NURS FPX 9030 assessment 3 Manuscript: Draft

Manuscript: Draft

Student Name

School of Nursing and Health Sciences, Capella University

NURS FPX9030

Professor Name

Submission Date

Introduction

The gap in practice is still empty as there is no standardized, protocolized follow-up pathway in outpatient primary care in adults with Type 2 Diabetes Mellitus, which accounts for the lack of universal education of patients, non-conformant monitoring of prescribed medications, and preventable complications of hyperglycemia. The practicum site revealed a figure of up to 42 percent of adult patients having a bulk of hemoglobin A1c that is above 9 percent, with a proportion of just 36 percent of the patients bearing a decreased bulk beneath 7 percent, which is considerably lower than the diabetes management perspectives in the USA (Adjei et al., 2025; APRN, personal communication, November 2025).

Follow-up by nurses, competency in the staff in primary care centers, and incorporating patient education still have loopholes, even with the existing evidence-based clinical recommendations provided by the American Diabetes Association so far. The hypothesis stating that the ADA diabetes follow-up protocol with an ADA nurse working with the affected adult with diabetes would lead to an increase in the level of glycemic control compared to the current practice at the time the study was implemented (8 weeks) was vindicated or disproved by the project pilot led by the PICOT question. The follow-up by ADA was designed and employed to harmonize with the intervention process to enhance glycemic management and reinforce the evidence-based management of chronic illness in the outpatient primary care.

Practice Problem

Defining the practice problem was constantly low glycemic control in adults with Type 2 Diabetes Mellitus who are provided with care in an outpatient primary care clinic. On-site, we were informed that 42-percent of the patients had an A1C of greater than 9, whereas only 36-percent of the patients had an A1C of less than 7 (APRN, personal communication, November 2025).

They outperformed the (revealing that) a quarter of all diabetic patients and above 65 years old have poor glycemic control, and half of them never reach the recommended levels of A1c (Adjei et al., 2025; Dinavari et al., 2023; Gomes et al., 2022). Surprisingly, behavior and demographic challenges have also turned out to be the cause of bad glycemic control, and hence, the system of specific, targeted intervention to the high-risk patients should be developed (Karmakar et al., 2025).

Workflow analysis, examination of charts, and EHR audits also revealed that the problem of bad scheduling, lack of follow-up, and low levels of patient education and multidisciplinary poor coordination of work also played a big role in poor results (APRN, personal communication, November 2025). The previous attempts at enhancing the diabetes results were based on randomly selected versions of education and non-programmed telehealth checkups that lacked systematic assessment and uniformity of the quality of the education (Dailah, 2024).

The gap constituted a clinical priority due to the increased numbers of hospitalizations and healthcare use (as well as the healthcare expenditure) of the long-term complications, since the factor contributing to the increased hospitalization, healthcare use, and healthcare spending was uncontrolled diabetes. Intervention programs that are highly adhered to, led by the nurses, have demonstrated that chronic disease management programs can be used to achieve a decreased level of HbA1c of 0.4-0.9 percentage points and an increased level of adherence (Sun et al., 2025; Centers for Disease Control and Prevention, 2024).

Project Site

This project was conducted in a diversified adult clinic in an urban outpatient primary care complex in New York City, and collaborated with each other in terms of the cultural and socioeconomic backgrounds. The majority of the clinic patients (patients with diabetes and hypertension) suffer from chronic diseases (APRN, personal communication, November 2025). The clinic will comprise six examination rooms, two different counseling points, workstations (which may be converted into telehealth workstations), and a staff of nurses working as nurse practitioners, medical assistants, care coordinators, health educators, and support staff.

This organizational environment was the most suitable to carry out a systematic diabetes follow-up intervention since it emphasized continuity of care, management of chronic illnesses, and preventive health care. It has used the current EHR infrastructure to support the process of booking appointments, and to manualize the process of overseeing patients and recording the latter, though it has also meant that the ADA protocol has also been applied to the current working processes since it does not entail any significant structural changes (APRN, personal communication, November 2025). The success of the enhanced glycemic control that would lead to value-based care, patient satisfaction, and quality measures within the organization was enough to make the project the priority in the decision-making of the leadership.

