Ormrod, 2020). To minimize the chances of errors, the primary investigator has hired a statistician to interpret the data patterns using statistical tests and perform data cleaning (Leedy & Ormrod, 2020).
Results
A chi-square test will be conducted to answer the clinical question: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks? The results are displayed in Table 2. There was an increase in medication adherence from the comparative (n = X, XX.X%) to the implementation group (n = X, XX.X%), X2 (1, N = xx) = x.xx, p =. xxx. The p-value was [less] than .05, which indicates that the increase in medication adherence was statistically significant.
Table 2
Medication Adherence Rates in the Comparative and Implementation Groups
Variable
Comparative
(n = xx)
Implementation
(n = xx)
X2
p-value
n
%
n
%
Medication Adherence
x
xx.x
x
xx.x
x.xx
.xxx
The results of the chi-square test analysis support the implementation of MAP resources to improve medication adherence as compared to current practice among Type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization. The rate increases in the implementation group and the p-value is less than .05 indicating (statistical or no statistical significance). Given these findings, the data analysis supports statistical and clinical significance of implementation of the MAP resources for improving medication adherence rates.
Summary
The purpose of this quantitative quasi-experimental project was to evaluate the impact of the Medication Adherence Project (MAP) resources on patient medication adherence rates for home health Type II diabetics. Data on medication adherence will be collected from the site’s EMR for four weeks before the SBAR intervention and for four weeks after the intervention. A total of XX patients were included in the study (n = xx in the comparative group and n = xx in the implementation group). The medication adherence rate was compared between the comparative and implementation patient groups using a chi-square test to address the project’s clinical question. There was an increased in medication errors from the comparative (n = X, XX.X%) to the implementation group (n = X, XX.X%), X2 (1, N = xx) = x.xx, p =. xxx. These results (showed or not showed) statistically significant increase in medication adherence after the MAP resource intervention compared to the comparative group and support the use of the MAP to improve medication adherence for adult home health patients with Type II diabetes.
Chapter 5 offered a summation of the results and conclusions based on the findings showing increased medication adherence after the MAP resource implementation. The theoretical and practical implications of the results will be summarized. The chapter concluded with recommendations for future projects, including adult home health patients with Type II diabetes, concerning the project findings that support MAP resources to improve medication adherence rates.
Chapter 5: Summary, Conclusions, and Recommendations
Diabetes impacts approximately one in ten Americans (Centers for Disease Control and Prevention, 2020). The prevalence of the disease continues to rise and is expected to grow by 0.3% annually until 2030 (Lin et al., 2018). This particularly troublesome for Type II home healthcare patients diagnosed with the disease. Polonsky and Henry (2016) emphasized that roughly 45% of this population fail in sustaining a normal glucose level. Poor medication adherence is associated with increased morbidity and mortality rates, finances, hospital readmissions, and diminished quality of life (Polonsky & Henry, 2016).
This quality improvement project was developed to address a standardized method for healthcare providers to assess their patients’ medication adherence. A quantitative, quasi-experimental design contributed to the participants promoting self-reliance and increased knowledge levels in maintaining healthier glucose levels. Furthermore, the project improved the practitioner’s awareness of the need to evaluate their patient regarding medication adherence frequently. The project provided current information related to Type II diabetic home health patients and medication adherence, which validated other studies such as Heath (2019) and Sharma et al. (2020).
Chapter 5 summarized the project related to Type II diabetic home health patients and medication adherence. Other segments comprised of the summary of the project’s findings and conclusions. The theoretical (Orem’s self-care deficit theory and Roger’s diffusion of innovation model), practical, and future implications were discussed. The last section consisted of recommendations for future projects and clinical practices.
Summary of the Project
The clinical question that directed the project was: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks? A chi-square test was conducted for a comparison of the medication adherence rates for the patients 30 days prior and 30 days post-implementation. A level of significance was set to .05, which indicated a p-value of less than.05 would reveal statistical or non-statistical significance.
A convenience sampling was used to recruit N=XX participants for the comparative group and N=XX for the implementation group. The nurses (XX) were educated regarding the use of the MAP resources. A retrospective chart audit (n=XX) was done to evaluate the medication adherence rates before the project implementation. The chi-square test was utilized to determine the variations among the two groups for statistical difference.
Summary of Findings and Conclusion
A sample size of N=XX participants was compared utilizing a chi-square test with the significance level at p <.05. Two groups were compared comparative (n=XX) and implementation (n=XX). The number of medication adherence rates were evaluated four weeks pre-implementation and post-implementation of the project. The clinical question that was answered using the chi-square analysis was: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients of a home healthcare agency in urban Texas over four weeks? There was an increase or decrease in medication errors from the comparative group (n= XX%) to the implementation (n=XX%), X2 [1, N=XX] = X.XXX, p= X. XX. These results (showed or not showed) statistical significance increase in medication adherence rates after the MAP resource intervention compared to the comparative group. It demonstrated the need for consistent use and the importance of healthcare providers to evaluate their diabetic patients frequently for medication adherence with each home health visit.
Implications
Nursing is a practice discipline, therefore when a quality improvement project is conducted it should focus on issues that directly affected the nursing practice (Polit & Beck, 2018). In this project, the emphasis is on patient care and offering the potential clinical consequences that impacted the findings (Polit & Beck, 2018). The theoretical, practical, and future implications are based on the data from the project and the literature preceding it.
Theoretical Implications
Orem’s self-care deficit theory was selected because it aligned appropriately with the clinical question that directed the project. The theory assisted the primary investigator and the staff nurses to implement the project solely based on the self-care requirements of the home health Type II diabetic patients. The theory helped build a foundation for the project by integrating strategies that aided the participants to understand their disease and sustain self-care management. Orem’s self-care deficit theory is comprised of three components: theory of self-care, self-care deficit, and the nursing system (RenpenningcN et al., 2003). The services designed were focused on the a) abilities and actions related to medication adherence of the participant, b) staff nurses coordinating resources for the diabetic patients, monitoring the disease, assessing the patient’s medication adherence using a patient-centered approach (Orem, 1985).
