Download File - Barbara Lentz

EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
The Effects of Nursing Education on the Reduction of
Cardiovascular Risk Factors in Diabetic Patients
Barbara Lentz, RN
Stephanie Monroe, RN
Alanna Fant, RN
Shenna Throop, RN
Ferris State University
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
Abstract
Diabetes is a global health issue with a patient population that is growing on a daily basis.
Unfortunately, diabetic patients, especially those who are poorly controlled are at a higher risk
for cardiovascular disease. The purpose of this study was to evaluate primary research articles,
that have shown evidence that nursing education directed towards diabetics has a positive effect
by reducing overall cardiovascular risk factors. Four primary articles are evaluated for content,
validity, and strength of conclusions. Outcomes of all four articles, heavily support the idea that
diabetic patients who are the recipients of direct and thorough nursing education have been
shown to exhibit a decrease in cardiovascular risk factors, decrease in overall hemoglobin A1c
(HbA1c) levels, increase in quality of life (QOL), and an increase in overall knowledge
regarding diabetes self-management and cardiovascular risk factors.
Keywords: nursing education, diabetic, cardiovascular disease, diabetic risk factors
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
The Effects of Nursing Education on the Reduction of
Cardiovascular Risk Factors in Diabetic Patients
Diabetes affects 25.8 million people in the United States; this is about 8.3 percent of the
total population. In 2007, 174 billion dollars was spent in medical expenses related to diabetes.
Individual medical expenses are two times higher for someone diagnosed with diabetes than one
without diabetes. Diabetes is a major risk factor for developing heart disease. Adults with
diabetes are two to four times more likely to die from heart disease than adults without diabetes
(Centers for Disease Control, 2011). “Interventions to prevent or delay type 2 diabetes in
individuals with pre-diabetes can be feasible and cost-effective. Research has found that lifestyle
interventions are more cost-effective than medications” (Centers for Disease Control, 2011, p.
12). This paper will assess the current literature on the relationship of diabetes and heart disease.
The effects of diabetes education on heart disease will be the focus of research.
Description of Research Articles
Article 1
Education and behavior modifying interventions given to patients with diabetes has had
only minimal effects on preventing disease progression and complications. This may be due to
lack of knowledge in diabetes management, lack of motivation, and poor compliance among
individuals with this disease. Intensive therapeutic interventions are studied for effectiveness in
reducing cardiovascular and other vascular complications of diabetes (Rachmani, Slavachevski,
Berla, Frommer-Shapira, & Ravid, 2005).
Population and samples.
One hundred and sixty-five patients with type 2 diabetes were consulted at the diabetes
clinic at Meir Hospital in Kfar-Sava, Israel. The criteria for acceptance were 40 to 70 years of
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
age, diabetes for less than ten years and no history of myocardial infarction, angina, vascular
disease, or stroke. One hundred and forty-four patients fit the profile needed for the research and
were randomly assigned equally to two separate groups by a computerized program. The SC
group only attended the standard consultation visits and medical treatment usually given to
patients with type 2 diabetes. The second group, the PP group additionally received two 2 hour
individual education sessions on controlling their diabetes. They also received a plan of lifestyle
modification and fitness program and were encouraged to keep a log of their blood sugar, blood
pressure, weight and laboratory values to go over with their primary care providers. In addition
to this they were encouraged to call the consultants any time they had a question or needed
advice. Both groups were followed by their primary care providers and various pharmaceutical
interventions were used (Rachmani et al. 2005).
Outcomes.
During the eight years of the study twelve participants of the SC group died, eight
cardiovascular related. The PP group there was nine deaths, five that were cardiovascular related.
“Of the non-fatal cardiovascular disease (CVD) events 72 in 45 patients were from the SC group
and 47 in 31 in the PP group” (Rachmani et al. p. 412). There were fewer strokes, coronary
interventions, amputations, and bypass surgery in the PP group compared to the SC group.
Article 2
Coronary heart disease (CHD) is one of the leading causes of death among women in
Trinidad and Tobago. Women with diabetes are three times more likely to die from CHD than
women without diabetes. A study was conducted to test the effects of self-monitoring of blood
glucose on the ten year CHD risk profile of female type two diabetes patients.