Project Population

The sample of the project included nursing staff who were employed in the outpatient clinic working with adults with Type 2 Diabetes Mellitus as well. Implementation program: A regular meeting of nurse practitioners, medical assistants, a care coordinator, and a health educator, who were involved in the implementation program, took part in the 8 weeks of the implementation program to provide the diabetes education, medication administration, and follow-ups of the participants of the implementation program (APRN, personal communication, November 2025).

It was found during pre-intervention tests that the confidence level, level of knowledge, and compliance with measures of diabetes management were not homogeneous, and the average level of competency was only 59 percent, which indicated that the competency development must be planned.

The inclusion criteria, such as experience in direct patient care in relation to diabetes and the capacity to attend to the entire implementation phase, were considered. The non-patients, including front staff and temporary staff, were not included, nor were the administrative staff. These standards enhanced intra-rater validity as the results were premised on the effect caused by the intervention on the nursing personnel who had direct responsibilities in the process of the ADA protocols implementation.

Evidenced-Based Interventions

This intervention was a standardized audit of ADA diabetes follow-up to enhance the nursing competency and consistency of follow-up, medication reconciliation, patient education, and self-management support. The protocol also suggested frequent communication (once a week) visits, telehealth options in case of having transport problems, a standardized registration in EHR, and employee education, which is based on the ADA Standards of care.

Interventions included education that was on simulation and case-based learning, testing of competency, fidelity checklists, and continuous monitoring of performance. The group of multidisciplinary nurses was measured prior to and subsequent to the intervention and had to achieve 80 percent competency in order to be qualified to provide the patient-facing side of the intervention on their own (APRN, personal communication, November 2025). The intervention aimed to stabilize the care offered and enhance compliance with the ADA guidelines, and integration of the process used in diabetic care.

Project Leading Role

The DNP student would become the project leader and design an ADA diabetes follow-up procedure, create informative resources, and manage the logistics of the implementation process (assessment of HbA1c levels, competency of these staff, and frequency of follow-up throughout the course of the initial assessment) (APRN, personal communication, November 2025). The organization stakeholders, the preceptor and faculty mentor of the site, and the interdisciplinary team were kept updated during the project regarding the meetings, feedback about the progress, and Plan-Do-Study-Act (PDSA) review cycles (Abuzied et al., 2023).

The ethical conduct was linked to CITI training, arranging IRB review, adhering to data management that is HIPAA-compliant data management, and conducting confidentiality agreements with the participants. During implementations of the intervention, 8 weeks later, the project lead believed in the intervention and could stick to scholarly and ethical principles.

The other roles of the members of the team

The site preceptor is an APRN, and he/she provided the needed clinical levels and were the primary high-level intermediary between the DNP student and the leadership of the organization (APRN, personal communication, November 2025). Nurse practitioners provided clinical assessment, Medication review, and ADA-guided patient counseling to substantiate the patient visits (biweekly visits) in order to provide optimal healthcare.

The care coordinator was forced to plan, organize EHR telehealth, EHR reminders, and follow-up monitoring to relax the adherence targets. The health educator provided culturally appropriate education materials based on the differences in the levels of literacy and language needs.

Recording clinical data, providing teaching materials, and the patients with the follow-up visit were also part of the medical assistants’ involvement process. As a source of academic consultation for the research project, the DNP faculty mentor and project progress were used. The regular biweekly interdisciplinary conferences turned out to be useful in providing a discussion, accountability, and solving the issues in the implementation within a time frame (Dellafiore et al., 2025; Grant et al., 2024).