The strength of Orem’s self-care deficit theory allowed the primary investigator to provide the nurses an increased awareness in understanding their patients while addressing barriers that could impact them from understanding and maintaining medication adherence. In Chapter 2, the literature review examined how patients could effectively manage medication adherence while contributing to previous literature that utilized the theory on Type II diabetic patients (Borji et al., 2017; Ebrahimi, 2015; Ghafourifard & Shahbaz et al., 2016). One strength noted in the project was the increased curiosity and desire to learn exhibited by the patients. This was related to the nursing staff using a patient-centered approach in addressing their medication adherence. The patients verbalized that they appreciated the extra time that the nurses spent with them regarding how to maneuver the chronic disease.
The weakness of the project was teaching the nurses to become familiar with Orem’s self-care deficit theory, which was the foundation for the project. Orem’s theory can be utilized and implemented in other projects related to Type II diabetic home healthcare patients, since the findings cannot be generalized. A second weakness noted was the time restrictions to conduct the project (four weeks). A longer time frame would have allowed the primary investigator to observe the nurses and patient interactions, trends, and analyze obstacles that prevented an individual from maintaining medication adherence procedures.
Practical Implications
One practical implication included the agency evaluating and developing medication adherence guideline patient-specific using the MAP resources and Orem’s theory. Many of the nurses suggested that one of the monthly home visits should be dedicated solely to the patient’s current medication list and medication adherence. Another suggestion was to incorporate a text-messaging component from the primary nurse via the patient’s cell phone to remind them to take their medications. The last practical implication was related to the nursing staff not confronting the patient regarding their medication adherence status; instead, develop interventions tailored to their needs Sansbury et al., 2014). Using strategies such as goal setting, behavior contracts, or having an accountability partner could decrease the challenges in medication adherence (Sansbury et al., 2014).
Future Implications
One future implication related to the project is for other quality improvement projects to examine medication adherence rates among teenagers in the home healthcare settings. This should utilize medication adherence strategies specific to their age group. A second implication is related to diabetic medications, home health patients should be encouraged to participate in phase three trials for new diabetic products that would enhance medication adherence. These products are becoming available and provided to the participants at monthly or longer intervals. This would address some of the short-term barriers to sustaining medication adherence (Polonsky & Henry, 2016).
The second future implication is for the nurses to implement strategies for medication adherence based on the participant’s demographic characteristics (race, gender, age, personal preferences, culture, and social determinants) (Williams et al., 2014). The factors that affect the patient should be identified and addressed as they appear to allow greater control of the disease (Williams et al., 2014). A systems approach towards medication adherence would help achieve higher effectiveness, adherence, healthcare outcomes, and decrease healthcare costs (Williams et al., 2014).
Recommendations
Recommendations provide a firm foundation for the nursing workforce by ensuring they are adequately educated and prepared to implement the practice fully (Institute of Medicine, 2011). They are needed to meet their patients’ future health care needs and lead as change agents within the healthcare arena (Institute of Medicine, 2011). For this home health agency implementing and sustaining the recommendations will take time, finances, resources, and commitment from the staff. In the following few paragraphs, the primary investigator addressed recommendations for future projects and clinical practices.
Recommendations for Future Projects
The first recommendation is for those projects to utilize a standardized assessment strategy to evaluate their patient’s medication adherence behaviors and practices. Inaccurate medical records and inadequate medication assessment result in poor healthcare outcomes and minimum patient engagement in the decision-making. Educating the diabetic patients regarding the need for medication adherence would help them remain compliant. The best determinant for medication adherence is for patients to demonstrate via their behavior the change.
The second recommendation is to conduct the project use a larger population size focused on the caregivers of diabetic patients. Focusing the attention on this sector would emphasize the emotional and family support to help the patient remain compliant. Since many Type 2 diabetic patients have friends, family, or caregivers in their circle, it would be significant to include them in the discussion and the importance of medication adherence. This would allow a greater understanding of the subject and generalization of the project findings on this populace.
The next steps in moving this type of project forward are for the home health agency to implement and sustain the MAP resources for maximum impact on the patients. The continued use of the assess tool would help decrease frequent hospitalizations, financial expenses, and increased quality of health. Adopting the project should be specific to the home health agency’s specific needs and demands, which would enhance the project’s sustainability.
Recommendations for Practice
One recommendation for current practices is for home health nurses to offer other options to help their patients remain medication adherence compliant. Kirkman et al. (2015) suggested via their project findings that encouraging patients to use mail-order pharmacies increases the patient’s chance for medication adherence. An analysis conducted by Medicare Part D showed an increase in medication adherence by diabetic patients (Kirkman et al., 2015). Another suggestion is the use of a medication events monitoring system to evaluate the patient’s medication adherence. The device would be incorporated into the patient’s packaging of the prescription medication (Lam & Fresco, 2015). It records the dosing events and stores the information with audiovisual reminders. The last option is to receive automated electronic reminders such as (text messages) using REMIND software from the visiting home health nurse.
The second recommendation is for future clinic practices to establish and educate the nursing staff on cultural competency care. This type of nurse-patient relationship allows a stronger connection with the patient who feels comfortable expressing the concerns and knowledge deficits because of a non-judgmental environment that helps them maintain medication adherence behaviors. Effective communication restores and improves patients’ capability to cope with Type II diabetes and improve their patient outcomes (Aloudah et al., 2018).
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Appendix A
The 10 Strategic Points
Broad Topic Area
1. Broad Topic Area/Title of Project:
Improving Medication Adherence among Type II Home Healthcare Diabetic Patients
Literature Review
2. Literature Review:
a. Background of the Problem/Gap:
· Medication adherence is defined as how well patients in home-based care adhere to their medication regimen in the absence of health practitioners.
· Medication adherence incorporates total adherence and compliance with the medical instructions that patients are given.
· Proper medication adherence can significantly improve patient-related healthcare outcomes.