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
Study.
Forty-nine female patients who had never used blood glucose monitors participated in the
study. Twenty-three patients made up the intervention group and twenty-six patients made up the
control group. The patients in the intervention group where given a three month supply of
glucose testing materials along with education on how to use it. The patients were given a
calendar to record blood glucose levels. The patients in the control group were given strict
instructions not to use blood glucose monitoring devices during the six month duration of the
study (Ezenwaka et al., 2011). The intervention and control group were scheduled for an
evaluation after three months then again at six months. The United Kingdom Prospective
Diabetes Study (UKPDS) risk engine was used to estimate the ten year CHD risk. The UKPDS
was used in this study because it “incorporates diabetes specific attributes such as glycated
hemoglobin A1 (HbA1c) level, an index of long-term glycemic control, in its calculation”
(Ezenwaka et al., 2011, p. 2). The UKPDS risk engine assessment incorporates data such as sex,
age, ethnicity, smoking, diabetes duration, blood pressure, cholesterol, glycated hemoglobin, and
presence or not of atrial fibrillation to calculate the 10 year CHD risk (Ezenwaka et al., 2011).
Outcomes.
Prior to the study both the control and intervention group had nearly equal HbA1c levels.
At the three month evaluation the intervention groups HbA1c levels had significantly decreased
from 9.2 to 7.4 then to 7.3 at six months. The control groups HbA1c level was an insignificant
change from 8.3 to 7.8. The systolic blood pressure for the intervention group was reduced from
154.7 to 144.0 after six months. Cholesterol levels for both groups were not a significant change.
The results of the study concluded that “provision of facilities for self-monitoring of blood
glucose in Afro-Caribbean women with type 2 diabetes improves both their glycemic control and
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
CHD risk profile” (Ezenwaka et al., 2011, p. 1).
Article 3
The authors of this article explore the knowledge differences in two groups of patients
with type 2 diabetes mellitus and their risk factors of cardiovascular disease.
Population and samples.
134 questionnaires were returned with no significant differences between age or gender
in the two groups or 94 participants in each group after adjustments were made for dropouts due
to non-compliance or patient death (MacMahon Tone et al., 2011). All patients had type two
diabetes mellitus and at least one risk factor for cardiovascular disease. Two groups of patients
were randomly assigned to one of two groups. The first group received standard follow-up care
in an outpatient clinic and the other group of patients received an intensive, nurse-led care in an
outpatient vascular intervention clinic (MacMahon Tone, Gallagher, Agha, & Thompson, 2011).
The patients in the nurse-led group were seen in the clinic every two or three months and were
given “individual education on diet, weight reduction, exercise, alcohol consumption and
smoking and on how blood tests results and BP readings related to current recommendations”
(MacMahon Tone et al., 2011, p. 90).
Outcomes.
Patients were given a questionnaire with four sections that included questions on
demographics that include current treatments and management of diabetes, knowledge of
vascular risk factors, knowledge of heart disease and attitudes towards diabetes management
(MacMahon Tone et al., 2011). It was found overall that results were similar in both of the
groups and the differences between the two groups were not significant. Specifically patients
didn’t know ideal targets for HbA1C, BP and cholesterol, but they did know target blood levels
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
and the majority of patients were aware heart disease, stroke and hardening of the arteries were
all complications that can be associated with diabetes and the differences between the two groups
were insignificant (MacMahon Tone et al., 2011). The study also showed that the majority of
participants knew that BP control is an important part of diabetes management (MacMahon Tone
et al., 2011).
Follow up with the intensive group were found to have not retained the information. The
authors recommended that patient involvement was a significant factor in increasing patient
compliance in treatment regiment, however if a patient chooses not to participate in treatment
recommendations that healthcare providers need to respect patient wishes (MacMahon Tone et
al., 2011). It is also important for patients and providers to set goals, including behavioral goals,
and for each to retain copies of goals and notes. It is also important for providers to assess patient
knowledge and educational needs to each individual patient (MacMahon Tone et al., 2011).
