The attached DNP-Project Paper need to be corrected as indicated. I need someone with extensive nursing knowledge and Doctor of Nursing Project to handle this for me.

All the highlighted portions of this project need to be updated and corrected as indicated by the Professor. Please read the professor’s comments to understand what she needed to be updated and corrected.

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6

Improving Medication Adherence in Diabetic Patients in Home Health Care Settings

Comment

by

Author: Bola, please use the updated DPI template that I shared with you previously. There are specific things within the template that are required. Your cover pages for example needs to follow the template.

Submitted by

Bola Odusola-Stephen

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

January 30, 2021

GRAND CANYON UNIVERSITY

Improving Medication Adherence in Diabetic Patients in Home Health Care Settings
by
Bola Odusola-Stephen

Proposed

January 30, 2021

DPI PROJECT COMMITTEE:

Mary Guhwe, DNP, Manuscript Chair

Bamidele Jokodola, DNP, Committee Member

Abstract

Home healthcare programs have been effective in the current environment as they provide a technique for improving health outcomes for diabetes patients. At the project site, although staff consistently assesses for patient medication adherence, there is no standardized process for addressing medication adherence when it is identified. Medication adherence project (MAP) resources have been utilized to improve medication adherence in chronic disease management. The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of Medication Adherence Project resources that include the Questions to Ask Pad, the Questions to Ask Poster, and the Adherence Assessment Padimpact medication adherence among Type II diabetic home healthcare patients, ages 35 to 64, at a home healthcare organization located in urban Texas. The theoretical frameworks guiding the project include ………….This paper shall assess the program in line with various articles that promote adoption of the technique. The peer reviewed journal articles would ensure the paper has factual information that ensure implementation of the home healthcare program would occur seamlessly. The inclusion of home healthcare providers promotes the validity of the program. Medication adherence rates will be abstracted from the EHR based on documentation from home health personnel and compared with baseline medication adherence rates.The project would use the proposed initiatives to enhance home healthcare provision based on the need to improve health departments. The project shall assess the validity of the proposed home healthcare initiative based on the availability of trained personnel to monitor patient outcomes. The methodology that shall get applied is using quantitate approach by studying various research articles about diabetes and home-based care. The quantitative approach shall get applied to determine how the proposed MAP resources would promote patient outcomes. The population size for the project shall be persons living with Diabetes in Texas. It shall be possible to enhance the project’s outcome based on the metrics mentioned.

Keywords: home-based care, MAP resources, quantitative approach, medication adherence, diabetes mellitus type II.

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

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Chapter 1: Introduction to the Project

According to the CDC (2020) diabetes impacts one in 10 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). There are two types of diabetes that plague a large proportion of Americans. Type I diabetes is dependent on insulin whereby the pancreas produces little amounts of insulin (Bellou, 2018). Type II diabetes is impairment related to the body’s ability to regulated glucose (Bellou, 2018). There are ways to curtail the onset of Type II diabetes; however, once individuals are diagnosed with diabetes, there is no cure (Kvarnström, 2017).

Among individuals with Type II diabetes, proper and effective medication adherence is critical (Kvarnström, 2017). According to the World Health Organization (2003), “increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvements in specific medication treatment.” Furthermore, Kvarnström (2017) stated that more than half of the population does not adhere to the prescribed medication regiment, thereby resulting in various health-related challenges. Health-related challenges associated with poor medication adherence include limited knowledge of patients, lack of proper technique of providing dosage, lac of patient self-management, and lifestyle constraints (Kvarnström, 2017). For individuals with Type II diabetes, lacking medication adherence can mean the difference between life and death (Rathish, 2019).

Various researchers have denoted the critical role that home healthcare providers play in promoting enhanced medication adherence (Bussell et al., 2017). Furthermore, the World Health Organization (WHO), as cited by Brown and Bussell (2011), explained that there are five factors that impact medication adherence, which include: (1) patient-related factors, (2) socioeconomic factors, (3) therapy-related factors, (4) condition-related factors, and (5) the health system/health care team-related factors. For the purpose of this project, the project investigator (PI) will explore focus on the role that health care team members play in addressing patient related factors that affect medication adherence enhancing medication adherence among home health care diabetic patients.

Background of the Project

Home-based healthcare has existed since 1909 (Choi et al., 2019). Since its inception, home-based healthcare has been perceived as a more costly method of patient care as compared to expenses associated with hospitalization (Singletary, 2019). In the early 20th century, home-based healthcare was mainly practiced due to financial disparities, specifically since many individuals were unable to afford hospitalized care. Furthermore, home-based healthcare was also practiced due to medical inaccessibility, which often existed in African-American communities to due to limited access to resources (Choi et al., 2019).

Present day, home-based healthcare is often selected due to an individual’s personal preferences. There are some situations in which individuals prefer the comforts of their own home as compared to that of a hospital or group home. As older generations continue to age, they often prefer to remain in their home for as long as possible. Given the needs of older generations and the impact of advances in healthcare and technology, home-based healthcare has grown exponentially (Wong et al., 2020). 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 and/or hypertension are often recipients of home-based healthcare (Wong et al., 2020).