· In the United States, alone, the number of patients who have been diagnosed with type II diabetes cannot be accommodated by hospital settings (Brown & Bussell, 2018). Therefore, to prevent overflowing hospitals, home healthcare programs have been created.
b. Theoretical Foundations (models and theories to be the foundation for the project):
a. Attachment theory: In accordance with Hunter and Maunder (2016), there are two key reasons why the attachment theory is considered effective for the following DPI. First, the theory acts as a solid foundation for the enhanced comprehension regarding the identified development of ineffective coping techniques, as well as the underlying dynamics associated with the emotional difficulties of the person. Clinicians can help people who have attachment anxiety and fail to comprehend past experiences. Through the involvement of caregivers and/or significant others, individuals can help to reshape their coping patterns.
b. Social cognitive theory: The social cognitive theory (SCT) is a critical theory that will be utilized during this DPI project. The SCT is utilized to explain the manner in which human behavior is associated with dynamic, reciprocal, and progressive types of interactions that exist between the person and his/her given surrounding (Bosworth, 2015). Therefore, the SCT is famous because it often proposes that identified behavior aspects are an outcome of the cognitive processes that individuals usually develop. Cognitive processes are developed through social knowledge acquisition.
c. Review of Literature with Key Organizing Themes and sub-themes (Identify at least two themes, with three sub-themes per theme)
a. Theme 1: Medication Adherence – To handle the issue of medication adherence among the diabetic patients who have had an issue with the adherence to medication needs, various strategic should be utilized. The primary focus of this review of literature is to ensure that drug adherence, though understanding why lacking adherence occurs, is improved upon.
i. Drug Adherence: This is the art of sticking to the drug prescription as being presented by the doctors. There are many reasons why home care patients might fail to take drugs as prescribed. For instance, when there is no person to remind them of what is supposed to be taken and at what time (Brown & Bussell, 2018). Some patients go ahead of suffering conditions that make it difficult for them to progress in life.
b. Theme 2: Enhancing Adherence through Understanding
i. Patient-Centered Communication Approach: This approach will incorporate the interests and preferences of the patients. It will also serve to determine the possible barriers that patients might be facing related to their medication adherence (Voortman et al., 2017). To address components associated with the patient-centered approach, the following MAP resources will be used: Questions to Ask Poster and an Adherence Assessment Pad.
ii. Chronic Care Models:It is important to understand that patients need care when they are dealing with a chronic illness. Therefore, to ensure that proper care resources are provided, the My Medications List will be used.
c. Summary
i. Prior studies: Prior studies have revealed that medical adherence among home healthcare-based patients is lacking and has been a smooth process. In fact, up to 14% of diabetic patients (nationally) do not adhere to their prescribed medication regimen; however, other sources note that this lacking adherence is much higher than 14%, thereby contributing an issue that must be addressed.
ii. Quantitative application: The WHO reports numerical data about medication adherence among home healthcare patients. Furthermore, researchers have cited that medication adherence is often impacted by lacking literacy, poor understanding/knowledge about the importance of one’s medication, etc., thereby resulting in inflated adherence rates.
iii. Significance: Using the MAP resources and providing patient-specific care, medical adherence among type II diabetes patients will likely improve, thereby resulting in enhanced health-related outcomes.
Problem Statement
3. Problem Statement:
It is not known if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization located in urban Texas.
Clinical/ PICOT Questions
4. Clinical/PICOT Questions:
To what degree does the implementation of Medication Adherence Project resources, which include the Questions to Ask Pad, the Questions to Ask Poster, an Adherence Assessment Pad, and the My Medications List impact medication adherence among Type II diabetic home healthcare patients, ages 35 to 64, of a home healthcare organization located in urban Texas over a period of four weeks? The following clinical question will guide this quantitative project:
Q1: Does using the MAP resources improve medication adherence among home health diabetic patients?
Sample
5. Sample (and Location):
a. Location: The location of this project is in urban Texas. The project site provides a larger percentage of patients with healthcare services who reside in the urban area as compared to the rural area.
b. At the selected project site, approximately 30 patients have been diagnosed with type II diabetes, though this census changes each month. Patients between the ages of 35 to 64, with no cognitive limitation, who speak English, will be invited to participate in this project.
c. Inclusion Criteria
i. 35 to 64 years of age
ii. Type II diabetes diagnosis
iii. English speakers
iv. Cognitively abled
d. Exclusion Criteria
· Younger than 35 and older than 64 years of age
· Not diagnosed with type II diabetes
· Non-English speakers
· Cognitively disabled/delayed
Define Variables
6. Define Variables and Level of Measurement:
a. Intervention: Use of the MAP resources, by nursing staff members, which will be implemented upon the completion of an educational training session. Starr and Sacks’s (2010) MAP Toolkit and Training Guide resources, include: (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List.
b. Outcome: Enhanced medication adherence.
c. Variables: Medication adherence, which is the dependent variable explored in this project, will be measured using data attained through the project site’s EHR. The MAP resources, which serve as the independent variables explored in this project, include (1) the Questions to Ask Poster, (2) an Adherence Assessment Pad, and (3) the My Medications List.
Methodology and Design
Methodology and Design:
A quantitative methodology, which employs a quasi-experimental design, will be used to examine medication adherence rates pre-project implementation and post-project implementation. Statistical analyses will be used to compare pre-and post-project data. Demographic data will be collected because the prevalence of non-adherence is often high among certain groups (e.g., impacted by socioeconomic status, gender, age, etc.).
Purpose Statement
Purpose Statement:
The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources, which include (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list, impact patient medication adherence rates when compared to current practice among Type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization located in urban Texas.
Data Collection Approach
Data Collection Approach:
The source of data for this project is the electronic medical record. Each week, nursing staff members will record medication adherence information in the patient’s EMR. If the patient expresses that he/she has not adhered to the medication regiment, during the previous week, lacking adherence information will be recorded in the system. Upon the completion of the four-week project, all information, input by nursing staff members into the EMR, will be assessed. The PI will compare pre-project implementation medication adherence rates to post-project implementation medication adherence rates. In addition to exploring medication adherence rates after the implementation of this project, pre-project implementation adherence rates will be explored over four weeks from April 1, 2021 to April 30, 2021.
Once pre-project implementation data and post-project implementation data are obtained, the results will be statistically analyzed. The PI will work with a statistician, who will assist in the data analysis process. Data will be compared analyze using various statistical techniques.
Data Analysis Approach
Data Analysis Approach: The facility uses Cradle Solutions, software for home health companies. It serves the specialized needs of home health care providers that give a web-based point-of-contact information entry and management.
The data will be collected using the project site’s EHR and will be presented to the PI by the secretary in a Microsoft Excel document. Data will be input into SPSS version 28 and analyzed using a t-test with a p-value of 0.05.
