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DNP-DPI- Project -Literature Reviews Assignment

DNP-DPI- Project -Literature Reviews AssignmentDNP-DPI- Project -Literature Reviews AssignmentI need help with chapter 2 (Literature Reviews) of this project. The chapter need additional 30 articles to be reviewed. Attached are the areas I need you to help me focus on. This has to be written with talking and evidence-based literature. Please follow the other attached sheet for how the articles should be written up. Follow it exactly!!!! haveI have attached the main project for your review, and likewise procedures for the articles and 2 articles that I found which can also be used.I need help with chapter 2 (Literature Reviews) of this project. The chapter need additional 30 articles to be reviewed. Attached are the areas I need you to help me focus on. This has to be written with talking and evidence-based literature. Please follow the other attached sheet for how the articles should be written up. Follow it exactly!!!!1. GCU wants more of an extended annotated bibliography than a literature review, so use the following formula for all of your paragraphs—it’ll get really boring but will also get the work done. DNP-DPI- Project -Literature Reviews Assignmenta. first sentence: statement about the project being discussed and what the purpose wasi. ex. Jones et al. (2020) conducted a systematic review to determine the  importance of DSME.b. second sentence: participant and sample size (or size of literature review)ORDER A PLAGIARISM-FREE PAPER HERE                 i. ex. A total of 25 peer-reviewed articles were selected for review from databases.c. third sentence: method used to obtain resultsd. fourth sentence: conclusion of projecte. fifth sentence: limitations and/or strengthsPatient-Centeredness Care.Clinician’s Cultural Awareness.Introduction paragraphFirst articleSecond articleThird articleDNP-DPI- Project -Literature Reviews AssignmentAcculturation.Introduction paragraphFirst articleSecond articleThird articleDepression and Diabetes-Specific Emotional Distress.Introduction paragraphFirst articleSecond articleThird article Patient Belief System.Stigma associated with the Disease.Introduction paragraphFirst articleSecond articleThird articleDNP-DPI- Project -Literature Reviews AssignmentRacism.Introduction paragraphFirst articleSecond articleThird article Healthcare Disparities.Introduction paragraphFirst articleSecond articleThird articleReferencesImproving Medication Adherence among Type II Home Healthcare Diabetic PatientsSubmitted byBola Odusola-Stephen Comment by Author: Greetings! Thanks for your iteration submission for DNP Academic Quality Review (AQR). Your AQR iteration has been reviewed. You did not make the required changes requested. If you made less than 100% of the changes: You cannot present your project until all 100% are made. This will also impact your grade. Students should carefully follow these instructions: Use the document that was returned to you Review all requested changes and log them on your AQR Revision Worksheet Accept the track changes Address each change/comment one by one As you make revisions, refer to resources on the bottom of the score sheet. There are great writing resources available on DC Network. Please format the name of the file as First Name.Last Name.Course#.mm.dd.yy.AQR2.DNP-DPI- Project -Literature Reviews Assignment -This is in preparation for that process Submit to correct dropbox in Loud Cloud by the due date in the course: DNP-965 (AQR-2) submits week 5. Failure to meet this benchmark could result in the failure of the course. One cannot defend an incomplete manuscript. DNP-965 (AQR-2 iteration) resubmits in DNP-965 Week 7 Do NOT share your document with the Reviewer or the AQR box. ALL AQR revisions are to be done inside of the courses, as assigned. Do NOT put any other document into the course dropbox. This will end the iteration, and a zero will be assigned in the classroom for the assignment. It is important for tracking purposes that you use your GCU email only and follow the directions on proper submission (see the DC network). [Bola: You have several revisions that need to be made. You are still short of articles in your literature review and there are multiple areas that need to be changed to past tense. Please address all comments in the margins. Please consider enlisting the help of a formatter/editor to assist in formatting issues. Please make all the necessary changes. The review team’s goal is to facilitate the success of all learners. Please work with your Chair on the Reviewer’s feedback.  If the Chair has concerns or questions, they should reach out to the Chair, and the Chair will aid in navigating questions or concerns. “Whatever you do, work at it with all your heart, as working for the Lord, not for men.” Colossians 3:23 Blessings, Dr. JoAnna CartwrightDNP-DPI- Project -Literature Reviews Assignment A Direct Practice Improvement Project Presented in Partial Fulfillmentof the Requirements for the DegreeDoctor of Nursing Practice       Grand Canyon UniversityPhoenix, Arizona  DNP-DPI- Project -Literature Reviews Assignment            © Bola Odusola-Stephen, 2021All rights reserved.  