Article 4
The purpose behind the research conducted in, “Effects of a Diabetes Self-Management
Program on Glycemic Control, Coronary Heart Disease Risk, and Quality of Life Among Thai
Patients with Type Two Diabetes”, was to support the hypothesis that “diabetic patients
receiving a self-management program would have lower levels of hemoglobin A1c (HbA1c) and
coronary heart disease (CHD) risk, and a better quality of life (QOL) than those receiving the
usual nursing care” (Wattana, Srisuphan, Pothiban, & Upchurch, 2007, p. 136).
Study.
The study included 147 participants, 75 allocated to the experimental group and 72 in the
control group. The experimental group members were placed in a diabetes self-management
program that was broken down into two segments. The first segment included a small group
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
diabetes education session and four small group discussions to promote self-efficacy in
managing diabetes, this included information on nutrition, physical activity, foot care,
medications, signs and symptoms of complications, and meditation (Wattana, Srisuphan,
Pothiban, & Upchurch, 2007). The second part of the program included 2 home visits from the
primary researcher. Participants in the experimental group also received an educational manual
that had been developed by the researcher (Wattana, Srisuphan, Pothiban, & Upchurch, 2007).
The control group was given typical nursing care and education as well as a physical exam
(Wattana, Srisuphan, Pothiban, & Upchurch, 2007). Both groups were evaluated after 24 weeks.
Evaluation criteria included if there was any difference in HbA1c, CHD risk, and QOL between
patients in the experimental and control groups (Wattana, Srisuphan, Pothiban, & Upchurch,
2007).
Outcomes.
All three evaluating factors showed marked improvement for the experimental group
over the control group after 24 weeks. HbA1c levels of the experimental group showed greater
improvement than that of the control group, CHD risk for patients in the experimental group was
decreased in comparison to the control group, and experimental patients showed a greater level
of increase in their QOL as compared to the control group. Overall the study was able to support
the hypothesis that, “diabetic patients receiving a self-management program would have lower
levels of HbA1c and CHD risk, and a better QOL than those receiving the usual nursing care”
(Wattana, Srisuphan, Pothiban, & Upchurch, 2007, p. 136).
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
Critical Appraisal of the Evidence
Article 1
Problem and purpose statement.
The problem and purpose statement was presented as an aim in the abstract. It was clear
and concise. The purpose was more obvious then the problem in the aim but the problem could
still be identified. It included the population, variables, and was empirically testable. However,
the aim was presented as a declarative sentence when an interrogative sentence would have been
a better choice. By presenting it as a declarative sentence and in the present tense it became more
of the hypothesis with a purpose.
Review of literature and theoretical and conceptual frameworks.
There is some mention in the discussion section of the article, that there were similar
studies done that include multiple interventions, but they were not identified to the reader. There
is no discussion of theoretical and conceptual frameworks discussed in this article. It was stated
in the introduction, “we now report the second, 4-year, phase of the study high-lighting the
influence of the intervention on cardiovascular outcomes” (Rachmani et al. p. 411). According to
that statement a previous study is available. If the reader is really interested in the study they
should obtain a copy of the previous study and perhaps these components would have been
addressed, and then the reader could decide the thoroughness of the report.
Limitations.
In the discussion portion of the article only one sentence was devoted to the study
limitations and that was the fact that the intervention and data assessment were carried out by the
same researchers (Rachmani et al. 2005), stipulating a possible assessment bias as a threat to
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
internal validity.
Research design.
No research design was identified or described in the article. The researchers stated that
they used a computer generated random number program to divide the two groups for the study.
The reader of the article has to determine if the approach to obtain data is appropriate for the aim
of the study.
Population and data collection methods.