References
Bosworth, H. B. (2015). Enhancing medication adherence: The public health dilemma. Philadelphia, PA: Springer Healthcare.
Brown, M. T., & Bussell, J. K. (2011). Medication adherence: WHO Cares? Mayo Clinic Proceedings, 86(4), 304-314. Retrieved from /orders/doi.org/10.4065/mcp.2010.0575
Hunter, J., & Maunder, R. (2016). Improving patient treatment with attachment theory: A guide for primary care practitioners and specialists. Switzerland: Springer International Publishing.
Starr, B., & Sacks, R. (2010). Improving outcomes for patients with chronic diseases: The Medication Adherence Project (MAP). NYC Health. Retrieved from /orders/www.hfproviders.org/documents/root/pdf_9a3a46fa03.pdf
Voortman, T., Kiefte-de Jong, J., Ikram, M. A., Stricker, B. H., van Rooij, F. J. A., Lahousse, L., … Schoufour, J. D. (2017). Adherence to the 2015 Dutch dietary guidelines and risk of non-communicable diseases and mortality in the Rotterdam Study. European Journal of Epidemiology, 32(11), 993-1005. /orders/doi.org/10.1007/s10654-017-0295-2
Appendix B
MAP Resources
Appendix C
Permission to Use the MAP Resources
Per the website of Starr and Sacks (2010), the MAP tools are available free of charge. Tools can be downloaded from
THIS IS NOT PART OF THE PAPER JUST A REFERENCE FOR THE LEARNER
Appendix C
Power Analysis Using G Power
Note: Public source G-Power Software available /orders/www.psychologie.hhu.de/arbeitsgruppen/allgemeine-psychologie-und-arbeitspsychologie/gpower.html
Appendix D
Example SPSS Dataset & Variable View
The SPSS database is set up with all variables coded to compare between or within the comparison groups. A comparison may be made within the same individual and it coded 1 for before and 2 after the intervention. Or if measuring between individuals, the data would be coded the same 1 for before and 2 after as noted in the Group Column. Software supplied by Grand Canyon University.
Appendix E
How to Make APA Format Tables and Figures Using Microsoft Word
Tables vs. Figures
0. See APA Publication Manual, Chapter 7 for additional details (APA, 2019).
0. Tables consist of words and numbers where spatial relationships usually do not indicate any numerical information.
0. Tables should be used to present information that would be too wordy, repetitive, or difficult to read as text.
0. Figures typically communicate numerical information using spatial relations. For example, as you move up the Y axis of bar graph the scores usually go up.
1. Examples of APA Tables
A. Descriptive table
Table 1
Characteristics of Variables
Variable
Variable Type
Level of Measurement
Group, Intervention or Tool
Independent
Nominal
Rates or events
Dependent
Nominal
Socio Economic Status or Categories in an order
Dependent
Ordinal
Time, Temperature
Dependent
Interval
Age, height, Scores of tests
Dependent
Ratio
Note. Add notes here = (Provide any reference, 2019).
Table 1
Number of Handoff Per Groups
Group
# of Handoffs (%)
Pre-Intervention Group (Baseline)
150 (50%)
SBAR Group
150 (50%)
Note. SBAR handoff was defined as …. (IHI, 2020)
Table 1
Number of Hours Per Week Spent in Various Activities
Group
Baseline
(n = 30)
Post Intervention (n = 30)
Total Sample
(n = 60)
M (SD)
M (SD)
M (SD)
Schoolwork
18.23 (7.79)
16.23 (3.99)
17.63 (1.2)
Physical activities
19.54 (3.63)
14.23 (2.84)*
18.67 (1.0)
Socializing
16.23 (3.99)
17.63 (1.2)
18.23 (7.79)
Watching television
14.23 (2.84)
18.67 (1.0)
19.54 (3.63)
Extracurricular activities
19.54 (3.63)
18.23 (7.79)
19.22 (5.45)
Note. Schoolwork was defined as time spent doing class work outside of regular class time.
*statistically significant at p <.05
B. Chi-Square example (Group IV x Group DV)
Table 1
Crosstabulation of Gender and Chronic Pain
Chronic
Pain
Gender
Female
Male
χ2
Φ
Yes
2
(-2.7)
8
(2.7)
7.20**
,60
No
8
(2.7)
2
(-2.7)
Note. Adjusted standardized residuals appear in parentheses below group frequencies.
**= p< .01.
C. t-Test Example (Dichotomous Group IV x Score DV) –Notice two separate t-test results have been reported.
Table 1
Chronic Paint Score and Exercise time for Males and Females
Gender
Female
Male
T
df
Pain Score
3.33
(1.70)
3.75
(1.79)
-2.20*
175
Exercise Time
4.28
(.7509)
3.87
(.9280)
4.2**
176
Note. Standard Deviations appear in parentheses below means.
* = p < .05, *** = p < .001.
D. One Way ANOVA with 3 Groups Example (Group IV x Score DV)
Remember with an ANOVA, you have to report paired comparisons associated with post hoc or planned comparisons) for significant analyses. The results of paired comparisons are indicated by the subscripts on the means within rows. Also, notice in this table that we report the results of four separate analyses. This is the real power of tables: we can convey a large amount of information very concisely.
Table 1
Analysis of Variance for Sleep Times and Experimental Groups
Experimental Group
Aerobic Exercise
Weight Lifting
No Exercise
F
η2
Total Sleep Time
8.23a
(.55)
7.93b
(.90)
7.73ab
(.55)
3.98***
.18
Total Wake Time
3.58a
(.70)
3.62a
(.55)
3.54a
(.90)
.03
.00
Total Light Sleep
3.19c
(.73)
2.80a
(.72)
3.02b
(.49)
2.95*
.06
Total Deep Sleep
3.21b
(.19)
3.10a
(.28)
3.30a
(.19)
.20
.01
Standard deviations appear in parentheses bellow means. Means with differing subscripts within rows are significantly different at the p< .05 based on Fisher’s LSD post hoc paired comparisons.
* = p < .05, *** = p < .001.
E. Factorial ANOVA Example 2 x 3 between subject’s design.
Notice that two tables are used here. The first table reports the overall results for the 2×3 factorial ANOVA, which includes the Main Effects for the two IV’s and the Interaction Effect for the two IV’s. The second table reports the means and simple effects tests for the significant interaction effect.