GRAND CANYON UNIVERSITYImproving Medication Adherence among Type II Home Healthcare Diabetic PatientsbyBola Odusola-Stephen   has been approved. DNP-DPI- Project -Literature Reviews Assignment September 1, 2021  APPROVED:Bridget Drafahl., PhD, CNL, CNE, RN-BC., DPI Project ChairpersonBamidele Jokodola., DNP., DPI Project Mentor  ACCEPTED AND SIGNED:________________________________________Lisa Smith, PhD, RN, CNEDean and Professor, College of Nursing and Health Care Professions_________________________________________DateAbstractMedication adherence is essential in controlling chronic health conditions such as Type II diabetes in home health patients. At the project site, there was no standard procedure for identifying and addressing patient medication adherence. The purpose of this quantitative quasi-experimental quality improvement project was to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients of a home healthcare agency in urban Texas over four weeks. The nursing theory and change model that guided the project was Orem’s self-care deficit theory and Roger’s diffusion of innovation model. The total sample size was ____, n = 10 in the comparative group and n = 11 in the implementation group. The data was extrapolated from Cradle Solutions the facility’s electronic health record. To analyze the comparison and implementation group data, a chi-square test was used, and showed that and analyzed using chi-square analysis. There was an increase in medication adherence from the comparative (n = 10, 66.7%) to the implementation group (n = 11, 73.3%), X2 (1, N = 30)DNP-DPI- Project -Literature Reviews Assignment = .159, p =. 999. The p-value of .999 showed no statistically significant different between medication adherence for the comparative versus the implementation group. Despite the lack of statistical significance, clinical significance was noted with the nurses consistently using the tool and conducting medication adherence screenings to assist the patient in remaining compliant with their treatment regimen. The findings suggested that implementing a medication adherence program could improve patient compliance rates. Future recommendations would include using larger populations of home health patients for the project. Comment by Author: Not sure what this is. Is this the electronic medical record, if so just refer to the electronic medical record. Comment by Author: Delete Cradle Solutions Comment by Author: Delete this portion.DNP-DPI- Project -Literature Reviews AssignmentKeywords: diabetes mellitus type II, Diffusion of innovation model, home-based care, medication adherence, MAP resources, Orem’s self-care deficit theoryDedicationAn optional dedication may be included here. While a practice improvement project is an objective, scientific document, this is the place to use the first person and to be subjective. The dedication page is numbered with a Roman numeral, but the page number does not appear in the Table of Contents. It is only included in the final practice improvement project and is not part of the proposal. If this page is not to be included, delete the heading, the body text, and the page break below. DNP-DPI- Project -Literature Reviews Assignment              AcknowledgmentsAn optional acknowledgements page can be included here. This is another place to use the first person. If it applies, acknowledge, and identify grants and other means of financial support. Also acknowledge supportive colleagues who rendered assistance. The acknowledgments page is numbered with a Roman numeral, but the page number does not appear in the Table of Contents. This page provides a formal opportunity to thank family, friends, and faculty members who have been helpful and supportive. The acknowledgements page is only included in the final practice improvement project and is not part of the proposal. If this page is not to be included, delete the heading, the body text, and the page break below. If you cannot see the page break, click on the Show/Hide button (go to the home tab and then to the Paragraph toolbar).DNP-DPI- Project -Literature Reviews AssignmentTable of Contents Chapter 1: Introduction to the Project 13 Background of the Project 14 Problem Statement 15 Purpose of the Project 16 Clinical Question 17 Advancing Scientific Knowledge 18 Rationale for Methodology 21 Nature of the Project Design 22 Definition of Terms 24 Assumptions, Limitations, Delimitations 26 Summary and Organization of the Remainder of the Project 28 Chapter 2: Literature Review 30 Theoretical Foundation 32 Review of the Literature 34 Patient-related Factors 34 Socioeconomic Factors 44 Interventions 48 Summary 51 Chapter 3: Methodology 53 Statement of the Problem 54 Clinical Question 55 Project Methodology 56 Project Design 56 Population and Sample Selection 59 Instrumentation or Sources of 61 Validity 62 Altman et al. (2018) stated hospital electronic health records are frequently being used in research studies. Many studies report validity using Cohen’s kappa, which measured performance and specificity (Altman et al., 2018)DNP-DPI- Project -Literature Reviews Assignment. In another study conducted by Goulet et al. (2007), a robust correlation was found (between .86 and .99) for measures obtained from data and compared in a manual review. 