Barriers to Outpatient Education

Diabetes is the chronic illness associated with increased risk of hospital re-admission. According to the literature 20% of the patients diagnosed with diabetes are found to be rehospitalised within 30 days. Further, 30% of these patients are found with rehospitalisation more than once in a year (Rubin, 2015). This trend is commonly observed in the patients with low educational attainment, low income, those without private insurance, low medication adherence among other socio-economic factors.  There are patients who are failing to acknowledge diabetes at discharge (Stenberg et al., 2018). There is a growing literature on the education of patients with poorly controlled diabetes. However, there is a very limited research on the impact of involving the diabetes specialist team in this process. There is literature available on the positive impact of diabetes education by nurses on decreasing hospital readmission within one month. It was to improve glycemic control (Powers et al., 2015). It includes increase in the A1c levels and medication adherence. However, there is limited research on the impact of inpatient education on diabetes management and decreasing the readmission rates. Hence, there is a need to explore the need for inpatient diabetic education consultation in patients with poorly controlled diabetes and evaluate the benefits of the education to the healthcare

The problem area is significant in the sense that there are various barriers to the outpatient education. It includes poor access, competing medical priorities and coverage. Inpatient education may reduce the barriers of the outpatient education. There is lack of resources for educating patients with challenging diabetic cases (Wexler et al., 2012). Consequently, at the time of discharge, patients leave with several unmet needs. It may be related to follow ups, medication reconciliation, supplies of medications, self-management and survival skills (Horigan et al., 2017). In future, there may be further increase in hospital readmission of these patients. It is estimated based on increasing number patients with co-morbidities.  The need for inpatient education is significant issue as the comprehensive education is given in outpatient setting that deals with self management strategies. It is considered that the patients are not suitable for comprehensive education in inpatient setting. Inside the hospital the focus is mainly on the survival skills.

The study on this area is justified as there is a gap in the literature pertaining to the efficacy of inpatient diabetes education program on illness management and rehospitalisation rates.  The poor management of diabetes and rehospitalisation signifies the need to address the problem with evidence based intervention. There is a gap in literature regarding the content of the education program in inpatient setting and required resources. In order to increase percentage of people well managing diabetes symptoms and reducing the frequency of the rehospitalisation, it is imperative to provide education in inpatient setting. To achieve such target it is imperative to understand the needs of education of the diabetic patients. It will help design effective education program by the nurses and the clinicians and critically analyse the effectiveness of such program and recognise the benefits to health care. This area needs to be explored to recommend the detailed diabetes education in inpatient education. This research is significant as it will contribute to the literature that mainly deals with effectiveness of diabetes education when given in outpatient setting.

Importance of Understanding the Needs of Education of Diabetic Patients

The aim of research is to understand the need for inpatient diabetic education consultation in patients with poorly controlled diabetes. The rational for the research is to develop valuable insights in promoting patient awareness about diabetes management through inpatient education. The outcome of the research would benefit the patients, students and prospective nurses in promoting the value of inpatient diabetic education. It may reduce the hospital readmissions in future as patients will be better able to manage diabetes.  

The research objectives are as follow-

• To identify the needs of the inpatient diabetic education in patients with poorly controlled diabetes
• To critically analyse the effect of  inpatient education consultation in patients with diabetes
• To evaluate the impact of education

In order to fulfil the purpose of the research, a secondary research would be conducted to examine the literature in this area.

Education and consultation have been seen to play a significant role in the control and management of diabetes.  Reports and evidences have revealed higher rates of presence of diabetes within the population of the Unites States. As reported by Mackey, Boyle, Walo, Gauthier & Cook (2015), the highest rates of type 2 diabetes have found in the south of the Unites States of America. Reports how that more than 29 million adults have diabetes and 86 million have pre-diabetes. Investigations have pointed towards the presence of inactive lifestyle, bad eating habits, addiction to alcohol and smoking as some of the causes which aggravates the symptoms of diabetes within the population (Hardee et al., 2015). Some of the diabetes education topics which are most actively taught to the patients are – nutrition management, monitoring of blood glucose, hypoglycaemia symptoms, treatment and insulin adjustment.  As commented by Drincic, Akkireddy & Knezevich (2018), educating the patients regarding diabetes survival skills can help in the provision of effective training to the patient to enable them a safe transition back to their home.  However as supported by Rushakoff, Rushakoff, Kornberg, MacMaster & Shah (2017), inspite of the need for inpatient diabetes education program many hospitals failed to provide the required training programs. This could be attributed to the lack of time and finances within the healthcare setup. The availability of space made outpatient venues more suitable for teaching lifestyle modifications in diabetes care. The research has been further evaluated through a number of objectives which have been further developed into the research question. The current section discusses the literature through main few sub themes as below:

Diabetes care and management could be handled through a number of educational and consultation programs within an inpatient setup. Some of these programs have been seen to produce positive effects in the reducing the readmission rates within hospitals by making the patients more self aware of their conditions and with a better control.  As commented by Wexler  et al.(2012), it is important to know the patient educational needs before designing of such as program. Some of the basic educational requirements of a person affected with diabetes have been listed over here which are – nutritional requirements and meal planning, importance of exercise and physical activity, effects of improvement in lifestyle on the health of the patients, self monitoring. However as argued by Kovarik  et al. (2016), the mode of administration and individual patient responses vary. In order to understand the health needs of the patient it is necessary to conduct a detailed clinical examination of the patients. Based upon the results of the clinical tests an appropriate plan for clinical care could be designed. However, there are a number of barriers which affect the quality and the quantity of data generated. Some of these are lack of trained diabetes educators, lack of protocols for conducting an effective inpatient diabetes management program, lack of computerized records and no standard educational curriculum. As supported by Rushakoff, Rushakoff, Kornberg, MacMaster & Shah (2017), the hospitals lack the effective infrastructure for conducting an inpatient education program. Additionally, there is lack of funds from the some of the supporting agencies which limits the resources required for the program. As argued by Hardee  et al. (2015, the presence of a large and diverse focus group often makes it difficult to design an effective educational strategy for the group. This is because the health needs of individual within the group may vary.

Potential Benefits of Inpatient Education to Healthcare

As commented by Essien, Otu, Umoh, Enang, Hicks, Walley (2017), the need for a diabetes management program is the most crucial for managing of the health condition and symptoms of the children as well as the older adults. As commented by Olson (2018), the children are most dependent upon their parents. Therefore, educating the parents regarding the right methods of delaing with the diabetic condition of their children by self managing the medications can give them autonomy. As reported by SARA, Dawn Black & Andrew Lorrenz (2018), 7.2 % of the older adults are dependent upon inclusion for controlling their blood glucose level. Therefore, the self managerial techniques can help them in gaining control of their day to day activities without  the need to visit the hospices.

  Consultation and education programs can contribute significantly in the development of the self control skills within the patient population.  Some of these are development of more awareness regarding lifestyle and dietary habits. As supported by Muchiri, Gericke & Rheeder (2016), fat and oil rich foods have been contributed significantly in the development of high blood cholesterol and hypertension. As commented by Essien  et al. (2017), a direct link have been found between consumption of fat rich foods and development of obesity as this are not digested easily by the liver. Obesity has been seen to make the conditions of diabetes worse. Evidences have been gathered from a number of diabetes management study programs for understanding the contribution of these in the development of self –management skills. The effects of diabetes education on patient health outcomes had been measured with the help of randomised control trial in a Nigeria based hospital. From the reports and evidences it was found that the burden of growing diabetes was significantly felt in the low and middle income countries. However, as supported by Kemmerer, Bashura, Dintzis, Mathioudakis & Golden (2015), there were a number of gaps such as the mechanisms via which the program achieved its results were not discussed. The success of the educational programs in the development of self control measures in the participants further depends upon the educational rate of the patients. Inspite of using simplified educational materials during the trial it was difficult to decipher the amount of impact produced upon the participants. In this respect, provision of oral and written information may have benefitted the highly educated participants more.  As commented by Dungan  et al.(2015), educating the patient about glycaemia control can also help in development of better self management strategies. However as supported by Wexler  et al. (2012), the self management education has to undergo through a number of barriers before the program could be actually successful. Some of these are the amount of knowledge possessed by the patients regarding their present health condition, the behaviour and beliefs possessed by the patients. Therefore, the success of the consultation techniques is dependent upon a number of psychological mediators.  The outcomes could be further divided into short and long term outcomes. The short objectives can help in gaining better glycaemia control whereas the long term objectives can help in the improvement of the quality of life.