Table 1
Experimental Group x Sex Factorial Analysis of Variance for Sleep Scores
Source
Df
F
η2
p
Experimental Group
2
7.93
.17
.001
Sex
1
31.41
.34
.001
Group x Sex (interaction)
2
7.85
.17
.002
Error (within groups)
30
Table 1
Analysis of Sleep Scores for Experimental Groups by Gender
Aerobic Exercise
Weightlifting
No Exercise
Simple Effects:
F df (2, 30)
Males
10.37a
(2.50)
10.30a
(2.34)
10.33a
(1.63)
.04
Females
4.83a
(1.60)
10.50b
(2.59)
4.50a
(1.52)
15.74**
Simple Effects:
F df (1, 30)
23.56**
.00
23.56**
Note. Standard deviations appear in parentheses bellow means. Means with differing subscripts within rows are significantly different at the p< .05 based on Fisher’s LSD post hoc paired comparisons.
** = p < .01
Notice that the simple effect comparing the 3 experiment groups only for females, requires follow up tests in order to determine which groups are significantly different. In this case, Fisher’s LSD test was used, and the results are represented with the different subscripts for each mean. In this case, female participants in the Aerobic exercise group did not differ from the no exercise group so they are given the same subscript (a). However, women in the control group and women in the Weightlifting group significantly differed from the Aerobic watching group and so the Weightlifting group was labeled with a different subscript (b). The male subjects did not differ from one another, so they all share the same subscript (a).
F. Correlations (Scores IV x Scores IV)
Table 1
Pearson’s Product Moment Correlations for Chronic Pain Score, Exercise Attitude Scores and Physical Activity
Demographic Influences on Exercise
Weight
Age
Chronic Pain Score
Pain Level
.39***
-.07
Pain Intensity
.15
.22*
Physical Exercise
Type of Exercise
-.26**
-.19†
Time of Exercise
-.13
-.21*
Intent to Exercise
.02
-.10
Note.N = 96 for all analyses.
† = p < .10, *= p < .05, **= p < .01, ***= p < .001.
1. Examples of APA Figures
Generally, the same features apply to figures as have been previously provided for tables: They should be easy to read and interpret, consistent throughout the document when presenting the same type of figure, kept on one page if possible, and supplement the accompanying text or table.
Figure 1
Graph of Scores Before and After
If the figure is not your own work, note the source or reference where you found the figure. Write, “Reprinted from” or “Adapted from,” followed by the title of the book, article, or website where you found the figure. Include the page number where you found the figure as well if you are citing a figure from a book. If you are citing a figure from a website, you may write, “Reprinted from The Huffington Post.” Or include the author’s first and second initial as well as their surname. Use the author’s first and second initial, if available, rather than the author’s full first name. Note their last name as well.
References:
American Psychological Association [APA]. (2019). Publication manual of the American Psychological Association. (7th ed.). Washington, DC; Author
Microsoft Word ®. (2019). Retrieved from /orders/products.office.com/
Appendix F
Writing up your statistical results
Identify the analysis technique.
In the results section (Chapter 4), your goal is to report the results of the data analyses used to answer your project question. To do this, you need to identify your data analysis technique, report your test statistic, and provide some interpretation of the results. Each analysis you run should be related to your clinical question or PICOT. If you analyze data that is exploratory or outside your clinical question, you need to indicate this in the results.
Format test statistics.
Test statistics and p values should be rounded to two decimal places (If you are providing precise p-values for future use in meta-analyses, 3 decimal places are acceptable). All statistical symbols (sample statistics) that are not Greek letters should be italicized (M, SD, t, p, etc.).
Indicate the direction of the significant difference.
When reporting a significant difference between two conditions, indicate the direction of this difference, i.e. which condition was more/less/higher/lower than the other condition(s). Assume that your audience has a professional knowledge of statistics. Do not explain how or why you used a certain test unless it is unusual (i.e., such as a non-parametric test).
How to report p values.
Report the exact p value (this is the preferred option if you want to make your data convenient for individuals conducting a meta-analysis on the topic).
Example: t(33) = 2.10, p = .03.
If your exact p value is less than .001, it is conventional to state merely p < .001. If you report exact p values, state early in the results section the alpha level used as a significance criterion for your tests. For example: “We used an alpha level of .05 for all statistical tests.”
If your results are in the predicted direction but are not significant, you can say your results were marginally significant. Example: Results indicated a marginally significant preference for pie (M = 3.45, SD = 1.11) over cake (M = 3.00, SD = .80), t(5) = 1.25, p = .08.
If your p-value is over .10, you can say your results revealed a non-significant trend in the predicted direction. Example: Results indicated a non-significant trending in the predicted direction indicating a preference for pie (M = 4.25, SD = 2.21) over cake (M = 3.25, SD = 2.60), t(5) = 1.75, p = .26.
Descriptive Statistics
Mean and Standard Deviation are most clearly presented in parentheses:
The sample as a whole was relatively young (M = 19.22, SD = 3.45).
The average age of students was 19.22 years (SD = 3.45).
Percentages are also most clearly displayed in parentheses with no decimal places:
Nearly half (49%) of the sample was married.
Frequencies or rates are reported including the range, mode, or median.
t-tests
There are several different designs that utilize a t-test for the statistical inference testing. The differences between one-sample t-tests, related measures t-tests, and independent samples t tests are clear to the knowledgeable reader so eliminate any elaboration of which type of t-test has been used. Additionally, the descriptive statistics provided will identify which variation was employed. It is important to note that we assume that all p values represent two-tailed tests unless otherwise noted and that independent samples t-tests use the pooled variance approach (based on an equal variances assumption) unless otherwise noted:
There was a significant effect for gender, t(54) = 5.43, p < .001, with men receiving
higher scores than women.
Results indicate a significant preference for pie (M = 3.45, SD = 1.11) over cake (M = 3.00, SD = .80), t(15) = 4.00, p = .001.
The 36 study participants had a mean age of 27.4 (SD = 12.6) were significantly older
than the university norm of 21.2 years, t(35) = 2.95, p = .01.
Students taking statistics courses in psychology at the University of Washington reported studying more hours for tests (M = 121, SD = 14.2) than did UW college students in general, t(33) = 2.10, p = .034.