Literature Synthesis

Both PubMed/MEDLINE and CINAHL, Cochrane Library, Web of Science, Scopus, and ProQuest were extensively searched to find evidence regarding nurse-led ADA-based diabetes follow-up interventions. The keywords were: diabetes mellitus, type 2 diabetes, glycemic control, HbA1c, interventions that a nurse does, ADA guidelines, and diabetes follow-up and self-management education. By eliminating copies and filtering, 20 studies were chosen depending on the inclusion criteria that involved the adult population, the nurse-based or structured intervention follow-up, and the glycemic outcomes to be measured.

The quality of the evidence was measured using the help of Strength of Recommendation Taxonomy (SORT) system, and seven, ten, and three studies with Level A, Level B, and Level C levels, respectively (Duke University, 2023). Structured nurse-led follow-up has always been rated high in the literature because it is an effective intervention that enhances the aspect of glycemic control in the outpatient primary care setting.

Analysis of Evidence

When applied to the follow-ups, the protocols on ADA-congruent led to statistically significant changes in HbA1c, which is typically between 0.25% and 1.69 percentage points across outpatient sites (Asmat et al., 2024; Chen et al., 2025; Koo et al., 2024). Self-efficacy and medication adherence, along with blood glucose monitoring behaviors, were also enhanced with the help of structured diabetes self-management education and support programs (Yimer et al., 2025; Chen et al., 2025).

The compliance with ADA requirements of care, nurse-directed competencies development, systematic diabetes self-management learning, and remote coach-using technologies via telehealth were the main themes developed out of the literature. Both barriers were also identified in evidence, and they included a knowledge gap among the providers, disjointed pathways, barriers of digital literacy, and no long-term follow-up procedures, which necessitated the intervention of a strategic quality improvement program, specific to the outpatient environment.

Synthesis of Findings

Among these 20 studies that summed the structured manipulations of HbA1c in programs with nurses as follow-up showed a similar positive impact of these programs in all studies, in all geographical regions, and all mediums of delivery. The most persistent and the strongest outcomes were demonstrated in the scenario of the ADA guidelines compliance; the process of nursing competence building; the process of patient self-management improvement; and technology-enhanced follow-up because it was used collaboratively as opposed to a one-time-only intervention (ElSayed et al., 2022; Sun et al., 2025).

There were still a few gaps in evidence that consisted of missing the post-12-month data of the studies, the absence of a frequency criterion of follow-up, and the absence of culturally customized and tech-enhanced delivery model studies (American Diabetes Association, 2024).

Implementation Plan

This intervention involved 8 weeks and a progressive process of implementation. The extraction of the measurable baseline levels established by the EHR for patients a few days before the intervention initiation and HbA1c levels, follow-ups, and nursing competency in the EHR during weeks one and two constituted the quantifiable measurement of the intervention period before and after the intervention (Lighterness et al., 2024; Willmington et al., 2022). Weeks 3 and 4 were allocated to the normal training of the staff about the pathophysiology of diabetes, ADA Standard of Care, medication reconciliation, and EHR documentation through simulation and case-based learning.

In Weeks 5 and 6 of PLAN-2509, visits to patients (transport, access to telehealth, etc.) along with competency evaluations during the middle of the week were also considered, as well as biweekly follow-ups. Week 7 and Week 8 were the weeks based on the tracking of Zoll usage and tracking of missed visits, reviewing of HbA1c results, audit fidelity, and audit review of the overall results. These interventions were gradually built (which helped in conformity), accountability, and quantifiable commitment at the intervention time.

Conceptual Model

The project has been developed based on the Plan-Do-Study-Act (PDSA) model as it is the most effective one in enhancing the quality of initiatives designed to ease chronic diseases (BARR & Brannan, 2024; Endalamaw et al., 2024). The team viewed the issue, which should be addressed at the Plan stage, as poor glycemic control and developed quantifiable standards. During the Do phase, telehealth follow-up and staff training, as well as EHR dashboards, ADA protocol were introduced.

The monthly examination of the HbA1c patterns, level of competency, and rates of follow-up and documentation accuracy were the components that characterized the stage of the study. Under the phase of the Act in the performance data, these workflow changes, education, and telehealth outreach plans have been changed, respectively. The PDSA model helped the intervention to adapt to the barriers to implementation and stay true to the best practices (Abuzied et al., 2023; Konnyu, 2023).

