Nursing Interventions and Hemoglobin Levels

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Table of Contents

Literature Synthesis
Discussion of Results
Implications for Nursing
Implications for Future Research
References

Authors and Year	Type of Research/Research Design	Hypothesis/Research Questions	Sample Size and Characteristics
Cinar, Akbayrak, Cinar, Karadurmus, Sahin, Dogru, Sonmez, Tosun & Kilic 2010	Single-center, prospective follow-up study	The purpose of the study was to examine how nurse telephone calls affected glycemic parameters of patients with Type 2 Diabetes and their adherence to diabetes management recommendations.	35 consecutive patients with Type 2 Diabetes were examined and recruited. Patients enrolled in the study had levels of glycosylated hemoglobin equal or higher than 6.5%, without surgical operations or acute diseases affecting diabetes management and control, without chronic psychosis or Alzheimer’s, and with no complications that might lead to hospitalization. All participants could support themselves and were settled in easy-to-reach places.
Kim, Kim & Ahn 2006	Quasi-experimental, pretest and posttest design	Does an intervention involving a nurse short message service through cellular phones and the Internet improve the levels of HbA1c and adherence to diabetes management recommendations in patients with Type 2 Diabetes mellitus?	A total of 45 patients agreed to participate and were hired, but only 33 completed the study. All participants had to be adult, able to perform self-injection of medications and blood glucose self-analysis. Only individuals with their own cellular phone and Internet access were hired. Participants had to be able to input health data at the website. Patients with a history of heart failure, renal insufficiency, hepatic dysfunction, and those using insulin pumps were excluded from the study. Patients using website information about diabetes were excluded.
Wong, Mok, Chan & Tsang 2005	Randomized controlled trial	Is there any difference in HbA1c levels, self-care diet adherence, exercise, medication, and blood glucose self-monitoring between the group receiving routine inpatient care and the group involved in a nurse-led early discharge program? Is there any difference in how the control and study groups utilize health care? Is there any difference in the levels of patient satisfaction between the two groups?	A total of 101 patients were involved in the study. Inclusion criteria: age (over 18 years old), the presence of diabetes mellitus (type I or II), stable medical condition, willingness to perform blood glucose self-testing, patients or supportive relatives able to write numbers and read simple Chinese. Patients in the state of hyperosmolar non-ketotic coma, with diabetic ketoacidosis, or those requiring intensive hospitalization were excluded from the sample.

Variables	Instruments	Findings	Limitations
Independent: Nurse telephone calls Dependent: Patients’ glycemic parameters Adherence to diabetic management recommendations	The Diabetic Patient Follow Up Form Metabolic Control Results Form Patient Satisfaction Questionnaire Form	˗8.2% baseline changes in HbA1c in the intervention group; Significant reductions in PPBG, FBG, LDL-C, total cholesterol, systolic and diastolic blood pressure, and BMI in the intervention group; Better adherence to diabetes management recommendations, including diet, exercise, and drug use in the intervention group.	Small sample size Short study period The use of self-reported questionnaire forms
Independent: Nurse SMS and Internet intervention Dependent: HbA1c levels Diabetes management adherence	High-performance liquid chromatography Diabetes self-care activities measure	Significant mean change in HbA1c for the intervention group (-8.1%) Patient physical adherence increased (a mean of about 1 day per week) Medication adherence mean increased 1.1 days per week No significant changes in diet adherence were found	The sample is not representative of the whole population with Type 2 Diabetes Mellitus Self-reported forms and questionnaires could lead to biased results The study did not determine the long-term effectiveness of the SMS intervention
Independent: Patient involvement in a standardized education program or nurse-led early discharge program Dependent: Levels of HbA1c Self-care adherence Utilization of health care services Patient satisfaction	Clinical data sheet Self-care adherence assessment form Patient satisfaction questionnaire	Patients in the study group demonstrated improved levels of HbA1c compared with the control group. The researchers found higher blood glucose monitoring and exercise adherence in the study group No differences in medication and diet adherence were detected. There was a considerable financial saving for patients that were discharged early and followed up by nurses in the community. No significant differences between satisfaction scores in the control and study group were found.	Small sample size Non-representative sample Self-reported questionnaires could lead to biased patient satisfaction scores and results The long-term effectiveness of the discussed intervention is yet to be determined.