The 25 participants had an average difference from pre-test to post-test anxiety scores of -4.8 (SD = 5.5), indicating the anxiety treatment resulted in a significant decrease in
anxiety levels, t(24) = -4.36, p = .005 (one-tailed).
The 36 participants in the treatment group (M = 14.8, SD = 2.0) and the 25 participants in the control group (M = 16.6, SD = 2.5), demonstrated a significance difference in
performance (t[59] = -3.12, p = .01); as expected, the visual priming treatment inhibited
performance on the phoneme recognition task.
UW students taking statistics courses in Psychology had higher IQ scores (M = 121, SD = 14.2) than did those taking statistics courses in Statistics (M = 117, SD = 10.3), t(44) =
1.23, p = .09.
Over a two-day period, participants drank significantly fewer drinks in the experimental group (M= 0.667, SD = 1.15) than did those in the wait-list control group (M= 8.00, SD= 2.00), t(4) = -5.51, p=.005.
ANOVA and post hoc tests.
ANOVAs are reported like the t test, but there are two degrees-of-freedom numbers to report. First report the between-groups degrees of freedom, then report the within-groups degrees of freedom (separated by a comma). After that report the F statistic (rounded off to two decimal places) and the significance level.
One-way ANOVA:
The 12 participants in the high dosage group had an average reaction time of 12.3.
seconds (SD = 4.1); the 9 participants in the moderate dosage group had an average
reaction time of 7.4 seconds (SD = 2.3), and the 8 participants in the control group had a
mean of 6.6 (SD = 3.1). The effect of dosage, therefore, was significant, F(2,26) = 8.76,
p=.012.
A one-way analysis of variance showed that the effect of noise was significant, F(3,27) = 5.94, p = .007. Post hoc analyses using the Scheffé post hoc criterion for significance indicated that the average number of errors was significantly lower in the white noise condition (M = 12.4, SD = 2.26) than in the other two noise conditions (traffic and industrial) combined (M = 13.62, SD = 5.56), F(3, 27) = 7.77, p = .042.
Tests of the four a priori hypotheses were conducted using Bonferroni adjusted alpha
levels of .0125 per test (.05/4). Results indicated that the average number of errors was
significantly lower in the silence condition (M = 8.11, SD = 4.32) than were those in both
the white noise condition (M = 12.4, SD = 2.26), F(1, 27) = 8.90, p =.011 and in the
industrial noise condition (M = 15.28, SD = 3.30), F (1, 27) = 10.22, p = .007. The
pairwise comparison of the traffic noise condition with the silence condition was nonsignificant.
The average number of errors in all noise conditions combined (M = 15.2, SD
= 6.32) was significantly higher than those in the silence condition (M = 8.11, SD = 3.30),
F(1, 27) = 8.66, p = .009.
Multiple Factor (Independent Variable) ANOVA
There was a significant main effect for treatment, F(1, 145) = 5.43, p < .01, and a
significant interaction, F(2, 145) = 3.13, p < .05.
The cell sizes, means, and standard deviations for the 3×4 factorial design are presented
in Table 1. The main effect of Dosage was marginally significant (F[2,17] = 3.23, p =
.067), as was the main effect of diagnosis category, F(3,17) = 2.87, p = .097. The
interaction of dosage and diagnosis, however, has significant, F(6,17) = 14.2, p = .0005.
Attitude change scores were subjected to a two-way analysis of variance having two
levels of message discrepancy (small, large) and two levels of source expertise (high,
low). All effects were statistically significant at the .05 significance level. The main
effect of message discrepancy yielded an F ratio of F(1, 24) = 44.4, p < .001, indicating
that the mean change score was significantly greater for large-discrepancy messages (M =
4.78, SD = 1.99) than for small-discrepancy messages (M = 2.17, SD = 1.25). The main
effect of source expertise yielded an F ratio of F(1, 24) = 25.4, p < .01, indicating that the
mean change score was significantly higher in the high-expertise message source (M =
5.49, SD = 2.25) than in the low-expertise message source (M = 0.88, SD = 1.21). The
interaction effect was non-significant, F(1, 24) = 1.22, p > .05.
A two-way analysis of variance yielded a main effect for the diner’s gender, F(1,108) =
3.93, p < .05, such that the average tip was significantly higher for men (M = 15.3%, SD
= 4.44) than for women (M = 12.6%, SD = 6.18). The main effect of touch was nonsignificant, F(1, 108) = 2.24, p > .05. However, the interaction effect was significant,
F(1, 108) = 5.55, p < .05, indicating that the gender effect was greater in the touch
condition than in the non-touch condition.
Chi Square
Chi-Square statistics are reported with degrees of freedom and sample size in parentheses, the Pearson chi-square value (rounded to two decimal places), and the significance level:
The percentage of participants that were married did not differ by gender, X2(1, N = 90) = 0.89, p > .05.
The sample included 30 respondents who had never married, 54 who were married, 26
who reported being separated or divorced, and 16 who were widowed. These frequencies
were significantly different, X2 (3, N = 126) = 10.1, p = .017.
As can be seen by the frequencies cross tabulated in Table xx, there is a significant
relationship between marital status and depression, X2 (3, N = 126) = 24.7, p < .001.
The relation between these variables was significant, X2 (2, N = 170) = 14.14, p < .01.
Catholic teens were less likely to show an interest in attending college than were
Protestant teens.
Preference for the three sodas was not equally distributed in the population, X2 (2, N =
55) = 4.53, p < .05.
Correlations
Correlations are reported with the degrees of freedom (which is N-2) in parentheses and the significance level:
The two variables were strongly correlated, r(55) = .49, p < .01.
Regression analyses
Regression results are often best presented in a table. A
PA doesn’t say much about how to report regression results in the text, but if you would like to report the regression in the text of your Results section, you should at least present the standardized slope (beta) along with the t-test and the corresponding significance level. (Degrees of freedom for the t-test is N-k-1 where k equals the number of predictor variables.) It is also customary to report the percentage of variance explained along with the corresponding F test.
Social support significantly predicted depression scores, b = -.34, t(225) = 6.53, p < .01. Social support also explained a significant proportion of variance in depression scores, R2 = .12, F(1, 225) = 42.64, p < .01.
Tables
Add a table or figure.