62 Reliability 62 Data Collection Procedures 63 Data Analysis Procedures 66 Potential Bias and Mitigation 68 Ethical Considerations 69 Limitations 70 Summary 71 Descriptive Data 73 Data Analysis Procedures 76 Results 78 Summary 80 Chapter 5: Summary, Conclusions, and Recommendations 82 Summary of the Project 83 Summary of Findings and Conclusion 83 Theoretical Implications 84 Practical Implications 86 Future Implications 86 Recommendations 87 Recommendations for Future Projects 87 Recommendations for Practice 88 References 90 Appendix A 104 Grand Canyon University IRB Approval Letter 104 MAP Resources 105 Appendix C 106 Permission to Use the MAP Resources 106DNP-DPI- Project -Literature Reviews Assignment    List of TablesTable 1 . Descriptive Data 61Table 2 . Descriptive Data Ages 62Table 3 . Medication Adherence Rates 65 List of FiguresFigure 1. Mean Knowledge Scores 66      Chapter 1: Introduction to the ProjectAccording to the Centers for Disease Control and Prevention (2020), diabetes affects one in ten Americans. Moreover, diabetes prevalence continues to rise and is expected to increase by 0.3% per year until 2030 (Lin et al., 2018). In individuals with Type II diabetes, proper and effective medication adherence is vital (Kvarnström et al., 2018). This is particularly significant among healthcare patients because diabetes is one of the leading diagnoses for admission to a home health care facility (Sertbas et al., 2019). In this population, approximately 45% of the patients fail to maintain glycemic control (HgbA1c < 7%) (Polonsky & Henry, 2016). Poor medication adherence is associated with increased rates of morbidity and mortality, increased financial costs for hospitals, insurance companies, and frequent hospitalizations (Polonsky & Henry, 2016).DNP-DPI- Project -Literature Reviews AssignmentAt the project site, the primary investigator, in collaboration with the stakeholders, observed that ten percent of the patients were not adhering to their prescribed medication regimen. This prompted frequent hospitalizations, infections, and other diabetic complications. In further investigation, it was found that there was not a standardized method for healthcare providers to evaluate the patients regarding medication adherence. Hence, the Medication Adherence Project (MAP) resources and education intervention will be introduced. Comment by Author: Needs to be past tense.DNP-DPI- Project -Literature Reviews AssignmentThe project was worth conducting because it focused on diabetic home health patients who are not the focal point of many literature reviews. Furthermore, little information is noted regarding the impact the healthcare team plays in addressing this population’s lack of medication adherence. The primary investigator aimed to introduce a standardized method of addressing patients’ medication adherence using MAP resources and education to minimize frequent hospitalizations, infections and increase their quality of life (Starr & Sacks, 2010). The purpose of the project was for the primary investigator (PI) to investigate how healthcare team members can address the various factors affecting medication adherence among diabetic patients receiving home health care.In Chapter 1, the project, background information, and problem statements are described. Other segments include the purpose of the project, the clinical question, the advancing of scientific knowledge, and the significance of the project. The last sections consist of the rationale for using a quantitative method and quasi-experimental design, definition of operational terms, assumptions, limitations, and delimitations. A preview of Chapter 2 is provided by the last few sentences.DNP-DPI- Project -Literature Reviews AssignmentBackground of the ProjectHome-based healthcare has existed since 1909 (Choi et al., 2019). Present-day, home-based healthcare is often selected due to an individual’s personal preferences. 