This is where the article started to show strength and possible validity. The population
and limitations were defined with the inclusion criteria of age, length of diabetes diagnosis less
than ten years, blood pressure values of greater than or equal to 140/90, and history of no
myocardial infarction, angina, vascular surgery, stroke, or malignant disease. Consents were
obtained for each participant and they were each randomly put into two groups. Letters were
written to each participant's health care providers. The data collection methods were obtained
from letters of the primary care providers, hospital discharge summaries, or other consultant’s
reports. All the laboratory values were done centrally to eliminate analytical discrepancies
(Rachmani et al. 2005). There is a risk of data collection errors by obtaining data from so many
different sources. Each participant probably has different care givers and relying on data from
these various sources runs the risk of inaccuracy and differences in judgment. On the other hand
by having the laboratory values centrally done eliminates the possibility of error of those
analytical values.
Data analysis.
This article presented the findings under a results category including the treatment,
modifiable risk parameters, nephropathy, retinopathy, and cardiovascular disease. The results
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
were both presented in narrative and in tables. Line graphs were used to emphasize the decline in
the laboratory values and blood pressures of the PP group as compared to the SC group. A bar
graph was used to show the survival rate of non-fatal CV events increased in the PP group
(Rachmani et al. 2005). The data analysis presented, clearly displayed that the better clinical
outcome was in the PP group.
Discussion and conclusion.
The findings were discussed more in-depth in this section of the article. The diagnostic
criteria and outcomes were examined and the one limitation discussed. It was stated that “the
present study isolates and highlights the indirect effect as there was no direct pharmaceutical
intervention in either group” (Rachmani et al. p. 413). This also can be seen as a limitation but
study was performed to test whether intensive education and motivation would provide better
outcomes. In conclusion the researchers stated that “the empowerment of the patients to monitor
their disease, the availability of the consultants, and the reinforcement of education and
motivation” (Rachmani, et al. p. 413), were the deciding factors in the decline of risk factors of
patients with diabetes.
Article 2
Problem/propose statement and population.
The problem and purpose statement are found in the background and aim section of the
abstract. The problem and purpose statement was clear and concise; it included the population,
variables and is empirically testable. The purpose of the study was to assess the difference in
CHD risk levels among the identified population when provided self-glucose monitors. The
author stated that the population being studied was Afro-Caribbean diabetic women (Ezenwaka
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
et al., 2011).
Review of literature, theoretical and conceptual framework.
There are thirty-three references listed, there is a mix of classic and current sources with
the dates ranging from 1987-2008. The sources relate appropriately to the subjects discussed in
the purpose statement; diabetes and coronary heart disease. The article stated that there is
currently only one existing study on the CHD risk profile among diabetic patients in Trinidad
and Tobago, but the name of this study was not identified to the reader. Theoretical framework
was used to guide the study. The researcher used the United Kingdom Prospective Diabetes
Study risk engine to estimate the 10 year CHD risk among the patients. This framework is
appropriate for this study because the risk engine incorporates HgA1c into the calculation. The
research study did not include a hypothesis.
Limitations.
Limitations of the study were mentioned in the discussion section of the article. There
were three identified limitations of the study. The first limitation was that the women in the study
showed motivation to monitor their blood glucose but this is an unlikely fact for the general
population. The second limitation was that compliance to medication and lifestyle changes were
not factored into the study. The last limitation was that the population sample was small,
containing only forty-nine people (Ezenwaka et al., 2011). A population sample this small may
not be an appropriate representation of the population.
Research design/data collection.
In this research study a time series design was used. The researcher observed and
measured the patients at the beginning, at three months, and last at six months. The design and
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
tools being used were clearly identified in the study. The tools used in the study were the
UKPDS risk engine and the glucose monitors. The female patients that participated in the study
were previous patients to the clinic who had participated in a project on blood glucose
monitoring. The patients were given leaflet handouts explaining the objectives and protocol of
the study. Twenty-three patients made up the intervention group and twenty-six made up the
control group. The patients in the intervention group were given glucose monitors and were
educated on how to use them. The control group was instructed to not monitor their blood
glucose during the study (Ezenwaka et al., 2011). Identifying these concepts on the research
design and the data collection process gave the reader a clear understanding of the study.
Data analysis and results.
The data analysis was found under the results section of the study. The results were listed
as statistical data in the text and were also displayed in tables and bar graphs. The HbA1c levels
of the intervention group decreased to 7.3 from 9.2 after six months of monitoring blood glucose.