Adding a table of figure can be helpful to the reader. See the current APA Publication manual for examples. In reporting the results of statistical tests, report the descriptive statistics, such as means and standard deviations, as well as the test statistic, degrees of freedom, obtained value of the test, and the probability of the result occurring by chance (p value).
•APA style tables do not contain any vertical lines
•There are no periods used after the table number or title.
•When using columns with decimal numbers, make the decimal points line up.
•Use MS Word tables to create tables
American Psychological Association [APA].(2019). Publication manual of the American Psychological Association (7th ed.). Washington, DC: Author.
ADDITIONAL INSTRUCTIONS FOR THE CLASS: Improving Medication Adherence among Type II Home Healthcare Diabetic Patients
Who We Are
We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.
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Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours. Improving Medication Adherence among Type II Home Healthcare Diabetic Patients
GuaranteeImproving Medication Adherence among Type II Home Healthcare Diabetic Patients
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ECON Assignment: Slowdown in economic growth and interest rates, microeconomics
ECON Assignment: Slowdown in economic growth and interest rates, microeconomics
The following macroeconomics concept/models should be used to answer when appropriate: The IS curve, Monetary Policy and Philipps curve, Stabilization Policy and he AS/AD framework, Exchange rates for international trade.
L A Slowdown in Economic Growth? (30 points, 5 points each part) Consider the extent to which the recent growth slowdown can be explained by data on R&D.
Download the series “Y001RX1A020NBEA’ from the FRED database on “Real Gross Private Domestic Investment in Intellectual Property Prod” This series will be our measure of real R&D for the economy (we’re ignoring global R&D to simplify things). Convert this series into an index so that the 1967 value equals one by dividing all entries by the 1967 value. Plot this series on a ratio scale with the labels “1 2 4 8…” on the vertical axis. This graph is the answer to part (a) of this question.
Suppose the idea production function for this economy takes the form
AAt±i _
________ zRtAt‘)‘
At
where z and 7 (the Greek letter “gamma”) are parameters that take some positive value, R. is the R&D series that you plotted in part (a), and At corresponds to total factor productivity in the economy (relative to the model we considered in class, we are setting ,3 = 1). In one paragraph, discuss the economic interpretation of this idea production function.
Assume that A1967 = 1 and z =02. Why does the value of 0.02 for make sense?
Use the idea production function from part (b) together with the parameter values we’ve assumed so far to simulate the time series of total factor productivity growth in this model from 1968 through 2022 and show your result in a graph. NOTE WELL: in order to do this, you will have to choose a value of -y. Experiment with different values of 7 and choose one that you think is reasonable.
What value of did you choose and why?
(1) In a paragraph, summarize the takeaway from this question: can U.S. R&D data explain the recent growth slowdown? What are the pro’s and Cons of this explanation?
Interest rates and inflation expectations. (30 points, 6 points each).
In this exercise we will look at the relationship between nominal and real interest rates, and the role of inflation expectations.
NOTE: For parts (b), (c), (d), and (e) below, your answer should consist of a single well-written paragraph.
Go to https: / /www.federalreserve.govidatadownload/Build.aspx?rel,H15 to obtain the yield on government securities. In the Data Set field pick “Selected Interest Rates” and click continue. Follow the instructions to get monthly yields for 5- and 10-year maturity Treasuries, nominal (TCMNOM) and inflation indexed (TCMII). Also get the Federal Funds Rate (FF). Get the data from Jan 2003 to April 2023. In the Maturity field, pick Overnight, 5 year, and 10-year. At some point you will have to click on “Format Package” to proceed. Download the CSV values into excel.
(a) The yield on nominal bonds is the interest rate at the corresponding maturity. Inflation indexed bonds are protected against inflation, so their yield is the real interest rate. Using the nominal and real interest rates, compute the 5- and 10-year ahead inflation expectations, as perceived by the market, at each point in time. For the purposes of this question, we will ignore risk-premia. Assume the Fisher equation holds in expectations.
Plot and show the following graphs (no other explanations are required for part (a)):
The 5- and 10-year nominal interest rate and the Federal Funds rate
The 5- and 10-year real interest rate
The 5- and 10-year expected inflation
(b) What are liquidity traps, and how is this concept relevant to monetary policy during the financial crisis and the COVID-19 crisis?
How would you describe the long-run behavior of real interest rates (over the last two decades)? Hint: Compare the average real rates before 2010 and after 2010. How is this related to the concept of “secular stagnation” and r? What does this imply about the likelihood of liquidity traps under inflation-targeting monetary regimes?
What is the main relationship between the FF rate and the 5-year and 10-year nominal rates? Why were 10-year nominal rates higher than 5-year rates after the financial crisis?
What happened to inflation expectations during the financial crisis (specifically, late 2008)? What was the effect on real interest rates and aggregate demand? Compare to what happened during the COVID-19 crisis and its
Inflation Targeting in the U.K. (30 points, 6 points each).
Suppose the Bank of England is considering whether or not to raise the target rate of inflation from 2 percent to 4 percent.
As background for this problem, obtain graphs of the inflation rate in the K. as well as the Bank of England’s “base rate” (which is an analog to the U.S. fed funds rate). (You can just find a source and copy the images; no need to make a new graph yourself.) Show these graphs in your solution and discuss in a paragraph what you see there.
Assuming that the U.K. economy begins in steady state, with inflation at the target level, explain how GDP and inflation would evolve in response to changing the inflation target from 2 percent to 4 percent.
What are some arguments in favor of this change?
What are some arguments against this change?
On balance, do you think moving to a 4% inflation target would be a good idea?
Estimating Potential GDP (30 points, 5 points each)
There are good reasons to believe the CBO’s estimate of potential GDP for the United States in 20202022 is not accurate. You are on the staff of the macroeconomics forecasting group for a leading company, and they have asked you to come up with your own estimate of potential output in these years.
Details: Use the Short-Run model as presented in class. Make whatever assumptions are necessary to implement your calculation and explain why you think these assumptions are plausible. It is not necessary for you to run any regressions in order to answer this question. All data that you use should come from /orders /fred.stlouisfed.org/ when possible. If you use a different source be sure to indicate it.
Explain the methodology you are using to estimate potential GDP for the U.S. in 2020-2022.