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 or hypertension are often recipients of home-based healthcare (Wong et al., 2020).DNP-DPI- Project -Literature Reviews AssignmentAdhering to diabetes medication regimen requirements can be complex. Raoufi et al. (2018) conducted a study using a multi-stage stratified cluster sampling method to recruit its participants. Two thousand one-hundred eight three diabetic patients participated in the study. Of the participants, 51.4% tested their glucose level more than once a month (Raoufi et al., 2018). The authors also noted that 10% of the participants did not monitor the glucose levels correctly or adhere to the medication requirements.DNP-DPI- Project -Literature Reviews AssignmentPatients with diabetes often express difficulties adhering to medication regimens, thereby reinforcing the critical role of receiving education from home healthcare providers (Wong et al., 2020). This is in part due to the patients not having sufficient knowledge and education regarding diabetes and proper management of the disease (Wong et al., 2020). With diabetes being one of the leading diagnoses for patients needing home health services, healthcare agencies must educate their staff to evaluate the factors prohibiting patients from adhering to their medication regimen.DNP-DPI- Project -Literature Reviews AssignmentProblem StatementIt was not known if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients. The population affected are home health Type II diabetic patients in an urban healthcare agency in Texas. At the project site, nursing administration and staff cited that medication adherence among diabetic patients is lacking. According to data obtained from the site’s electronic health record (EHR), home healthcare providers documented that ten percent of diabetic home healthcare patients are not adhering to their medication regimen. Although this percentage is four to six percent lower than other percentages cited in the literature for medication non-adherence. In terms of chronic disease management, researchers have noted increased implications associated with lacking adherence to medication regimens (Camacho et al., 2019; Hamrahian, 2020; Misquitta, 2020). Comment by Author: Needs to be past tense. Comment by Author: Awkward, reviseThe lack of medication adherence can be attributed to inadequate drug-related knowledge, medication costs, poor understanding of medication regimen, etc., reinforcing the need for this quality improvement project (Heath, 2019; Sharma et al., 2020). Kvarnström et al. (2018) emphasized healthcare providers play a critical role in ensuring medication adherence. To promote medication adherence among patients of a home healthcare facility, the primary investigator will introduce a standardized method for the healthcare providers to assess the patient’s medication adherence. The staff will achieve greater insight by using MAP resources and an education intervention created by Starr and Sacks (2010). The tools utilized in this study, which are from Starr and Sacks’s (2010) MAP Toolkit and Training Guide resources, include: (1) the questions to ask poster, (2) an adherence assessment pad, and (3) my medications list. Comment by Author: Stick with calling this the New York City ……… Do not use Starr and Sack’s as this confuses the issue about which toolkit you used. Comment by Author: This is not a study it is a project.DNP-DPI- Project -Literature Reviews AssignmentThe project contributes to solving the problem by introducing a standardized method of evaluating the patient’s medication adherence. It will improve the healthcare provider’s knowledge and awareness regarding the obstacles or factors the patient may face in maintaining a medication regimen. This would help the facility adhere to the current Centers for Disease Control and Prevention (2020a) guidelines in the participants maintaining their normal daily glucose levels, deter healthcare costs, frequent hospitalizations, and infections. Comment by Author: Please review your manuscript for past tense. This paragraph needs to be put in past tense.DNP-DPI- Project -Literature Reviews AssignmentPurpose of the ProjectThe purpose of this quantitative quasi-experimental quality improvement project was to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients in urban Texas over four weeks. The independent variable is the MAP resources and educational intervention. The dependent variable is medication adherence rates. Comment by Author: Delete. DNP-DPI- Project -Literature Reviews AssignmentThe project contributes to the nursing field by increasing the healthcare providers’ knowledge and awareness of the obstacles and other risk factors involved in a patient not adhering to their medication regimen. Furthermore, it would help increase dialogue between the provider and patient in sharing the details of their behavior (Bussell et al., 2017). This creates a positive, blame-free atmosphere allowing the patients to discuss their medication-taking behavior (Bussell et al., 2017). Comment by Author: Past tense Comment by Author: Please review your manuscript for past tense. This will be the last time I highlight this needed revision.DNP-DPI- Project -Literature Reviews AssignmentClinical QuestionA well-developed clinical question must be related and relevant to patient care. This