Ms. Wimer is an assistant nurse manager at the VA Staunton Community Based Outpatient Clinic in Virginia and adjunct faculty in the RN to BSN program at Eastern Mennonite University. Dr. Shipman is a nurse educator for the Office of Employee Education and a music student at the Performing Arts Institute of Virginia in Blacksburg. Ms. Lea is a physician assistant. All authors work for the Salem VAMC in Virginia.
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies.
Nurses play a vital role in educating and securing adherence of patients in the management of their disease(s).13 In addition to educating patients, families, and friends of the family, nurses assist with helping them make informed decisions.16 The VHA uses the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) to teach health care staff about diabetes self-management education (DSME). Tisdel and colleagues found that DSME established through telemedicine or clinical mentoring improved patient outcomes.17 Mendoza and Rosenburgfound nurse-led DSME was linked to minimizing cardiovascular risk factors and improvements in HbA1c.13
Background
Staunton Community Based Outpatient Clinic (CBOC) in rural Virginia is a primary care clinic that serves veterans in the surrounding area. About one-fourth of the Staunton patients have diabetes. According to June 2014 data from the VHA Support Service Center, the physician at the Staunton CBOC was responsible for 946 patients (225 with diabetes) and the nurse practitioner was responsible for 707 (184 with diabetes). The VHA Support Service Center 2014 data indicated that veterans with poorly self-managed diabetes were at increased risk for poor outcomes, such as kidney failure, cardiovascular disease, and limb amputation. Veterans with diabetes use the emergency department more often and are admitted to the hospital more often than are veterans who do not have diabetes.18
Methods
The primary objective of this pilot study was to explore whether weekly structured nursing education sessions lasting 45 minutes and subsequent follow-up weekly conferences would improve their HbA1c for veterans identified as having ≥ 9 HbA1c and ≤ 3 health literacy score on the NVS 7 study assessment. Most recent HbA1c prior to beginning the study was used to identify potential participants. After completion of 12 weekly education interventions, an additional HbA1c was obtained.
The Salem VAMC and Eastern Mennonite University Institutional Review Board approved the study. Veterans’ questions were answered prior to signing consent forms. All data collected were kept confidential.
Veterans with ≥ 9 HbA1c were evaluated for possible participation. Forty-nine veterans met the criteria to participate in this pilot study. Exclusion criteria included diagnosis of any cognitive disorder, such as dementia, Alzheimer disease, or memory impairment. In addition, veterans unwilling or unable to commit to weekly follow-up sessions were excluded. The veterans eligible for participation were contacted by telephone, and 9 agreed to participate in the pilot study. Inclusion criteria included those aged ≥ 18 years and a diagnosis of diabetes with most recent HbA1c of ≥ 9 and a score of < 4 on the NVS health literacy assessment. After taking the NVS health literacy assessment, 6 of the 9 participants qualified to continue in the study.
Education interventions included assessing medication adherence, discussing diet, reviewing physical activity for the previous week (based on diet and activity logs), and reviewing home blood glucose monitoring. Weekly education sessions were either face-to-face or by telephone. This choice was given to accommodate veterans who may have had transportation issues. A total of 12 weekly appointments were scheduled for each participant, and education was directed at the specific needs and goals of each participant. Interventions for education were based on those found in previous studies.13,14,18,19
Data Collection and Analysis
All 6 participants were white male veterans who were diagnosed with diabetes for at least 3 years. Their ages ranged from 59 to 72. Three participants were service connected for diabetes and 3 were not. One participant dropped from the study after completing 4 appointments, stating he was just too busy to be available for a weekly appointment. Another participant completed 6 appointments and removed himself from the study due to time constraints. The 4 participants who completed the pilot study were followed for 12 weeks by a registered nurse (RN), and all had reductions in their HbA1c.
Participants were assessed at weekly appointments using a predetermined template for medication adherence, diet, activity, and blood glucose monitoring. Responses of the participants guided the education interventions to meet the individual veteran’s learning needs. For example, one veteran was given specific education on carbohydrate counting and another was educated on how to read food labels. Participants were also encouraged to express satisfaction, frustration, anger, or other emotions in managing their chronic illness. The premise for spending additional time with the veteran was to promote positive self-management behaviors as recommended by Radhakrishnan.19
Veterans who completed the study stated that the education interventions positively impacted their health status. One veteran was able to delay dialysis due to self-directed improvement in his lifestyle (exercising and watching his diet), which improved his HbA1c. This veteran attributed his health improvement to the individualized education sessions with the RN and knowing he had to be accountable to someone. Additionally, it was found there was a strong familial-social component to diabetes self-management. Several veterans were knowledgeable about diabetes self-management as evidenced by their responses to weekly questions. However, disease management for these veterans was strongly impacted by family and life events.
One veteran did not manage his disease for an entire week due to “being busy with a death in the family and planning for a wedding.” This veteran took his medication but did not check his blood glucose or monitor his diet. Another veteran spoke of eating ice cream and other concentrated sweets because his young grandson was with him for the week. A third veteran was able to manage his diet better when his wife packed snacks for him but when left to his own accord did not do well with his food selection. Even though these veterans understood how to effectively manage their diabetes, they may have chosen to inconsistently translate that knowledge into practice if they perceive those familial-social forces to be more important or more powerful.