Home healthcare providers often visit patients three and engage in assessment of the patient’s blood pressure, cognitive functioning, and adherence to treatment proposals. During patient visits, home healthcare providers are responsible for biological assessment of patients (Wong et al., 2020). One of the paramount functions of home healthcare providers is to ensure that patients are adhering to their medication regiment (Wong et al., 2020). According to Wong et al. (2020), medication adherence is predicated on medication understanding and education, which should be conveyed by home healthcare providers (Wong et al., 2020).

Adhering to diabetes medication regiment requirements can be complex. In fact, in a study by Rauofi et al., (2018), researchers noted that 0.1 % of diabetic patients did not properly monitor their glucose levels nor did they adhere to medication requirements. Dr. Goldbach, who is the Chief Medical Officer for Health Dialogue, stated, “Especially for people with chronic illness that are facing challenges like depression, or transportation, or complexity of medication regimens – that these interpersonal, trusted interactions with a nurse tend to be very effective” (Heath, 2019). Patients with diabetes often express difficulties in adhering to medication regimens, thereby reinforcing the critical role of receiving education from home healthcare providers (Wong et al., 2020).

In a study by Wong et al. (2020), home healthcare patients expressed that they did not have sufficient knowledge about the requirements associated with diabetes treatment. Often times, diabetic home healthcare patients fail to practice medication adherence, thereby resulting in health complications, which is due to unmanaged health conditions.

Problem Statement

The issue of implementation of the home healthcare-led Medication Adherence Project resources (e.g., the Questions to Ask Pad, the Questions to Ask Poster, and the Adherence Assessment Pad; intervention) will impact medication adherence (outcome) 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. It is not known if or to what degree the implementation of Medication Adherence Project resources that include the Questions to Ask Pad, the Questions to Ask Poster, and the Adherence Assessment Pad will impact medication adherence among Type II diabetic home healthcare patients, ages 35 to 64, of a home healthcare organization located in urban Texas.

At the selected project site, which is a home healthcare organization located in urban Texas, the stakeholders have cited that medication adherence among diabetic patients is lacking. In fact, according to data attained from the site’s electronic health record (EHR), home healthcare providers have documented that 0.1 % of diabetic home health care patients are not adhering to their medication regiment. At the project site, failure to adhere to the prescribed medication regiment has resulted in physiological issues. Although this percentage is lower than other percentages cited in the literature for medication non adherence in chronic disease management, Vvarious researchers have noted the implications associated with lacking adherence to medication regiments, specifically among diabetic patients (Heath, 2019), thereby reinforcing the need for this practice improvement project. Comment by Author: This is not such a huge percentage compared to the other percentages cited in the literature for non-medication adherence. Probably better for you to give a number of patients instead of the percentage. Also make sure this percentage is not based on calculations using the home health entire patient population as the denominator but rather only diabetic patients as the denominator and the non-adherent diabetic patients as the numerator.

According to (Kvarnström et al., 2017) healthcare providers play a critical role in ensuring medication adherence. While there are many reasons for lacking adherence among patients, for the purpose of this project, the WHO’s (2019) focus on the role of healthcare team members in enhancing medication adherence will be addressed.

As previously noted, among diabetic patients, lacking medication inherence at the project site is 45 %. Nationally, in home healthcare settings, lacking adherence to diabetic regiment is 14 % (Ong et al., 2018). In hopes of improving patient-related outcomes and reducing preventable issues, home healthcare nursing staff members will utilize medication adherence project tools, which were created by Starr and Sacks (2010). The tools utilized in this study, which are from the MAP Toolkit and Training Guide resources (Starr & Sacks, 2010), include: (1) a Questions to Ask Pad, (2) A Questions to Ask Poster, (3) a Medication Adherence Pad, and (4) the My Medications List. Before implementing these tools, the project investigator (PI) will provide a 30 minute information session on this project as well as the MAP resources educate home healthcare staff members about how to properly utilize these resources. Comment by Author: Please review your manuscript for inconsistencies and make sure the details are aligned. On page 4, you said this percentage was 0.1% and I even remarked that the percentage was small, please review and edit for the final percentage and make sure it aligns throughout. If it is really 45% then please edit the number on the previous page and the sentence that follows that addresses the prior small percentage that was listed Comment by Author: You need to edit your entire project and make sure you take out any references of the project as a study. I will not highlight all instances Comment by Author: Make sure you edit the rest of your manuscript to make sure that you do not use the word educate for the information session you will have the staff about the project. If you refer to it as education, you will need to measure an outcome for that education. So really important to keep it as an information session and edit that throughout your manuscript

During the onset of this project, once home healthcare nursing staff members have attended the educational training session, patients will be assessed for patient specific medication adherence barriers using the medication adherence pad and then educated about the importance of diabetes-related medication adherence as well as other medication related questions that they can ask their healthcare provider or pharmacist. Specifically, nursing staff members will address the items of using the Questions to Ask Pad and the Questions to Ask Poster. Then, patients will be asked the question noted on the Medication Adherence Pad, which states, “What gets in the way of taking your diabetes medicines?” To further understand some of the challenges associated with medication adherence, and to answer any additional questions or concerns noted by patients, the nursing staff members will keep detailed notes about rationale for medication non-adherence which is noted by patients All of this assessment and education will be documented in the HER per current documentation process.. Finally, after providing patient-specific education, home healthcare nursing staff members will ask patients to complete the My Medications List to ensure an accurate medication list is maintained in the EHR. During every home healthcare meeting, nursing staff members will explore medication adherence concerns and adjust the My Medications List accordingly.