Data Collection and Analysis

This design of evaluation was a pre-post evaluation where the following data were recorded: baseline and follow-up on 20 patients with Type 2 Diabetes Mellitus and 8 nurses. The baseline of HbA1c levels was taken during preimplementation, and the follow-up rate, along with competency levels (Klaic et al., 2022; Lee et al., 2022). The clinically significant difference was the difference in mean HbA1c at Baseline and Week 8, and a difference of 0.5 percentage points was declared to be the difference (Tiwari and Aw, 2024).

The secondary outcomes were the nursing competency score, follow-up rate of visits, behavioral outcomes such as checking of medication and Glucose levels. All the instruments were measured using all measurement points, and specialists reviewed them to ensure that they would be assessed in the same manner to guarantee the content validity. The pre-post comparisons assessed the change in the glycemic control and competency of the staff, but the descriptive statistics provided an idea of the changes in both the operational and behavioral outcomes (Gabriela et al., 2025).

Ethical Considerations

This is because, before the project was implemented, the IRB screened the project and decided that the project had been deemed a Quality Improvement project and not a Human Subjects Research, given they had no intention of coming up with a research finding that would be generalized (APRN, personal communication, November 2025). The needed training CITI and HIPAA-compliant operations controlled data collection, data storage, data analysis, and reporting were applied to all the personnel who worked on the project.

The data regarding patients were de-identified, and they were analysed with the aid of coded identifiers on patient information. The encrypted electronic data accessed by the password was locked in the system and was accessed only by the project team members authorized, and the paper data were locked in the cabinets within the clinic (Centers for Disease Control and Prevention, 2024; Lulamba et al., 2025). The data security and confidentiality were observed by undertaking weekly compliance checks to monitor compliance throughout implementation.

Project Results

The follow-up ADA diabetes program had clinically meaningful improvement of glycemic, operational, competency, and behavioral outcomes. The Mean HbA1c Week 8 was less than the baseline of 8.22 percent, compared to the baseline of 9.95 percent, and the difference was found to be 1.52 percentage points, with a set level of 0.5 percent. The average levels of follow-up were 89.2%, referring to the patient’s interest in the system of organized weekly biweekly.

The mean score of the nursing competency increased between pre-training (59.0 working) and post-training (85.4 working), and 7 out of 8 employees who passed the 80 percent competency score in nursing that would enable them to give an independent protocol (APRN, personal communication, November, 2025).

It also saw an improvement in patient self-management, with the average engagement scores being 7.4/10, 70 percent of the participants saying they are completely adhering to medication, and 65 percent of the study participants were taking regular readings of blood glucose. Transport stalling was also one of the greatest hiccups of operations, which some patients who would not seem to be able to cover all the planned face-to-face visits could not afford, hence reaffirming the role of telehealth as an intervention follow-up solution.

Project Outcomes

The main goal of the project was to reduce the HbA1c by 1.52 percentage-points that was not only clinically significant but also very different compared to the success criterion of the project, which had been met with the success criterion kept at 0.5 marginally% decided itself as the exact success criterion.

Others also found similar results to those that were published, reporting that there is a decrease of 0.25 percent to 1.69-percent HbA1c with the nurse as the leader of the follow-up on diabetes (Asmat et al., 2024; Koo et al., 2024). The nursing skills and patient self-management rates were also significantly more biased towards the effectiveness of the implementation of the ADA-based follow-up and methodical staff training and patient education (Dailah, 2024).

High protocol fidelity, high follow-up compliance, adequate documentation in EHR, multi-disciplinary collaboration, and adherence to the nationally recognized Standards of Care in ADA were some of the strengths in the project (Endalamaw et al., 2024; Ebbers et al., 2023). The limitations have been identified to be the intervention length (8 weeks), small sample size of the staff, and single location (which may confine the study to the aspect of the long term and generalization of glycemic sustainability).