The patients in the control group had almost no change in their HbA1c levels. The intervention
group decreased their risk for CHD by almost half of what it was prior to the study (Ezenwaka et
al., 2011). These results were clearly stated in the text, tables, and bar graphs.
Discussion and conclusion.
The discussion section of the study further examines the results. The researcher
concluded that even though diabetic Afro-Caribbean women are at low risk for developing CHD,
self-monitoring of blood glucose further decreases the risk. It was also concluded that the HgA1c
was the best measurement that could have been used to measure long term blood glucose control.
The study has strong evidence that patients who monitored their blood glucose levels were able
to have better control of their diabetes and decrease the risk of secondary diseases such as CHD
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
(Ezenwaka et al., 2011).
Article 3
Problem and purpose statement.
The purpose statement is presented in the introduction of the article. “little is known
about the understanding of blood pressure (BP) or awareness of BP and lipid targets that people
with diabetes have, especially those with established vascular disease”, (MacMahon Tone et al.,
2011, p. 89-90). According to Nieswiadomy sources for research include previous research as
well as personal experiences and literature sources (2008). From the references in the purpose
statement included by the authors it is obvious that they are using previous research and
literatures sources to aid in guiding their research. The authors also mention their own previous
research on vascular interventions in patients with type two diabetes in the background section of
the article (MacMahon Tone et al., 2011), so they have their own research to build on as well.
The reader could also conclude that the authors have some personal interest in the topic as well
as they have done at least two research studies in patients with type two diabetes and
cardiovascular disease risk reduction.
The aim of the present study was to compare the retention of diabetes and heart disease
knowledge between the two groups (nurse-led vs. standard care) from the intervention study at
18 months after study completion. The authors hypothesized that participants in the intensive
group, who had received more focused input, would retain greater knowledge (MacMahon Tone
et al., 2011, p. 90).
The problem statement should meet the following criteria that (1) it is written in
interrogative form, (2) includes the population that is to be included in the study , (3) the
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
variables are included and (4) can be empirically tested (Nieswiadomy, 2008). Although the
statement given by the authors meets almost all the criteria presented by Nieswiadomy for a
purpose statement, it lacks interrogative form. Instead of being written in a statement form it
could be rewritten as “Do the participants in the nurse-led intensive group retain greater
knowledge of diabetes and heart disease than participants given standard care?” According to the
text, a question seems to “demand an answer more that the declarative form” (Nieswiadomy,
2008, p. 81). The other three criteria are met by the statement. The population is defined in the
statement “the two group from the intervention study” (MacMahon Tone et al., 2011, p. 90). The
problem is testable by other researchers; however it seems from the information given that
researchers wanting to repeat this study will also have to complete the first study done by these
authors as this is an off branching of a previous study. The variables are also defined in this
statement as “the two groups (nurse-led vs. standard care) from the intervention study”
(MacMahon Tone et al., 2011, p. 90).
Review of literature.
References to other studies are made throughout the article. The authors of the article list
29 references in their article, however there are several references that are not referenced to
throughout the text of the article, but all the citations within the text are found on the reference
list. The reference list appears to be free from major errors (Nieswiadomy, 2008).
It is difficult to be sure if the references used are considered classic sources unless the
reader is an expert in this area of study, however the articles are dated from 2001 to 2009 making
it suspect that there are not many, if any, classic sources cited by these authors (Nieswiadomy,
2008). All the articles do come from journals so the reader can infer that the sources are primary
sources (Nieswiadomy, 2008).
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
The authors present research information that both supports and opposes their research
and research findings (Nieswiadomy, 2008). MacMahon Tone et al. present a study that opposes
their high rate of findings that BP control is known by the participants to be important as part of
diabetes treatment (2011). The same opposing study also showed a higher level of participants
knew their ideal cholesterol levels (MacMahon Tone et al., 2011).
Theoretical and conceptual framework.
No theories or theoretical framework is presented in this study. One could wonder if the
theory of learning or a learning model was used for this study, but it is not discussed within the
text of the article.
Limitations.