To explore the impact of the intervention, the PI will compare pre implementation medication non adherence rates in diabetic patients receiving home health services at the project site to post implementation medication non adherence rates after implementing the MAP resources. pre-project implementation data, from March 1 2021 to April 30th, 2021, to post-project implementation data. Medication adherence data is available through the project site’s EHR. This project will take place over a four-week period from June 1st, 2021 to July l 30th, 2021. The ultimate goal of this project is to enhance medication adherence among Type II diabetes patients, through the involvement of home healthcare providers, thereby resulting in enhanced patient related outcomes. 

Purpose of the Project

The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the MAP resources, which will be delivered by home healthcare nursing staff members, will impact medication adherence when compared to current practice among Type II diabetic patients, ages 35 to 64 in a home healthcare setting in urban Texas.

Medication adherence, which is the independent variable explored in this project, will be measured using data attained through the project site’s EHR. The MAP resources, which serve as the dependent variable explored in this project, include the (1) a Questions to Ask Pad, (2) A Questions to Ask Poster, (3) a Medication Adherence Pad, and (4) the My Medications List. Comment by Author: Make sure this matched your purpose statement from prior pages that I corrected Comment by Author: This is incorrect. Medication adherence is the dependent variable. You have it right in other parts of your manuscript so this is all editing that just needs to be updated. I will not highlight this throughout the manuscript so make sure you edit your manuscript throughout Comment by Author: This is the independent variable. Make sure you edit this throughout your manuscript and ensure it aligns and is corrected throughout. I will not highlight this throughout the manuscript

The selected project site, which is located in urban Texas, serves 100 patients, on average, each month. Of the total number of patients, approximately 20 patients have Type II diabetes. Patients with Type II diabetes, who are between the ages of 35 and 64, and are of sound mental status, will be the target population for this project. The goal of the PI is to improve medication adherence among Type II diabetic patients, through the implementation of the MAP resources. Comment by Author: Anytime you speak of the goal of the project you are discussing the purpose of the project so really to stick to the same purpose statement anything you speak of the goal or objective of the project. Please edit throughout your manuscript and ensure that it aligns throughout

The project is significant since home based healthcare enhances the outcome of treatment initiative. Wong et al. (2020) stated that physicians visit patients to ensure proper status of patient’s blood pressure, cognitive functioning, and adherence to treatment proposals.

Starr and Sacks (2010) explained that engagement with health care providers was imperative to ensure expected outcomes. Biological assessments get conducted to ensure treatment approaches at home would not be affect by social encounters. The project is vital as it enhances positive outcomes after assessing diabetes occurrence, effects, and management.

Clinical Question

This project will explore the impact of the MAP resources, which include the (1) a Questions to Ask Pad, (2) A Questions to Ask Poster, (3) a Medication Adherence Pad, and (4) the My Medications List, on improving medication adherence among diabetic patients, ages 35 to 64, who are receiving home-based care through the selected project site. The PI will explore how the use of the newly implemented MAP protocol contributes to medication adherence among patients over a four-week period. Pre-project data will be analyzed from March to April using the project site’s electronic health record, to determine medication adherence among patients. After the four-week implementation of the newly revised medication adherence protocol, using MAPS, post-project data will be explored. Comment by Author: See comments about when you discuss what goal objective or purpose for the project Comment by Author: Please edit and remove this word throughout the manuscript. Your project is not going to explore….it is going to evaluate ….the two are different in that exploration is more qualitative and evaluation is more quantitative Comment by Author: I edited this in your abstract so please use that edited version and edit this section and throughout your manuscript to make sure it aligns throughout. I will not highlight every instance

Prior to the project’s implementation,Currently, the nursing staff members of the selected project site assessed medication adherence using interviews and observations of the site. Unfortunately, the method of assessing medication adherence differsed among nursing staff members. The medication adherence assessment in documented in the EHRMedication adherence, before the implementation of this project, was documented physicians and home aides using the project site’s electronic health record. Since there is was not site-specific patient protocol developed/utilized to encourage medication adherence among patients, this project is necessary to ensure standardization of the process as well as ensure appropriate addressing of any patient specific medication adherence barriersconduct.

At the selected project site, issues associated with nonadherence to medication regimens, among diabetic patients, has been an ongoing problem. In fact, according to nurses from the project site, 20 % of diabetic home healthcare patients do not adhere to the medication regimen. Therefore, in hopes of improving medication adherence, which can result in improved patient-related outcomes (e.g., control of glucose levels and moderate production of insulin), the PI has selected MAP’s resources. Through introducing MAP resources into practice, when home healthcare providers interact with diabetic patients, it is likely that medication adherence will be improved. Comment by Author: This number keeps changing throughout the manuscript . You 0.1% initially and then it changed to 45% and now it is 20%. Really need to pin this down and be consistent throughout the manuscript as well as the 10 strategic points document.

The following PICOT question will guide this project: To what degree does the implementation of Medication Adherence Project resources that include the Questions to Ask Pad, the Questions to Ask Poster, and the Adherence Assessment Pad 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 4 weeks.