You will need to use data (see next part) and make assumptions about parameter values and shocks to implement your methodology. What assumptions are you making? Defend those assumptions.
What data are you using in order to implement your method; provide the series code for each measure. Plot the key data series since 1990 that you are using.
Create a graph of the CB0 series GDPPOT (from FRED) for the period 2018 to 2022. Also include your alternative estimate for 2020-2022 on this plot.
Create a table for the years 2020, 2021, and 2022 showing Y measured using (i)the CBO potential GDP and (ii) your new estimate of potential. In the same table, show the inflation rate and the expected inflation rate that you are using.
Provide two paragraphs of discussion about your results.
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Who We Are
We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.
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Yes. We have posted our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill out our Order Form. Filling the order form correctly will assist our team in referencing, specifications, and future communication.
Is it hard to Place an Order?
1. Click on “Order Now” on the main Menu and a new page will appear with an order form to be filled.
2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
3. Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
5. From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.
We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
GuaranteeECON Assignment: Slowdown in economic growth and interest rates, microeconomics
We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium. ECON Assignment: Slowdown in economic growth and interest rates, microeconomics
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NUR-635D2Q1 – Minimum of 300 words with at least two peer review reference in 6th edition apa style.
Select a route of administration (e.g., oral, IV, subcutaneous, IM, transdermal, rectal, inhalation, SL) and discuss the advantages and disadvantages of this administration route. Give an example of a medication administered by your chosen route and a good patient candidate or rationale for choosing your given route of administration. You can consider special populations (e.g., pediatrics, geriatrics, pregnancy).
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Who We Are
We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.
Do you handle any type of coursework?
Yes. We have posted our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill out our Order Form. Filling the order form correctly will assist our team in referencing, specifications, and future communication.
Is it hard to Place an Order?
1. Click on “Order Now” on the main Menu and a new page will appear with an order form to be filled.
2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
3. Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
5. From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.
We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
Looking for a Similar Assignment? Order a custom-written, affordable, plagiarism-free paper
In this week, you will explore traditional and contemporary conflict resolution theories (i.e., traditional view, the behavioral/ contemporary/ human relations view, and the interactionist view) and their merits and limitations.
Prepare a 10-slide PowerPoint presentation on the three theoretical underpinnings of conflict resolution in workplaces – traditional view, the behavioral/ contemporary/ human relations view, and the interactionist view.
Be sure to support your work with at least two high-quality references, including at least one from peer-reviewed journals accessed through the Herzing University Library or other sources.
This criterion is linked to a Learning OutcomeContent
15.0 pts
5
Demonstrates the ability to construct a clear and insightful problem statement/thesis statement/topic statement with evidence of all relevant contextual factors.
14.0 pts
4
Demonstrates the ability to construct a problem statement, thesis statement/topic statement with evidence of most relevant contextual factors, and problem statement is adequately detailed.
12.0 pts
3
Begins to demonstrate the ability to construct a problem statement/thesis statement/topic statement with evidence of most relevant contextual factors, but problem statement is superficial.
11.0 pts
2
Demonstrates a limited ability in identifying a problem statement/thesis statement/topic statement or related contextual factors.
9.0 pts
1
Demonstrates the ability to explain contextual facts but does not provide a defined statement.
0.0 pts
0
There is no evidence of a defined statement.
15.0 pts
This criterion is linked to a Learning OutcomeAnalysis
20.0 pts
5
Organizes and compares evidence to reveal insightful patterns, differences, or similarities related to focus.
18.0 pts
4
Organizes and interprets evidence to reveal patterns, differences, or similarities related to focus.
16.0 pts
3
Organizes and describes evidence according to patterns, differences, or similarities related to focus.
14.0 pts
2
Organizes evidence, but the organization is not effective in revealing patterns, differences, or similarities.
12.0 pts
1
Describes evidence, but it is not organized and/ or is unrelated to focus.
0.0 pts
0
Lists evidence, but it is not organized and/ or is unrelated to focus.
20.0 pts
This criterion is linked to a Learning OutcomeWriting
10.0 pts
5
The paper exhibits a excellent command of written English language conventions. The paper has no errors in mechanics, grammar, or spelling.
9.0 pts
4
The paper exhibits a good command of written English language conventions. The paper has no errors in mechanics, or spelling with minor grammatical errors that impair the flow of communication.
8.0 pts
3
The paper exhibits a basic command of written English language conventions. The paper has minor errors in mechanics, grammar, or spelling that impact the flow of communication.
7.0 pts
2
The paper exhibits a limited command of written English language conventions. The paper has frequent errors in mechanics, grammar, or spelling that impede the flow of communication.
6.0 pts
1
The paper exhibits little command of written English language conventions. The paper has errors in mechanics, grammar, or spelling that cause the reader to stop and reread parts of the writing to discern meaning.
0.0 pts
0
The paper does not demonstrate command of written English language conventions. The paper has multiple errors in mechanics, grammar, or spelling that cause the reader difficulty discerning the meaning.
10.0 pts
This criterion is linked to a Learning OutcomeAPA
5.0 pts
5
The required APA elements are all included with correct formatting, including in-text citations and references.
4.5 pts
4
The required APA elements are all included with minor formatting errors, including in-text citations and references.
4.0 pts
3
The required APA elements are all included with multiple formatting errors, including in-text citations and references.
3.5 pts
2
The required APA elements are not all included. AND/OR there are major formatting errors, including in-text citations and references.
3.0 pts
1
Several APA elements are missing. The errors in formatting demonstrate limited understanding of APA guidelines, in-text-citations, and references.
0.0 pts
0
There is little to no evidence of APA formatting. AND/OR there are no in-text citations AND/OR references.
5.0 pts
Total Points: 50.0
ADDITIONAL INSTRUCTIONS FOR THE CLASS
Who We Are
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Yes. We have posted our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill out our Order Form. Filling the order form correctly will assist our team in referencing, specifications, and future communication.
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1. Click on “Order Now” on the main Menu and a new page will appear with an order form to be filled.
2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
3. Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
5. From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.
We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
Discussion Questions (DQ)
Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.
Weekly Participation
Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.
APA Format and Writing Quality
Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.
Use of Direct Quotes
I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.
LopesWrite Policy
For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.
Late Policy
The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.
Communication
Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.
We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.
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