Study limitations are specifically discussed and acknowledged by the authors. According
to the text the authors should openly acknowledge study limitations (Nieswiadomy, 2008). The
design of the study is a self-reporting questionnaire with no means to verify accurate
information, participants may have received information on diabetes control and cardiovascular
risk factors from other sources during the intervention and the following 18 months, and last,
discussed within the article there was no validation to the questionnaire, but no other
questionnaires were available for the researchers to assess their questionnaire for this study
(MacMahon Tone et al., 2011). It is noted that no standard instrument exists for assessing
patients for their knowledge base on diabetes and cardiovascular risks (MacMahon Tone et al.,
2011).
Mortality, when participants do not complete the study (Nieswiadomy, 2008), is
addressed early on in the article by the authors. A total of 9 participants defaulted during the
study and dropped out, three from the standard group and six from the intensive group and a total
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
of three participants died, two from the standard group and one from the intensive group
(MacMahon Tone et al., 2011).
Research design.
The posttest only design was used in this study (Nieswiadomy, 2008). Participants were
randomly assigned to groups, given either the standard diabetes follow up care or the intensive
nurse-led cardiovascular follow up and then given a questionnaire 18 months after their
interventions to assess the amount of information retained after the intervention (MacMahon
Tone et al., 2011).
Population and data collection methods.
The population studied in this study was participants in a standard or nurse-led
cardiovascular clinic from a previously conducted study (MacMahon Tone et al., 2011). This
would be considered purposive sampling because the subjects were chosen for previous
participation in the intervention study (Nieswiadomy, 2008). For the interventional study, the
participants were chosen for a diagnosis of type two diabetes and at least one cardiovascular risk
factor (MacMahon Tone et al., 2011). The time frame is also clearly defined as 18 months after
the intervention was completed (MacMahon Tone et al., 2011).
Data was collected through questionnaire sent to participants and compiled into the
Statistical Package for Social Sciences program for analysis (MacMahon Tone et al., 2011).
Sources of error were discussed by the authors as there was no way to validate the questionnaire
used to evaluate the accuracy of the information reported by the participants and there are no
other existing instruments to evaluate participant knowledge of cardiovascular risks and type two
diabetes to validate their questionnaire against (MacMahon Tone et al., 2011).
Discussion and conclusion.
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
It was concluded by the authors that “assessment of patient knowledge is important for
education to be tailored to meet individual needs” (MacMahon Tone et al., 2011, p. 96). Other
recommendations including making time to listen to the patients concerns, providing
encouragement and advice on lifestyle and measuring and monitoring risk factors (MacMahon
Tone et al., 2011). It is also recommended that educational programs should not only include
information on the consequences of prolonged hyperglycemia, but information on risks of
hypertension and dyslipidemia as well (MacMahon Tone et al., 2011). Finally the authors
recommend that "educational programs should be patient centered, flexible and quality assured"
(MacMahon Tone et al., 2011, p. 96). The study concluded that the retention of knowledge in
both groups was poor, but that overall awareness of cardiovascular disease risk factors was better
than previous studies (MacMahon Tone et al., 2011).
Article 4
Problem, purpose, and hypothesis
The purpose of this article is very clearly stated as the study aim. The researchers were
looking to make a comparison between HbA1c levels, CHD risk, and QOL between diabetic
patients enrolled in a self-management program vs. diabetic patients from the control group who
received only general nursing care. The hypothesis of the article, “that diabetic patients receiving
a self-management program would have lower levels of HbA1c and CHD risk, and a better QOL
than those receiving the usual nursing care” (Wattana, Srisuphan, Pothiban, & Upchurch, 2007,
p. 136), is also clearly stated and lists both population and independent and dependent variables.
The hypothesis is also testable and verifiable. The researchers additionally included the research
question, “after 24 weeks, is there any difference in the HbA1c, CHD risk, and QOL between
diabetic patients receiving a diabetes self-management program and those receiving the usual
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
nursing care” (Wattana, Srisuphan, Pothiban, & Upchurch, 2007, p. 136)? Again, the research
question presented is directional and testable.
Review of literature, theoretical and conceptual framework.