To what degree does the implementation of the newly implemented MAP protocol (i.e., the [1] a Questions to Ask Pad, [2] A Questions to Ask Poster, [3] a Medication Adherence Pad, and [4] the My Medications List) impact medication adherence when compared to no standardized protocol among Type II diabetic patients, ages 35 to 64, in a home healthcare organization in Texas over four-weeks?

The following clinical question guide this quantitative project:

Q1: Does using the MAP resources improve medication adherence among diabetic patients patients in home healthas compared to no standardized medication adherence protocol?

Advancing Scientific Knowledge

This quality improvement project seeks to enhance medication adherence among diabetic home healthcare patients through the use of the MAP resources. As previously noted, at the selected project site, medication adherence among home healthcare patients is lacking. In fact, according to Polonsky & Henry (2016), of all home healthcare patients, diabetes patients of the project site have the highest rates of medication nonadherence. According to information gathered from the home healthcare’s electronic health record, from 2018 to 2019 10% of diabetic patients did not adhere to their prescribed medication regimen. Issues associated with lacking medication adherence/nonadherence include high medical bills for future management, limited glycemic control, and frequent hospital visits (Polonsky & Henry, 2016).

Various researchers have noted the critical role that patients and providers play in medication adherence. In fact, according to Polonsky & Henry (2016), patients often do not adhere to their medication regimens because ignorance. To enhance medication adherence, providers can provide education about the critical nature of adherence, can offer information about issues associated with nonadherence, can assist patients in overcoming noted medication concerns, and more. For the purpose of this project, the aforementioned provider-specific medication adherence support will be provided using (1) a Questions to Ask Pad, (2) A Questions to Ask Poster, (3) a Medication Adherence Pad, which all comprise aspects of the MAP protocol.

In addition to the important role that nursing staff members play in terms of a patient’s medication adherence, patients also need to be committed to ensuring they are complying with their medication regimen. Lacking adherence to the prescribed medication regimen, by diabetic patients, can result in inability to control glucose and insulin levels (Polonsky & Henry, 2016). At the selected project site, issues associated with lacking diabetes medication adherence have resulted in inability to offer suitable diagnosis to some patients. Through providing patients with resources and support related to medication adherence, through the three MAP resources, and by empowering patients to keep track of their medication regimen, patient adherence can improve. To empower patients to enhance their medication adherence, the My Medications List, which is available through MAP, will be utilized.

In addition to project site-specific medication adherence issues, various researchers have noted that medication adherence among diabetic patients is lacking a great deal. In fact, in a study conducted by Ong et al., (2018), medication adherence among diabetic patients was 7 %. Furthermore, Ong et al., (2018), noted that medication adherence, despite the implementation of nurses’ participation only improved by 50%. Various researchers have cited the benefits associated with patient-provider engagement and collaboration in improving medication adherence. Therefore, to answer a call by researchers (Ong et al., 2018, Polonsky & Henry, 2016 and Wong et al., 2017) to improve medication adherence among diabetic patients, the MAP protocol will be used. Ultimately, through improving medication adherence among diabetic patients, of the selected project site, using the MAP protocol, it is likely that a sitewide protocol can be utilized to enhance medication adherence among all patients. Although the project targets diabetes patients, the findings might provide insight about how to improve medication adherence among other home-based care populations (i.e., those with hypertension, heart disease, etc.).

Significance of the Project

The rise in chronic diseases has resulted in the need for more patient care options (Polonsky & Henry, 2016). Lately, to meet the unique needs of various population groups, home-based care has gained popularity. Individuals who qualify for home-based care options must meet the criteria of having type 1 or type 2 diabetes and have inability to cope well without intervention. When individuals/patients receiving home-based care fail to adhere to the care requirements set forth, negative outcomes can ensue (Polonsky & Henry, 2016).

Medication adherence among home-based healthcare patients is of the upmost importance (Polonsky & Henry, 2016). In fact, in a study conducted by Polonsky & Henry (2016). medication adherence among home healthcare patients was lacking a great deal. Due to lacking medication adherence/nonadherence, home healthcare patients experienced limited conformity to objectives of the study, thereby, at points, resulting in discontinuation of home-based healthcare.

Through empowering healthcare providers to adequately address medication questions and patient concerns and by ensuring the patients keep track of their medication regiment, it is likely that medication adherence can improve, thereby resulting in a reduction in adverse events. According to a study by Holecki et al., (2018) when the MAP resources were utilized, adherence to medication increased by a large margin. 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.

Caring for diabetes includes assessment of their grooming and diet. The condition often causes patients to have blisters, gum disease and dry mouth. It is thus imperative for the care giver to ensure proper adherence to the care procedures so that it would be possible to limit stress related to the other outcomes of diabetes. The cost of managing diabetes is often high due to the effects of low- and middle-income areas.

Rationale for Methodology

To answer the PICOT question, the PI will utilize a quantitative methodology. Specifically, the PI will examine if implementing the MAP resources will improve medication adherence over a four-week period as compared to a four-week period before, when no medication adherence protocol was utilized. Medication adherence data, at the selected project site, is available through the site’s electronic health record. When homecare providers meet with patients, they attain information about medication adherence. Before the implementation of this project, there was not universal, site-specific protocol used by providers to encourage medication adherence among patients. Therefore, when meeting with patients, healthcare providers only asked, “Are you taking your medications?” Based upon the response of the patient, the healthcare provider updated the patient’s chart, in the EHR, accordingly.