helps the primary investigator search for evidence-based answers. The clinical question that will direct this quality improvement project is: To what degree does the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients in urban Texas?The independent variable is the MAP resources. The dependent variables are the medication adherence rates. To address the clinical question, the medication adherence rate for 30-days before and 30-days after the implementation of MAP resources will be compared using a chi-square test. The chi-square test will allow for a comparison of the medication adherence rate for patients 30 days before and 30 days after the implementation, thereby answering the clinical question. The level of significance will be set to .05, indicating a p-value of less than .05 would reveal statistical significance. The clinical question is aligned with the problem statement in examining the effect of the MAP resources on the diabetic patients.DNP-DPI- Project -Literature Reviews AssignmentAdvancing Scientific KnowledgeThis direct practice improvement project seeks to enhance medication adherence among diabetic home healthcare patients using the MAP resources. Various researchers have cited the benefits associated with patient-provider engagement and collaboration to improve medication adherence (Ong et al., 2018; Polonsky & Henry, 2016; Wong et al., 2020). The advancement of a small step forward at the clinical site is that by improving medication adherence rates among diabetic patients’ positive patient-related outcomes will likely occur using the MAP protocol. This will add to the current literature and address the gap found regarding non-medication factors among home health diabetic patients.DNP-DPI- Project -Literature Reviews AssignmentThe importance of medication adherence among diabetic patients has been demonstrated in numerous studies (Ong et al., 2018; Polonsky & Henry, 2016). Despite this, a limited amount of literature has been published regarding how Type 2 patients in the home health setting are affected by this knowledge. In the United States, home healthcare nurses are essential providers in the community (Omidiran, 2018). As a result, they may be able to provide deeper insights regarding strategies that will result in higher medication rates (Omidiran, 2018). The expected population of older adults is expected to double from 40 million to roughly 88 million by 2050 (Administration on Aging, 2015; Omidiran, 2018). Many of these individuals reside in a community dwelling setting (other than a hospital such as home health) and are non-compliant for various reasons.DNP-DPI- Project -Literature Reviews AssignmentThe theoretical framework used in the quality improvement project was Orem’s self-care deficit theory (1995), which was developed to improve patient health outcomes in the context of nursing contribution (Yip, 2021). It is comprised of three related sections: theory of self-care, self-care deficit, and the nursing system (RenpenningcN et al., 2003). It fits the project because it includes healthcare providers assisting patients in diabetic patients’ self-care and management to improve their function at a home level (RenpenningcN et al., 2003). The patients cannot effectively manage medication adherence for diabetes, which affects their quality of life and health. Orem’s self-care deficit theory advances the project by contributing to previous research conducted on Type II diabetic patients using the theory (Borji et al., 2017; Ghafourifard & Ebrahimi, 2015; Shahbaz et al., 2016).DNP-DPI- Project -Literature Reviews AssignmentBased on the theory, the primary investigator was able to increase the patient’s awareness of their disease and minimize their non-compliance with their regimen (Borji et al., 2017). The theory helped in identifying the educational needs of home healthcare patients, which are more important than the proper treatment (Borji et al., 2017). It has been recommended that Orem’s self-care deficit theory be implemented to increase a patient’s knowledge level and adherence to self-care practices (Shahbaz et al., 2016).DNP-DPI- Project -Literature Reviews AssignmentThe change model that will be used in this quality improvement project is the Diffusion of Innovation Model developed by Rogers (2003). There are five stages: a) knowledge or awareness, b) persuasion or interest, c) decision or evaluation, d) implementation or trial, e) confirmation or adoption (Rogers, 2003). Diffusion is defined as a social process, which occurs among individuals in response to knowledge regarding a new strategy for improving their health (Dearing & Cox, 2018).DNP-DPI- Project -Literature Reviews AssignmentThis change model provided the primary investigator with methods to share and educate regarding a new diabetic prevention strategy (Lien & Jiang, 2016). The model has been utilized in various fields to help healthcare providers understand and translate new