The researchers listed 33 different literature sources. These sources were both current,
and classic, and the majority of the articles cited were primary sources. The researchers discuss
the differences in their findings with that of opposing findings and studies. References were
written in appropriate format and inclusive of all of the required information.
A conceptual framework was utilized by the researchers for this study. This is indicated
by the use of several theories being used by previous research that had been conducted.
Limitations.
Limitations of the study were discussed as part of the articles conclusion. The limitations
included; a small sample size and the fact that the research was only conducted within one
geographical location. The authors made the recommendation, that further research should be
completed with a larger sample size, as well as with randomly selected participants comprised
from different locations (Wattana, Srisuphan, Pothiban, & Upchurch, 2007). This would increase
the support and generalizability of the study.
Research design/data collection.
The research design was a randomized controlled trial. All participants were randomly
placed in either the experimental or control groups. Informed written consent was obtained prior
to data collection and patients’ confidentiality was maintained throughout the study. The study
was approved by the Research Ethics Committee of the Faculty of Nursing at Chiang Mai
University, Thailand. Prior to the study and again at the end of a 24 week period, both groups
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
were re-evaluated. HbA1c levels along with a cholesterol blood panel were drawn, a QOL
questionnaire was given, and a CHD risk profile was completed for all patients in both the
control and experimental groups (Wattana, Srisuphan, Pothiban, & Upchurch, 2007, p. 136).
Data analysis and results.
The researchers displayed the results on two tables. Descriptive statistics were used to
evaluate patients’ demographic data while an independent t-test, Fisher’s exact test, rank sum
Mann-Whitney U-test, and X squared test for examination of the treatment group and control
group at baseline (Wattana, Srisuphan, Pothiban, & Upchurch, 2007). ANCOVA, the analysis of
covariance was utilized in determining the difference in the mean scores of CHD risk, QOL, and
HbA1c (Wattana, Srisuphan, Pothiban, & Upchurch, 2007).
Results indicated that the diabetes self-management program successfully promoted a
decrease in HbA1c, decrease in CHD risk factors, and an increase of overall QOL.
Recommendations by the researchers include,
“Diabetes self-management programs should be promoted in both community hospitals
and primary-care settings by incorporating them into the regular care. Diabetes selfmanagement should also be addressed in nursing education. Staff and registered nurses at
diabetic clinics will be key in promoting and educating diabetic patients about selfmanagement. A short course in the diabetes self-management training program should be
developed for the nurses and nurse practitioners who work at the diabetic clinics. It
should focus on self-efficacy as the concept of self-management to promote behavior
changes, as well as specific skilled behaviors” (Wattana, Srisuphan, Pothiban, &
Upchurch, 2007, p. 140).
Discussion and conclusion.
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
The discussion section of the study reiterates the study results and compares them to previous
studies, including one with opposing results. The specific tools utilized were discussed as well as
their benefits and potential need for improvements and changes in future research. The
researchers concluded, through their study, that the implementation of a diabetes selfmanagement program could in fact alter diabetic patients’ HbA1c, CHD risk, and QOL. This was
clearly stated in the conclusion portion of the article, as well as a reiteration of tools used, and
study limitations.
Experiences
Based on our experiences, this group of cardiac nurses agree, that diabetic education has
been grossly overlooked in the acute care of our patients, especially in reference to the
relationship between diabetes and heart disease. Time constraints and lack of diabetic education
knowledge are two of the major reasons we feel that this important intervention is not
implemented. Diabetic education is usually done in an outpatient setting, unfortunately many
patients’ we have worked with are newly diagnosed diabetics and some are unaware of their
diabetic condition until a cardiovascular or other vascular disease brought them to us.
On the open heart unit at Munson Medical Center the surgeons have enlisted the care of
an internist for a large majority of their diabetic patients. This is to facilitate better management
once the patient is discharged. It has also brought about a huge opportunity for education for the
nursing staff as well. The nurses are now aware of community education opportunities,
educational classes, new oral medications, diet and weight control recommendations, and the
importance of early detection in an effort to manage, control, and decrease the incidence of
complications of heart disease.