During the implementation of this project, healthcare providers will begin by addressing patient-specific questions through the use of three MAP resources: a Questions to Ask Pad, (2) A Questions to Ask Poster, and (3) a Medication Adherence Pad. Any patient-specific concerns regarding medication, medication accessibility, etc. will be addressed. These concerns will also be documented by nursing staff members in the patient’s paper-based files and electronic chart. After the patient’s questions and concerns are addressed, the MAP resource entitled the “My Medications List” will be presented to patients. The healthcare provider will explain the My Medications List and determine an appropriate medication timeline for patients to adhere to, which should encourage medication adherence. During each subsequent visit, with the patient, over the four-week period, the healthcare provider will ask patients if they have additional questions about their medication(s) or prescribed regimen. Then, providers will ask if patients are adhering to their “My Medications List” requirements.

Pre-project data and post-project data Pre project and post project medication adherence , following the four-week implementation period of this project, will be analyzed. Specifically, the PI will report the impact of the newly implemented protocol on improving medication adherence among diabetes patients through comparing adherence rates from the month during which the project took place to adherence rates, in in the same each month, during 2020 and 2021.

A quantitative methodology is appropriate for this project, as numerical data regarding adherence will be analyzed. According to Creswell and Creswell (2017), a quantitative methodology is best suited for projects that require data in numerical form. Quantitative research is presented using charts and graphs. These charts and graphs will allow readers to compare medication adherence rates pre-project implementation and post-project implementation.

Nature of the Project Design

A quantitative methodology, which employs 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. According to Chiang (2015), “In a pretest-posttest design, the dependent variable is measured once before the treatment is implemented and once after it is implemented” (Chapter 7, para. 6). Often times, quasi-experimental designs are carried out when research occurs in a controlled environment. While this project will not take place in a controlled environment, a quasi-experimental design was selected since this design is more cost-effective than an experimental project design (Schweizer et al., 2016). Furthermore, since data pre-project implementation and post-project implementation needs to be collected and analyzed to explore the impact of the intervention, a quasi-experimental design is most appropriate.

Pre-intervention data that will be attained for this project is available through the project site’s EHR. Specifically, each time that a home healthcare provider engages with patients, the provider asks a variety of questions related to the patient’s health. Examples of questions explored include: (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? Medication adherence is an important topic of exploration. Any information attained about a patient’s medication adherence/nonadherence is documented by the home healthcare provider and is entered into the project site’s EHR. Therefore, pre-project data regarding medication adherence is already available in the EHR. Medication adherence questions are not always asked by healthcare providers, since an organization-wide policy does not exist. Comment by Author: Please adjust this statement. You said you have data on medication adherence because they do ask questions but just that the questions are not standardized. Review your statements earlier in the manuscript so that they align to these statement here and elsewhere throughout the manuscript.

The home healthcare organization, which will serve as the project site, is located in Texas. Patients of the home healthcare organization range in age from 35 to 64. Patients have a variety of health-related diagnoses; however, for the purpose of this project, only patients with diabetes will be included in the sample. According to recent data, attained from the project’s site electronic health record, on January 14th of the 50 who are receiving home healthcare through the project site. Of the patients with diabetes, 5 are eligible to participate in this project. Patients who are eligible to participate in this project are between the ages of 35 to 64, do not have a mental impairment (e.g., anxiety disorder) that would prevent them from understanding the nature of the project or engagement requirements, and have been diagnosed with Type II diabetes. While 5 are eligible to participate, according to data attained from the project site’s EHR on 20th January this data does not reflect the patient census at the time of the project. Comment by Author: Clarify this better here, you said 20 patients have diabetes earlier in your manuscript. So is it that the company has 50 total patients, 20 of whom have diabetes and 5 are non-adherent? You also want to word this as data from the project site indicates that potentially there would be a convenience sample of (number……)participants . Site appropriately if you got this in an email or the source of the data. Because you have not started the project officially you cant be the person to pull the data Comment by Author: Why not? I would expect you to not include people who have cognitive impairment but people with anxiety can be included

Definition of Terms

The following terms were used operationally in this project: Comment by Author: You have other terms eg. MAP resources,

Diabetes. For the purpose of this study, Type II diabetes is the topic of exploration. While there are two types of diabetes (Type I and Type II), unless otherwise specified, the term diabetes references Type II diabetes. Diabetes references a medical condition that is characterized by high levels of sugar in the blood. Once diagnosed with Type II diabetes, patients can manage their diagnosis with medication/insulin (Bellou, 2018).

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).

Assumptions, Limitations, Delimitations

As with all practice improvement projects, there are assumptions, limitations, and delimitations that must be addressed. For the purpose of this project, the PI assumes that medical non-adherence among diabetes patients is caused by lacking knowledge, inaccessibility to resources, etc., which will be analyzed using the MAP resources. As noted by Polonsky & Henry (2016) through further understanding the needs, concerns, and experiences of patients, health care providers can foster stronger patient-provider relationships, thereby enhancing communication and dialogue, which ultimately improves patient-related outcomes. Additionally, the PI assumes that after engaging in dialogue with patients and thoroughly addressing their concerns, that medication-related barriers will be minimized. Furthermore, in alignment with the literature, the PI assumes that medication adherence will improve when patients are provided with a detailed schedule, which is patient-drive and provider-supported, using the MAP resource entitled the “My Medications List.”