Literature Synthesis

Inclusion/ exclusion criteria: That effective management of diabetes patients involves a complex set of procedures and decisions has been abundantly established. However, not all studies are equally valuable in the examination of nursing monitoring/ intervention programs and their effects on Hemoglobin A1c levels in older adults with diabetes within 6 months. The three studies used in this literature analysis investigated the effects of various nursing interventions on hemoglobin levels in adult diabetes patients. All studies relied on or incorporated the features of follow-up designs. All studies were published within the last 10 years. Excluded studies were those which explored changes in hemoglobin levels in diabetes patients under the influence of factors other than nursing interventions/ programs. Only articles that can be easily accessed through scholarly databases were used.

Compare and contrast: The table above provides a brief but detailed observation of the research designs and findings for the three studies in question. Notwithstanding the fact that the studies were published at different times and involved different sample populations, they focused on the analysis of hemoglobin changes in diabetes patients under the influence of various nursing programs/ interventions. Hemoglobin parameters were the main outcome measure in all studies. Researchers also investigated the effects of nursing monitoring/ intervention programs on other parameters and outcomes, which included but were not limited to diet adherence, exercise regime adherence, medication use adherence, and even patient satisfaction. Healthcare utilization and the changes in diabetes care costs were analyzed. The use of secondary measures adds to the picture of nursing interventions and their implications for diabetes management in older patients.

None of the three studies made predictions or hypothesized about changes in hemoglobin levels in older patients with diabetes under the influence of nursing monitoring/ interventions. Nevertheless, the research questions for each of the three studies exhibited remarkable similarities. Cinar et al (2010) sought to examine how nurse telephone calls affected glycemic parameters (namely, hemoglobin levels) and adherence to diabetes management recommendations in patients with Type 2 Diabetes. Kim et al (2006) tried to define whether an intervention involving a nurse short message service through cellular phones and the Internet could improve HbA1c levels and adherence to diabetes management recommendations in patients with Type 2 Diabetes. Wong et al (2005) tried to see whether there was any difference in HbA1c levels, self-care diet, exercise, and drug use adherence between the group receiving routine inpatient care and the group involved in a nurse-led early discharge program. The researchers used the benefits of prospective follow-up, quasi-experimental, and randomized controlled research designs. Nursing interventions were a common independent variable in all three studies; in a similar vein, HbA1c levels were the main dependent variable.

Methodological quality: The methodological quality of the three studies is not without controversy. All three samples were too small to explain the quality and effectiveness of nursing monitoring programs on the levels of hemoglobin in patients with Type 2 Diabetes. Cinar et al (2010) engaged only 35 consecutive patients; that the researchers used a single-center prospective follow-up study also suggests that the results may not be generalizable to other populations. In Kim et al (2006), 45 patients agreed to participate but only 33 completed the study. Kim et al (2005) used quasi-experimental design, which lends credibility to their research findings, but the sample was limited to patients who could input the data at the website. Finally, the use of the randomized controlled trial framework by Wong et al (2005) contributes to the validity and reliability of their study results. Unfortunately, none of the three studies investigated the long-term effects of nursing interventions on hemoglobin levels in diabetes patients. Therefore, how nursing monitoring changes or improves the levels of HbA1c in older diabetes patients over long-term periods remains a common concern with all three studies. Nevertheless, all studies fit the purpose of this analysis and provide a relevant picture of the effects which nursing interventions/ monitoring produce on HbA1c levels in patients with Type 2 Diabetes over a 6-month period.