Sustainability and Recommendations

The clinic will turn the ADA follow-up protocol on diabetes follow-up practices into a continuous process, integrate with routine nursing work, and add EHR dashboards, automated specifics, and fidelity checklists to the set of permanent tools at work to ensure that the practice change is in practice (APRN, personal communication, November 2025).

Additional surveillance of the protocols and protocol compliance through continued use of competency reviews and the introduction of the Diabetes Protocol Coordinator on a quarterly basis has the potential to aid further protocol monitoring. However, it should be observed to check on the long-term sustainability and institutionalization of the change in practice with the assistance of the glycemic results in the context of the recent follow-up in the course of at least 12 months (Jahed et al., 2025; Endalamaw et al., 2024).

Recommendations for the future would be to follow up for 12 months, extend the protocol to other chronic disease groups at the outpatient clinic, additional telehealth and other digital interaction interventions, and publication of the project findings in institutional reports, conference sessions, and in peer-reviewed journals, as they will aid in experiencing the protocol in other outpatient primary care settings.

Summary

This Quality Improvement project was able to measure how successful it was to adhere to a structured protocol of the American Diabetes Association (ADA) diabetes follow-up to enhance glycemic control in adults with Type 2 Diabetes Mellitus in a nurse-led outpatient primary care unit.

The project was created to address the heavy gaps in diabetes management existing in the practicum site, where 42% of patients had a hemoglobin A1c level of more than 9%, and 36% patients had a hemoglobin A1c level of less than 7%, which is the recommended target. Led by the Plan-Do-Study-Act (PDSA) model, the intervention was planned with evidence-based ADA follow-up standards, nursing development competency, systematic patient education, telehealth connectivity, and regular system monitoring by using the electronic health record system.

Results revealed that the introduction of the ADA diabetes follow-up protocol showed significant changes with regard to glycemic, operational, and behavioral outcomes. The mean of HbA1c levels was reduced to 8.22% at Week 8 compared to baseline, measuring 9.95, which has a percentage change of 1.52 decrease, even more than the predetermined measure of success of 0.5 percentage change. The adherence to the follow-up was 89.2%, which poses a strong engagement of the patients with the structured protocol.

The competency of nursing staff improved significantly after the training, raising the average score (59.0) to 85.4. Most of the participants had the necessary competency level to use and apply the established independent protocols. A positive change was also noted in patient self-management practices, such as adherence to medication, checking of blood sugar level, and general participation in activities involved in the management of diabetes.

The results of the project are consistent with available data showing that structured nurse-led programs aimed at managing diabetes serve to enhance glycemic outcomes and enhance chronic disease management procedures (Asmat et al., 2024; Dailah, 2024; Jiang et al., 2024). Cooperative involvement of standardized follow-up, competency-based education, and technology-based care led to enhanced regularity in the administration of diabetes and patient involvement in self-care undertakings. Despite the fact that the intervention was constrained by the comparatively small duration of the implementation process, use of a small sample size, and transportation constraints related to some face-to-face interactions, the project showed that ADA-based evidence-supported follow-up protocols can cause tangible differences in clinical outcomes in a primary care setting.

Another key concept that was highlighted by the project is the sustainability planning in order to sustain the gains that are made during the implementation. Incorporation of the ADA protocol into the regular nursing practices, ongoing deployment of EHR-based monitoring tools, regular competency evaluations, and broader telehealth resources were also listed as the most important tools in the process of maintaining the long-term positive changes. The protocol has to be assessed further in the future, with more participation groups of patients and further integration of digital health technologies to facilitate access and continuity of care.

In general, the project was able to meet its main goal of enhancing glycemic control in adults with Type 2 Diabetes Mellitus, together with improving nursing competency, adherence to follow-up, and self-management behaviors in patients. The results strongly support the idea of continued usage of structured ADA-based follow-up protocols as a sustainable, evidence-based solution to improving the outcomes of diabetes management in outpatient primary care.

For complete details and all assessments of this class, visit: NURS-FPX 9030 Doctor of Nursing Practice 4