This project is limited because patients are responsible for self-reporting their medication adherence. While the PI assumes that patients will be honest about medication adherence, or lack thereof, there is no way to confirm medication adherence among patients. In addition to self-reporting limitations, the PI is also limited by the fact that COVID-19 is impacting healthcare organizations. Therefore, since COVID-19 guidelines change, fairly regularly, due to new literature and findings, impacts to the home healthcare delivery model may occur. Additionally, this project is limited to an urban location. Therefore, patients who are in rural areas, who may have different needs or challenges, will not be involved in this project. Finally, this project is limited to a four-week data collection period, during which the intervention will take place. Given the complexities, at points, which are associated with behavior modification (Ahmed et al., 2018), medication may not always be the issue when dealing with diabetes.

Project delimitations also exist. This project is delimited in the sense that only patients with diabetes, ages 35 to 64, will be included as participants. Since the main focus of this project is to explore medication adherence among diabetes patients, which is a concern at the project site, the PI has delimited this project to only diabetes patients. Furthermore, as noted previously, this project is only being conducted in one urban area, which is located in the southeastern region of the United States, thereby impacting the generalizability of any findings.

Summary

and Organization of the Remainder of the Project

Chapter 1 provided detailed support for utilizing the MAP resources to aid in improving medication adherence among diabetic patients of the project site. A quantitative, quasi-experimental design will be utilized to explore the impact of the MAP intervention on improving medication adherence among Type II diabetes patients of the selected project site. The project site has a history of lacking medication adherence among diabetic patients, which is due to a multitude of factors (e.g., selection of participants and determining the correct medical provider). Through utilizing the MAP resources, which foster communication among home healthcare providers and patients, and equipping patients to use the “My Medications List,” it is likely that medication adherence will improve.

This project will be carried out over a four-week period. To analyze the impact of the intervention, pre- and post-project data will be attained, by the PI, from the project site’s electronic health record. Data will be analyzed by the PI, with the support of a statistician, through using SPSS. No patient-related data will be attained. There are various benefits associated with this intervention, which impact individuals (patients and providers), groups (family members and communities), and society as a whole.

Chapter 2 provides a detailed summary of the literature collected that is related to the project’s PICOT question. Information about the theoretical framework will be detailed. Furthermore, Chapter 2 is broken down into 5 sections, which highlight information about literature used in the paper that was attained from 2016 to 2021. The information presented in Chapter 2 provides readers with further topic-related knowledge, which has been published in peer-reviewed journals.

Chapter 3 presents research methodology details, which will be employed by the PI. The information presented in Chapter 3 includes information about the selected research detail, the target population, and the sample size. Furthermore, data collection tools (specifically the MAP resources) and data analysis procedures will be discussed. The reliability and validity of the project instruments will be detailed. Furthermore, ethical considerations for collecting data will be addressed.

Chapter 4 will present research findings, which will be analyzed using statistical methods. Results regarding the descriptive and inferential data analyses will be offered. Furthermore, a brief discussion of project-related findings will be provided. Information in Chapter 4 will be presented using graphics and tables. Chapter 5 will present 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 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.

Chapter 2 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, scoping reviews, and narrative were realized as well as utilized in the advancement of the DPI conceptual framework. Overall, the literature review revealed six main sub-themes as well as other sub-themes that promoted the strength of the DPI project. 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.

Theoretical Foundations Comment by Author: You have two great theories but remember one of your theories needs to be a change theory. Lewin’s theory tends to be a great one for quality improvement project so your cognitive theory is appropriate but I would say change the attachment theory to lewin’s change theory. Also make sure that you cite the original theory source not the secondary sources discussing the theories in the last 2 years.

According to Liu and Butler (2017), medication adherence is considered to be the largest challenge that healthcare workers and patients are facing in their daily lives. This is a critical issue since that requires more attention. 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.

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 (Hunter & 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 and 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 (Hunter & Maunder, 2016). 

Social cognitive theory (SCT). 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 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 (2019) conceptual model regarding the reciprocal associated determinism is often utilized in addressing all the personal determinants associated with health. Bandura 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 (2019) 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. Bosworth (2015) explained that self-control should get promoted since it improves the ability of individuals to adopt healthy habits. 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.

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

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
.
This refers to the art of taking medication as prescribed by healthcare practitioners. It is the duty of healthcare providers to offer patients prescriptions that are suitable to their conditions. Ahmed et al., (2018) stated that the quality of healthcare can get influenced by the ability of the body to respond to treatment. It is important to conduct physical assessment for patients so that they would receive high quality care.

Enhancing 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 Comment by Author: Please see DPI template for appropriate formatting of your headings and subheadings i.e differentiating between themes and subthemes. It is not clear to me which are your themes and which are your subthemes. Your Literature review requires significant work still. Remember that your literature review has specific requirements listed in the template and requires at leats 3 themes that have subthemes. Please call me about this because it seems you are having some issues with this. Also review some examples of literature reviews in DC network within the available manuscript examples in there. The writing in chapter 1 was a great improvement but the writing in this chapter is a little off still. Likely because your lit review is still lacking.