concepts, treatments, disease knowledge, and educational methods (De Civita & Dasgupta, 2007; Lien & Jiang, 2016). For this project, the primary investigator used the MAP resources provide the participants a new approach to be integrated into the daily practices to improve quality of life and diabetic outcomes. Utilizing these methods will help the project advance by helping the healthcare providers to implement a standardized method in evaluating the patient’s medication-taking behaviors.DNP-DPI- Project -Literature Reviews AssignmentSignificance of the ProjectThis project is significant since chronic diseases such as diabetes continue to rise, resulting in a more comprehensive array of treatment options for patients (Polonsky & Henry, 2016). Home-based care has been gaining popularity as a means of meeting the unique needs of various population groups (Holly, 2020). Type II diabetes patients who qualify for home-based care options must demonstrate their willingness to work with the home healthcare agency at the selected project site. When patients who receive home-based care fail to adhere to the care requirements set forth, adverse outcomes can ensue (Polonsky & Henry, 2016). Comment by Author: Awkward sentence and needs to be past tense.DNP-DPI- Project -Literature Reviews AssignmentThe possible results based on the clinical question and problem statement should increase patient compliance related to medication adherence. The project also helps to empower healthcare providers to adequately address medication questions and patient concerns and ensure patients keep track of their medication regimen, resulting in a reduction in adverse events. According to Holecki et al. (2018), when MAP resources were utilized, medication adherence increased. Comment by Author: You have results now so possible should be removed. Comment by Author: Past tense needed for this sentence.DNP-DPI- Project -Literature Reviews AssignmentThe 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. For this quality improvement project, it fits within helping to correct the gap noted in the literature (regarding medication adherence) for this population. Furthermore, it contributes to the clinical site by helping the patients maintain their medication regimen. The project findings assisted the participants to decrease potential infections, hospitalizations, and incurring financial costs (patients and the facility). Comment by Author: Review this entire section for past tense.DNP-DPI- Project -Literature Reviews AssignmentRationale for MethodologyThe methodology chosen for this quality improvement project is quantitative.Creswell and Creswell (2018) noted a quantitative methodology is best suited for projects that require data in numerical form. In this project, the numerical data will be presented using charts and graphs. These charts and graphs will allow readers to compare medication adherence rates pre-project implementation and post-project implementation.While qualitative research studies are beneficial, they examine experiences, perspectives, and beliefs about a specific issue (Creswell & Creswell, 2018). The data collection used in this type of methodology is interviews (semi-structured, one-on-one, and focus groups). For this project, the primary investigator is not seeking to understand the participants’ feelings, behaviors, or lived experiences related to medication adherence.DNP-DPI- Project -Literature Reviews AssignmentA quantitative methodology supported the project because it permitted the primary investigator to remain objective in providing the project’s findings (Leedy & Ormord, 2020). Furthermore, the methodology allowed the primary investigator to summarize the data that could support generalizations for a larger or similar population. The methodology was less costly with easy replication for future quality improvement projects to obtain the same results (Leedy & Ormord, 2020).DNP-DPI- Project -Literature Reviews AssignmentNature of the Project Design Comment by Author: Review section for changes to past tense.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. Price et al. (2017) stated that in a pretest-posttest design, the dependent variable is measured once before the treatment is implemented after it is implemented. Delete, these designs are used when research occurs in a controlled environment. While this project was be conducted in a controlled environment, the primary investigator selected a quasi-experimental design because it is more cost-effective than an experimental project design (Schweizer et al., 2016). Furthermore, since data pre-project implementation and post-project implementation need to be collected and analyzed to explore the intervention’s impact, a quasi-experimental design is most appropriate.DNP-DPI- Project -Literature Reviews AssignmentA correlational design was considered but not appropriate for the project because the primary investigator is not seeking to understand