Diabetes Care and Management through Inpatient Educational and Consultation Programs

There are a number if benefits of the inclusion of diabetes inpatient program within a health care setup. Some of these have been discussed with reference to the current literature review. As commented by Olson (2018), increasing diabetes awareness hospital wide and implementing effective management systems can have lengths of hospital stay reduced. As commented by SARA, Dawn Black & Andrew Lorrenz (2018), improvement of the coding could more effectively the complexity of care provided. Glycaemia control is a cost effective strategy for the maintenance of diabetes. As commented by Kemmerer  et al. (2015), behaviour change is curial to self management. The primary objective is to understand the economic value of diabetes education within the patient population. In this regard, some of the government and federal government agencies have been providing reimbursements for the conduction of diabetes education program. A number of benefits have been observed with the implementation of the Diabetes Self Management Education Program (DSME). It helped in reducing the healthcare use among Medicaid users which resulted in significant lowering of the overall healthcare costs. As commented by Rushakoff  et al. (2017), the counselling for self management is associated with positive behavioural change. The increase in glycaemia control have been seen top reduce the risk of diabetes related health complications. The lifestyle intervention programs have been seen to control the rate of development of cardiovascular diseases. However, the efficacy of the program has been challenged by a number of limitations such as the lack of sufficient knowledge and expertise in the healthcare providers. Additionally, the patient population might be affected with a number of co-morbidities each of which requires separate intervention strategies. The American diabetes association focuses on the benefits of the attainment of a proper certification in inpatient diabetes care. The figures and reports point at the presence of an ineffective diabetes management and care.   Here, 20% of the patients admitted to US hospital end up having readmission within 30 days (Dungan et al., 2014). It could be related to the lack of effective follow up strategies. Therefore, inclusion of an inpatient program can improve the quality and the standards of care. Some of the objectives such as meal planning, safe medication administration are some of the self managerial skill which could reduce the dependency upon emergency trauma care or ambulatory setups. However as commented by Mackey  et al. (2015), the provision of an effective impatient program within the hospital premises often requires approval from a large number of multi channels including the stakeholders. Additionally, huge number of audio and video resources may be required for the conducting of the inpatient training. As supported by Essien (2017), managing sufficient space within the hospital working hours also becomes an issue.

The Development of Self Control Skills within the Patient Population

Research methodology can be defined as the systematic articulation of the step by step procedures that will be attempted in any research study in order to achieve the final outcomes of the study. A research methodology helps the researcher to underpin all the activities that is going to be undertaken to achieve the goal of the research in a very systematic and organized manner, it also helps a researcher to not miss out on any important step of the research (Taylor, Bogdan & DeVault, 2015).

For this research study the main research objective had been to discover the need for inpatients diabetic education consultation. It has to be understood that there are various related co-morbidities associated with diabetes. Along with that the patient’s often need to follow a strict and controlled lifestyle to ensure not aggravate the hyperglycaemia or in an attempt to not to trigger hypoglycaemia events as well. Hence health literacy and patient education is a very important concept that can help the patients avoid any risk of exacerbation and development of related disorders.  

As the purpose behind this research study had been to discover the key concepts in the researched need of impatient diabetic education consultation and the data had been based on the previous literature to explore and understand the pattern of change in the need.  Hence the research design had been completely qualitative, utilizing secondary data from relevant and authentic articles published in 2012 and onwards. The mode for research under qualitative study design had been a descriptive, with a set of research objectives and research questions predetermined by the researcher (Lewis, 2015). Different relevant and authentic search databases had been used for the literature that had been carried out in the study. Databases like Google Scholar, PubMed, Proquest, MedLine had been used to search for the literature evidence. The key search terms were designed with the use of boolean operators and research limiters to optimize the researching procedure and get maximum results. The search strategy focussed on discovering randomized control trial studies, review studies and observational studies in the need for patient education for diabetes and related health adversities. All articles with relevant and reliable data with inpatient sample setting were given preference. Any article published before 2012 were discarded along with the articles focussing on outpatient data or information. The articles with incomplete and no reliable findings were also discarded along with the journal articles that were not written on English.

Impact of Diabetes Education on Patient Health Outcomes

The data analysis for the research study had been thematic where the three specific key themes have been designed based upon the literature review. The themes have been extracted from the five articles chosen for the research. Each theme decided upon in the analysis had been critically linked with the research objectives and were discussed extensively in the discussion section. The extracted data from the research articles selected for the research study had been analyzed critically with respect to the research questions decided for the study and the final verdict had been based the link between the data found in the previous research literature published and the research objective (Silverman, 2016).

The limitation in this research had been the time constraint to sort out through the myriad of data available on the internet. Another limitation had been in the data findings that only considered the inpatient setting and is not transferable to the other patient care settings. This research study had been an excellent opportunity to understand the different patterns prevalent in the diabetic patient education. Although the researchers faced certain accessibility issues, few of the articles were later rejected and replaced by similar relevant articles. Hence it can be concluded from this research methodology that the researcher had been successful in extracting and analyzing in depth data from the journals that had effectively addressed the research questions and gas efficiently discovered the gap as well for further studies to explore (Flick, 2015). The findings of the secondary data collected are represented in the form of thematic analysis on the next chapter.