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 (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 (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.

Importance of Adhering to Medication Regimen

An estimated American adult of about 35% 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, 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 [IOM], 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 (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 (Forman & 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 (Costa & 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 who 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 (Balogh, 2015). For the less salutary reasons, the identified incidences associated with Type II diabetes is considered to be highly increasing in the creating in the children as well as the young adults. Patients that possess the Type II diabetes as well as those that have Type I 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 (Corcora & Roberts, 2015). 

Advocacy for Individuals 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 (D’Onofrio & 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 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). 

Summary

The existence of chronic illnesses such as diabetes requires study of affected persons in order to limit negative events. The proposed intervention techniques should get studied in order to limit the occurrence of diabetes related issues like frequent urination, fatigue, and thirst. The issues affect an individual’s capability to function in life. 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 DPI project has been constructed using careful techniques that promote the development of patient initiatives. The purpose of the project is to ensure diabetic patient care techniques get applied to enhance the validity of treatment proposals. There are practical solutions to limiting the effects of diabetes which require careful 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 empirical review point to the complications caused by lack of medication adherence in diabetes patients. It also highlights 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.

Chapter 3: Methodology

Medication adherence is a critical aspect in minimizing the impact of negative patient-related outcomes among those with chronic illnesses. According to Ahmed et al. (2018), medication adherence, for the purpose of this practice improvement project, refers the extent to which a home-based care patient can correctly take his/her medication in the absence of health practitioners. Medication adherence requires the patient to totally adhere and comply with all the medical instructions given (Bellou, 2018).

According to Ahmed et al. (2018), diabetes impacts one in 10 Americans. Furthermore, the prevalence of diabetes continues to rise and is projected to increase by 0.3 % by 2030 (Lin et al., 2018). There are two types of diabetes that plague a large proportion of Americans. Type I diabetes is insulin-dependent (Bellou, 2018). Type II diabetes is glucose related (Bellou, 2018). There are ways to curtail the onset of Type II diabetes; however, once individuals are diagnosed with diabetes, there is no cure (Bellou, 2018).

At the selected project site, patients with Type II diabetes often failed to adhere to their prescribe medication regimen. In fact, among all home-based healthcare patients, of the project site, diabetes patients do not adhere to their medication regimens approximately 30% of the time. Various researchers have noted the importance of educating patients about medication adherence, partaking in patient provider conversations about the importance of medication adherence, and creating methods to assist patients in further adhering to their prescribe medication regimen (Ahmed et al. 2018). Through the use of the MAP resources, which incorporate education and patient accountability, it is the hope of the PI that medication adherence, at the project site, among Type II diabetes patients, ages 35 to 64 will improve. Comment by Author: See feedback about this in chapter 1

This quality improvement project will be guided by the PICOT question, which seeks to explore the impact of a intervention and improving medication adherence among Type II diabetes patients. The question explored reads: To what degree does the implementation of the newly implemented MAP protocol (i.e., the [1] a Questions to Ask Pad, [2] A Questions to Ask Poster, [3] a Medication Adherence Pad, and [4] the My Medications List) impact medication adherence when compared to no standardized protocol among Type II diabetic patients, ages 35 to 64, in a home healthcare organization in Texas over four-weeks? Comment by Author: Most of the data you need in this chapter was already edited in chapter 1 so please edit this chapter based on previous chapter edits especially with the standardized things like the PICOT question, purpose and problem statements

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? The issue of implementation of the home healthcare-led Medication Adherence Project resources (e.g., the Questions to Ask Pad, the Questions to Ask Poster, and the Adherence Assessment Pad; intervention) will impact medication adherence (outcome) 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. Comment by Author: Is this your clinical question or is this your problem statement? Also please review the DPI template, based on what the template says you do not need to state your PICOT question, purpose statement and problem statement all together in the introduction here

The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the MAP resources, which will be delivered by home healthcare nursing staff members, will impact medication adherence when compared to current practice among Type II diabetic patients, ages 35 to 64 in a home healthcare setting in urban Texas.

Chapter 3 will detail the project methodology. Information about the project’s design, selection of the sample, instrumentation, validity, and reliability will be presented. Additionally, 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 if or to what degree the implementation of the home healthcare-led Medication Adherence Project resources (e.g., the Questions to Ask Pad, the Questions to Ask Poster, and the Adherence Assessment Pad; intervention) will impact medication adherence (outcome) 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.

At the selected project site, which is a home healthcare organization located in urban Texas, the stakeholders have cited that medication adherence among diabetic patients is lacking. In fact, according to data attained from the site’s electronic health record (EHR), home healthcare providers have documented that 50 % of diabetic home health care patients are not adhering to their medication regiment. At the project site, failure to adhere to the prescribed medication regiment has resulted in limited capability to deal with diabetes related issues. Various researchers have noted the implications associated with lacking adherence to medication regiments, specifically among diabetic patients (Ahmed et al., 2018), thereby reinforcing the need for this practice improvement project.