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
Recommendations
Our group is unanimous in agreement that the literature supports a recommendation of
implementing a diabetic self-management program for diabetics. The literature shows that a
self-management program has the potential to greatly reduce cardiovascular risk factors. Even
though the evidence was a small representation of the population, the results between the control
and intervention groups were significant. A movement towards preventative screening and
education on a wide scale basis should be implemented, otherwise the education needs to start in
the acute care setting, but be followed up in an outpatient setting.
Conclusion
In all four articles, researchers found strong evidence, that empowering patients with the
knowledge needed to monitor their diabetes, decreased their risk of secondary CHD. Deciding
factors were decreased HbA1c levels, decreased cardiovascular events, increased quality of life,
and increased overall awareness of cardiovascular disease risk factors. Limitations to these
research studies were the small population samples enlisted, which could prove to be a threat to
the external validity. Internal validity was intact with the researchers having control of all
variables except the dependent variable.
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
References
Center for Disease Control. (2011). National diabetes fact sheet, 2011. Retrieved July 11, 2011,
from http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
Ezenwaka, CE., Dimgba, A., Okali, F., Skinner, T., Extavour, R., Rodriguez, M., et al. (2011).
Self- monitoring of blood glucose improved glycemic control and the 10-year coronary
heart disease risk profile of female type 2 diabetes patients in Trinidad and Tobago.
Nigerian Journal of Clinical Practice, 14(1), 1-5. Dio:10.4103/1119-3077.79230
MacMahon Tone, J., Gallagher, P., Agha, A., & Thompson, C. J. (2011, ). Patient knowledge of
risk factors 18 months after a nurse-led vascular intervention. Journal of Diabetes
Nursing, 15(3), 89-98. Retrieved from http://0web.ebscohost.com.libcat.ferris.edu/ehost/detail?vid=7&hid=111&sid=8a13c4f3-450041a8-998ac4b32576b42e%40sessionmgr111&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=c
in20&AN=2011027194
Nieswiadomy, R. M. (2008). Foundations of nursing research (5th ed.). Upper Saddle River, NJ:
Pearson Prentice Hall.
Rachmani, R., Slavachevski, I., Berla, M., Frommer-Shapira, R., & Ravid, M. (2005). Teaching
and motivating patients to control their risk factors retards progression of cardiovascular
as well as microvascular sequelae of Type 2 diabetes mellitus—a randomized prospective
8 years follow-up study. Diabetic Medicine , 22(4), 410-414. Doi:10.1111/j. 14645491.2005.01428.x
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
Wattana, R. M., Srisuphan, R. M., Pothiban, R. M., & Upchurch, R. P. (2007). Effects of a
diabetes self-management program on glycemic control, coronary heart disease risk, and
quality of life among Thai patients with type 2 diabetes. Nursing and Health Sciences , 9,
135-141.
EFFECTS OF EDUCATION ON DIABETICS CARDIOVASCULAR RISKS
Paper #1 Evidence-Based Group Project Paper
Grading Criteria
30% of grade for paper can be deducted for APA errors including Spelling and grammar after
paper graded.
Headings
Possible Points
points Earned
Abstract and Title Page
10
10
Introduction
(What is the problem or question; Provide support for
relevance of the question; Clearly describe the aim of the
project & paper)
10
10
A descriptive summary of the most relevant & best
evidence to answer the research question (there is not
analysis here, just a description of what you found in the
literature)
20
20
An analysis of the evidence (this is a critical appraisal of
the evidence and what you feel as a group the evidence
suggests and whether there is strong or weak evidence to
support the suggested findings)
20
18
Describe how the evidence is affected by your
experiences as nurses, patient preferences, nursing's
or other's values and how these factors would
influence your decision to utilize the evidence in
practice
Make a recommendation as to whether or not to
utilize the evidence (support your recommendation with
rationale)
APA spelling and
Grammar Deductions
20
20
20
20
Total points
100
Comments
I didn’t see evidence
if you felt each was
strong or weak.
-2
96
Good paper to do as a poster presentation. STT has a forum in the fall for a poster presentation.