DNP 752 Week 6 The Final DNP Applied Project Manuscript Example

Asking About the Weight of Diabetes: A Nurse-Led Distress Screening and Follow-Up Pathway in a Community Health Center, Reported to SQUIRE 2.0

[Student Name]

University of Phoenix

DNP/752: DNP Applied Project III

Week 6 Assignment: Final DNP Applied Project Manuscript

[Instructor Name]

[Date]

The health center, staff and figures are composites written for a model paper.

Abstract

Background: Roughly one in three people living with type 2 diabetes carries diabetes distress, which is linked with adherence and glycemic control, but primary care screening usually covers depression only. Local problem: a community health center clinic caring for 820 adults with type 2 diabetes had no distress screening. Methods: a 12-week quality improvement pilot added a two-item screener at rooming, a 17-item scale for positive results and nurse care manager responses matched to the dominant subscale, refined through three Plan-Do-Study-Act cycles. Results: 81.4% of 231 eligible visits included a screen, 85.2% of 61 positive screens received contact within 14 days, and the 44 patients assessed twice averaged a drop of 0.54 on the scale's 1 to 6 range. Conclusions: the pathway was feasible and acceptable, and distress fell among patients followed up, though the design cannot attribute the change to the pathway alone.

Introduction

Diabetes distress is the emotional burden of managing a demanding chronic illness. Pooled data from 55 studies put it at 36% in type 2 diabetes (Perrin et al., 2017), and prospective work has tied it, more closely than depression, to adherence and A1C. Validated tools exist: a 17-item scale with four subscales (Polonsky et al., 2005) and a two-item screener drawn from it (Fisher et al., 2008). Structured attention reduces distress in trials, yet routine screening remains uncommon in safety-net primary care.

At the project clinic, a yearly depression screen reached 93% of the diabetes panel while a distress screen reached no one, while 41% had a most recent A1C above 9%. The rationale for a matched response came from the transactional model of stress and coping (Lazarus & Folkman, 1984): different subscales reflect different appraisals, so they call for different responses. The revised Iowa Model guided the change (Iowa Model Collaborative, 2017).

The aim was to introduce the pathway and evaluate screening, timely follow-up and change in distress over 12 weeks.

Methods

Context: a federally qualified health center clinic in a mid-sized Midwestern city serving about 6,400 adults, most with Medicaid or no insurance. Intervention: medical assistants offered the screener on a tablet at rooming; a mean score of 3 or more opened the full scale; care managers reviewed subscales the same day and responded by phone or in person within 14 days with problem-solving support, a goals review with the clinician, family or peer resources, a behavioral health introduction or, added during the pilot, community health worker referral. Three improvement cycles shortened the introduction, moved the screen ahead of vital signs, added phone completion and moved first contact to the next day.

Measures: the screening rate, timely follow-up, change in the full-scale mean item score at 12 weeks with high distress defined as 3.0 or more (Fisher et al., 2012), added rooming time as a balancing measure, and staff acceptability, appropriateness and feasibility on brief validated scales (Weiner et al., 2017). Analysis: run charts read with standard rules for shifts and trends (Perla et al., 2011), and a paired t test with the mean difference, confidence interval and Cohen's d. Ethics: both the university and the health center determined the pilot to be quality improvement; a safety protocol covered disclosures of self-harm.

Results

Two hundred nineteen patients attended 231 eligible visits; 16% preferred Spanish and 38% used insulin. Screening rose across cycles from 61% to 93%, with a shift on the run chart beginning after cycle two. Of 61 positive screens, 57 completed the full scale and 52 were contacted within 14 days; once next-day calls started, the typical wait for a first contact shrank from nine days to three. For the 44 patients reassessed, the average item score went from 3.02 down to 2.48 (95% CI for the change, -0.71 to -0.37; d = 0.96), and the number in the high distress range fell from 20 to 9. Regimen-related distress fell most among patients for whom it was dominant. On the three five-point staff scales, feasibility (3.9) trailed acceptability (4.3) and appropriateness (4.4). Median added rooming time was 1.5 minutes. Behavioral health referrals doubled.