Clinical Question

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: Comment by Author: This is not a report but a project. Please edit the entire manuscript and make sure the terminology is consistent and aligns throughout

To what degree does the implementation of the newly implemented MAP protocol (i.e., the [1] a Questions to Ask Pad, [2] A Questions to Ask Poster, [3] a Medication Adherence Pad, and [4] the My Medications List) impact medication adherence when compared to no standardized protocol among Type II diabetic patients, ages 35 to 64, in a home healthcare organization in Texas over four-weeks?

The following table shows the characteristics of the variables involved.

Table 1

Characteristics of Variables

Variable

Variable Type

Level of Measurement

Family-led strategiesMAP resources

Independent

Nominal

Pharmaceutical-led strategies

Independent

Nominal

Medication adherence

Dependent

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. The content getting studies is various literature reviews that are connected to the research topic. This will facilitate the discovery of the effectiveness of family-led strategies as in comparison 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).

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. Comment by Author: Please see previous chapter feedback on this number as it has varied throughout the manuscript. Comment by Author: Why the discussion on questionaries when you are using the MAP tools to guide assessment by the staff nurse and not the patient? Comment by Author: Why is this still being discussed in the manuscript since this is not really what you are doing now based on what you said in chapter 1. It seems that the editing doe on your manuscript may have been done by separate people for each chapter. Chapter 1 varies significantly from the other chapters and all chapters do not align well . Comment by Author: Use pre-project or pre implementation and post project or post implementation instead of this terminology

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. This figure of The figure that will be used as target population in this project is the 88,988 outpatient claims was considered for a calculation of power for the project but this was not pursued as the convenience sample that the project PI has is only ……..patients that are currently under the care of the project site. The sample size if a power were to be calculated would be will be determined using the Taro Yamane formula: Comment by Author: I think you had a limit here in chapter 1, please edit to be consistent

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. Comment by Author: Since you said this is an organizational change that every patient with diabetes medication non adherence is going to be getting , then you do not need informed consent.

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. Comment by Author: Too many inconsistencies in your manuscript. You said in chapter 1 that the outcome data i.e the medication adherence rates will be abstracted from the EHR why are we using this questionnaire still now that you are using the MAP resources? Please edit your manuscript throughout so that it aligns throughout. Chapter 1 lays the foundation and then you build on that foundation. You can not have chapter 1 saying you will do this a certain way but then chapter 2 and 3 mentions something else.

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

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. Comment by Author: You are discussing the MAP resources here and their validity same with the reliability because that is your tool that you are utilizing. Please edit accordingly

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

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. Comment by Author: Please see prior feedback on the informed consent as well as the questionnaires. This will need to be edited to reflect what you re actually planning to do based on what you said in chapter 1

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 electronically and analyzed using the SPSS software. Through descriptive statistics, the numeric and categorical variables in the questionnaires will be summarized.

Descriptive statistics will be used to describe the patient’s demographic information such as age, weight, gender, level of education and marital status. This ensures the promotion of home-based care if the patient has a spouse. 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: Provide a citation

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 shall be possible to assess 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.

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. Empathy would ensure the researchers connect with the project’s participants. It would also be possible to acknowledge the project’s validity based on first-hand account of the mitigation techniques.

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. 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. Comment by Author: See feedback on informed consent earlier in the chapter

Written informed consent will then be sort from all the participants in this research. Fiesler (2019) stated that the development of the research project is concerned with principles of ethics. It is imperative to create effective programs that ensure integrity of the participants. Comment by Author: See feedback above. Please edit the entire chapter to reflect changes to align with chapter 1

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. Aggregate data will only be shared among people who are directly affected by the project, mainly the family of the diabetic persons. Personal information about the participants will not be collected in this research since that would offer restricted viewpoints. 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).

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 (Brown et al., 2018). Errors are common in research and should get identified early.

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.

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Appendix A

The Parts of a Practice Improvement Project

GCU requires the Publication Manual of the American Psychological Association (6th ed.) as the style guide for writing and formatting Direct Practice Improvement (DPI) Projects. . A DPI Project has three parts: preliminary pages, main text, and supplementary pages. Some preliminary or supplementary pages may be optional or not appropriate to a specific project. The learner should consult with his or her practice improvement project chairperson and committee regarding inclusion or exclusion of optional pages.

Preliminary Pages. The following preliminary pages precede the main text of the practice improvement project.

Title Page

Copyright Page (optional)

Approval Page

Abstract

Dedication Page (optional)

Acknowledgements (optional)

Table of Contents

List of Tables (if you have tables, a list is required)

List of Figures (if you have figures, a list is required)

Main Text. The main text is divided into five major chapters. Each chapter can be further subdivided into sections and subsections.

Chapter 1: Introduction to the Project

Chapter 2: Literature Review

Chapter 3: Methodology

Chapter 4: Data Analysis and Results (not included in the proposal)

Chapter 5: Summary, Conclusions, and Recommendations (not included in the proposal)

Supplementary Pages. Supplementary pages, which follow the body text, include reference materials and other required or optional addenda.

References

Appendices

Keep in mind that most formatting challenges are encountered in the preliminary and supplementary pages. Allocate extra time and attention for these sections to avoid delays in the electronic submission process. In addition, as elementary as it may seem, run a spell check and grammar check of your entire document before submission.

Appendix B

What is my DPI project design?

THIS IS NOT PART OF THE PAPER JUST A REFERENCE FOR THE LEARNER

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Appendix C

Enter the Title here