Discussion of Results

That all studies lead at similar conclusions lends credibility to their results. Wong et al (2005), Kim et al (2006), and Cinar et al (2010) found significant improvements in patients’ levels of hemoglobin following nursing interventions. Cinar et al (2010) found significant improvements in HbA1c levels in the intervention group. Besides, Cinar et al (2010) discovered that nurse telephone calls resulted in significant reductions in patients’ PPBG, FBG, LDL-C, systolic and diastolic blood pressure, cholesterol, and BMI. Previously, Kim et al (2006) found that nurse SMS and Internet intervention programs led to significant mean changes in HbA1c levels for patients with Type 2 Diabetes. Nursing interventions further increased physical exercise and medication adherence in diabetes patients (Kim et al, 2006). However, no changes in diet adherence were found (Kim et al, 2006). Wong et al (2005) created the fullest picture of nursing interventions and their implications for diabetes management. Wong et al (2005) demonstrated that patients with Type 2 Diabetes had their levels of hemoglobin improved as a result of nursing monitoring. Moreover, patients in the study group improved their blood glucose monitoring and exercise adherence (Wong et al, 2005). Although no differences in medication and diet adherence were detected, Wong et al (2005) suggested that nursing interventions could result in considerable financial savings for patients and hospitals and reduce the extent of health care utilization for individuals with Type 2 Diabetes. That the synthesis involves only three studies is its main weakness. Simultaneously, it creates a foundation for investigating the effects of nursing interventions on HbA1c levels in long-term perspectives.

Implications for Nursing

These results have far-reaching implications for nursing. First, nursing interventions affecting hemoglobin levels in diabetes patients rely on four C’s, namely continuity, comprehensiveness, coordination and collaboration (Wong et al, 2005). These interventions exemplify a form of transitional care that is particularly suitable for patients with chronic diseases (Wong et al, 2005). Second, these interventions empower patients to be responsible for managing their health (Wong et al, 2005). Third, nursing monitoring and interventions reduce the costs of health care for patients with Type 2 Diabetes (Wong et al, 2005). Here, a model of telephone and cell phone monitoring that combines the features of Kim et al (2006) and Wong et al (2005) nursing frameworks could be used. The benefits of this model are obvious. First, it is cheap and convenient. Second, it is available to everyone, since the prevailing majority of patients have access to telephone communication. Finally, telephone communication does not require patients to have sophisticated technical skills (Wong et al, 2005). It is a straightforward nursing intervention that has a potential to improve HbA1c levels in patients with Type 2 Diabetes within 6 months.

PICOT Question: In older adults with diabetes, how does nursing intervention/monitoring compare to non-monitored clients by nurses affect the Hemoglobin A1c levels within 6 months? The answer: based on the current state of research, nursing intervention/ monitoring significantly improves the Hemoglobin A1c levels in patients with diabetes within 6 months.

Implications for Future Research

The current state of knowledge about nursing interventions and their effects on HbA1c levels in patients with Type 2 Diabetes is incomplete. Small, non-representative samples, self-reported forms and measures, as well as poor emphasis on the long-term outcomes reduce the overall validity of the research results. Future research could shed light on how nursing monitoring affects and/ or improves HbA1c levels in patients with Type 2 Diabetes within long-term periods, e.g. during a 24-month follow-up. Future research must rely on larger, representative samples and incorporate objective measures of changes in management recommendations adherence among diabetes patients.

References

Cinar, F.I., Akbayrak, N., Cinar, M., Karadurmus, N., Sahin, M., Dogru, T., Sonmez, A., Tosun, N. & Kilic, S. (2010). The effectiveness of nurse-led telephone follow-up in patients with Type 2 Diabetes Mellitus. Turk Jem, 14, 1-5.

Kim, H.S., Kim, N.C. & Ahn, S.H. (2006). Impact of a nurse short message service intervention for patients with diabetes. Journal of Nursing Care Quality, 21(3), 266-271.

Wong, F.K., Mok, M.P., Chan, T. & Tsang, M.W. (2005). Nurse follow-up of patients with diabetes: Randomized controlled trial. Journal of Advanced Nursing, 50(4), 391-402.

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Nursing Interventions and Hemoglobin Levels

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