As per the results the educational needs of the diabetic patient identified are knowledge of meal planning, nutritional requirements, physical exercises, self-management, and effects of improvement in lifestyle. Further, patients need trained diabetes educators, and standard educational curriculum. The results on the educational needs of the diabetic patient imply that there is a need of appropriate strategy or protocol for designing appropriate education program.  Patient are in need of appropriate discharge planning which in most cases are unmet. There is very less data available on the educational needs of the diabetic patients undergoing surgery. It may be due to the complexity with surgical care and multiple comorbidities associated with it. Addressing this area will lead to earlier discharge of the patients and improved outcomes (Stenberg et al., 2018). According to Kovacs Burns et al. (2013) there is a need of variation in the health needs of the diabetic patients and there must be appropriate methodology to cover all the needs of different patients.   

Based on the literature review impact of the education on the self control of diabetes in the patients was found to be positive. The short term impact of the educational consultation is the control of the diabetes symptoms such as glycemic control, medication on time, healthy eating, screening for complications and knowledge of symptoms. The long term impact is no rehospitalisation within one month of the discharge. Further, benefits include modification of comorbidities other than improved glycemic control. Self control and monitoring measures in patients seem to be directly correlated with the diabetic education program, of the patients.  It is however associated with the educational attainment of the patients according to Ko et al. (2012). Patients with high educational attainment are benefitted by the written and oral information. The same in the patients with low educational attainment is doubtful (Gagliardino et al., 2012). The impact of the education consultation varies in different people depending on their values, beliefs and other psychological mediators. The long term impact of the education can be achieved by teaching the patient about survival skills instead of focusing on management of symptoms (Rygg et al., 2012).  However, there are very few studies covering this aspect.  

The benefits of the diabetes education program, to healthcare are plenty. The hospital can created efficient system of learning as management support is critical. It will help the nurses, administrators and the managers to reduce the readmission and save the health care costs. Inpatient education consultants are the unique opportunity created by the educators to diagnose the undiagnosed. Further benefits include improvement in medical coding and decreasing the complexity of care.  It addresses the limitations of the outpatient education as Medicare play a little.

The inpatient education consultations prevent the health care providers to postpone the unique learning needs of the patients according to Myers (2017). Despite the benefits there is an ongoing debate among the health care providers to invest in inpatient education consultant. There are several barriers to inpatient education as well. It includes lack of nurse’s knowledge on the learning needs of diabetic patients. Lack of sufficient diabetic educators and resources for inpatient education are other barriers (Munshi et al., 2016).  

There is a need of prospective randomised control trials in the future to determine the impact of the actual inpatient diabetic education on management of the illness and comorbidities. Trials are recommended to assess the impact of such education in reducing the hospital readmission rates and its cost effectiveness. A more research is recommended to clinicians and researchers to determine the characteristics of the patients that predict greater benefits from the inpatient education (Wexler et al., 2012). There is also a literature gap in regards to learning needs of the patients undergoing major surgeries. Patients need inpatient education consultation for wound care, infection control and ways to adjust to glucose-lowering medications after discharge. Further studies are recommended to cover these areas.

As there are lack of knowledge among the nurses and the hospital managers about appropriate content of the education program in the hospital setting. Thus, there is the need to identify and develop the methodology of the inpatient education program. Diabetes as chronic illness is highly prevalent in developed countries. Considering the large number of diabetes affected patients, increasing hospitalisation rates, mortality rates, it is imperative to know the appropriate criteria to obtain an educational consult. It is important to know the content of such education program (survival skills Vs intensive skills). As per the literature review the, inpatient education program is recommended to focus more on survival skills self care. Further, institutions are recommended to come up with proper teaching guidelines, nursing care paths to teach patients with more disease comorbidities. A multi-component education program would be beneficial (Munoz et al., 2012).

 There is also literature available on the knowledge deficiencies of hospital staff, involved in inpatient diabetes education. It implies for staff training and education on what to teach the newly diagnosed diabetes patients. Thus, continuous education for nurses in the hospital is recommended as in some cases patients were found to be more knowledgeable than the nurses. Nurses must come up with interpersonal education tool (Herring et al., 2013). As the data obtained from this research signify positive implications of inpatient education in managing the diabetes symptoms and reducing the hospital readmission, it may be confirmed to further analysis. These results are important when considering the broad context of the complexities, poor management and rehospitalisation of diabetes patients.  In future, there may be the need to identify the appropriate resources for implementing the inpatient education as an integral part of the diabetes care (Powers et al., 2015).

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