Discussion

The pathway reached most eligible visits once the workflow was simplified, and the positive rate matched published prevalence. The fall in distress exceeded effects reported in trials, which is best explained by regression toward the mean, selective loss to follow-up and the benefit of attention itself, alongside any effect of the matched responses. The larger change in regimen distress fits both prior trial analyses and the stress and coping rationale.

Limitations include the absence of a comparison group, 23% loss to follow-up weighted toward Spanish speakers and higher scorers, self-reported distress, sampled rooming times, a single site and the project lead's role as a colleague. Most of these would make the results look better than the truth, so the estimates above should be read as an upper bound on what the pathway achieved.

Conclusions

Nurse care managers in a community health center can deliver distress follow-up with a short guide and modest time, making a national standard part of routine diabetes care. The clinic has adopted the pathway, with a sustainability plan built on roles, protocols and a monthly dashboard. Before other sites adopt it, the health center needs more behavioral health time and follow-up in Spanish; a stepped rollout would then allow a stronger test of effect.

Implications for Practice

Three lessons may help other primary care teams. First, screening rates depend less on staff willingness than on where the screen sits in rooming; placing it before vital signs, when patients would otherwise sit waiting, did more than any reminder or incentive could have done. Second, the speed of follow-up depends on the channel; a next-day call reached patients faster than waiting for a clinic slot and did not reduce the quality of the conversation, according to care manager notes. Third, the response guide gave nurses permission to act on distress without a therapy credential, while the behavioral health introduction handled the patients whose emotional burden needed more.

Next Steps at the Site

The clinic has written the pathway into its rooming protocol and care manager role, added the process rates to its monthly dashboard and scheduled a sustainment review at 12 months. A Spanish-speaking follow-up option is under review, and the medical director has asked for behavioral health staffing to be addressed in the next budget before a second site begins.

Acknowledgments

The author thanks the clinic's medical assistants, care managers, behavioral health consultant and quality coordinator, and the patients who answered the questions and told the team what they meant to them. The project received no external funding.

Reporting Note

The manuscript follows the SQUIRE 2.0 publication guidelines for quality improvement (Ogrinc et al., 2016). Tables of process outcomes, distress scores, subscale results and subgroups, the two run charts, both instruments and the approval letters appear in the appendices.

References

Fisher, L., Glasgow, R. E., Mullan, J. T., Skaff, M. M., & Polonsky, W. H. (2008). Development of a brief diabetes distress screening instrument. Annals of Family Medicine, 6(3), 246-252. https://doi.org/10.1370/afm.842

Fisher, L., Hessler, D. M., Polonsky, W. H., & Mullan, J. (2012). When is diabetes distress clinically meaningful? Establishing cut points for the Diabetes Distress Scale. Diabetes Care, 35(2), 259-264. https://doi.org/10.2337/dc11-1572

Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182. https://doi.org/10.1111/wvn.12223

Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. Springer.

Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895

Perrin, N. E., Davies, M. J., Robertson, N., Snoek, F. J., & Khunti, K. (2017). The prevalence of diabetes-specific emotional distress in people with type 2 diabetes: A systematic review and meta-analysis. Diabetic Medicine, 34(11), 1508-1520. https://doi.org/10.1111/dme.13448

Polonsky, W. H., Fisher, L., Earles, J., Dudl, R. J., Lees, J., Mullan, J., & Jackson, R. A. (2005). Assessing psychosocial distress in diabetes: Development of the Diabetes Distress Scale. Diabetes Care, 28(3), 626-631. https://doi.org/10.2337/diacare.28.3.626

Weiner, B. J., Lewis, C. C., Stanick, C., Powell, B. J., Dorsey, C. N., Clary, A. S., Boynton, M. H., & Halko, H. (2017). Psychometric assessment of three newly developed implementation outcome measures. Implementation Science, 12, Article 108. https://doi.org/10.1186/s13012-017-0635-3