the relationships occurring among the variables (Creswell & Creswell, 2018). This design is typically descriptive relying on a hypothesis (Leedy & Ormord, 2020). The primary investigator will not seek the relationships between the independent variable (MAP resources and education intervention) and the dependent variable (medication adherence rates).DNP-DPI- Project -Literature Reviews AssignmentThe targeted population were home health patients ages 35 to 64 years old. The selected site serves approximately 100 patients annually, and 30 patients are diagnosed with Type II diabetes. The inclusion criteria were males and females diagnosed with Type II diabetes, oral medication or insulin, and home health patients. The exclusion criteria comprised of individuals with language or cognitive deficits and diagnosed with Type I diabetes.DNP-DPI- Project -Literature Reviews AssignmentThe data collection process began once approved by Grand Canyon University Institutional Review Board (IRB). Recruitment will occur from informational flyers given to the patients during their home health visits with the providers. The nurses will answer any questions regarding the project’s risks, benefits, and purpose and be instructed that the participation is voluntary. The primary investigator will use a convenience sample because of the access to the participants.DNP-DPI- Project -Literature Reviews AssignmentData will be collected four weeks prior to project implementation from the electronic medical records (Cradle Solutions software) (medication adherence rates) (Cradle Solutions, 2021). In the last three days of the first week the primary investigator will educate the healthcare providers regarding using the MAP resources. The staff will begin implementing the tool, and the post medication adherence rates will be assessed four weeks post-implementation. The primary investigator will document the data in a Microsoft Excel 2016 codebook developed by the primary investigator. Once completed, it will be exported into the SPSS-27 and analyzed using an independent t-test. A five-item demographic questionnaire will be used for descriptive statistics of the population. The survey will include (age, gender, years with Type II diabetes, oral or insulin, and education).DNP-DPI- Project -Literature Reviews AssignmentPre-intervention and post-intervention data will be obtained via the project site’s EHR. The questions that will be analyzed are: (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?” In addition to the questions, home healthcare providers will ask the patient “Are you taking your medications?” Any information attained from the question and due to probing, observation of patient’s medications, and patient-related medication adherence will be documented in the project site’s EHR. The data will be analyzed using an independent t-test to determine the statistical significance.DNP-DPI- Project -Literature Reviews AssignmentDefinition of TermsThe following operational terms will be used interchangeably throughout the manuscript. In this project, the terms utilized were significant to the project’s foundation and background. By using functional terms, the reader is provided with transparency and insight into the project. Comment by Author: Needs to be changed to past tense.DNP-DPI- Project -Literature Reviews AssignmentAdherence Assessment Pad.The Adherence Assessment Pad is part of the MAP resources that explores answers via the patient perspectives. Using the Adherence Assessment Pad, nursing staff members will be able to explore the concerns of patients and adjust, pending further project team review, to the patient’s medication regimen (Starr & Sacks, 2010).DNP-DPI- Project -Literature Reviews AssignmentHome-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.DNP-DPI- Project -Literature Reviews AssignmentMedication 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).My Medications List .Is a list that provides a breakdown of the patient’s medications, in an easy-to-follow chart format, thereby improving patient medication adherence (Starr & Sacks, 2010).Questions to Ask Poster .Is a part of the MAP toolkit, which will be utilized during this project. When using the Questions to Ask Poster, home healthcare providers answer six questions to patients about medication adherence and medication knowledge. The questions that providers will answer include: (1) “Why do I need to take this medicine?,” (2) “Is there a less expensive medicine that would work was well?,” (3) “What are the side-effects and how can I deal with them?,” (4) “Can I stop taking any of my other medicines?,” (5) “Is it okay to take my medicine with over-the-counter drugs, herbs, or vitamins?,” and (6) “How can I remember to take my medicine?” Providers must answer all the questions and should assume that individuals have no medication knowledge, thereby confirming that patients know and understand these critical answers (Starr & Sacks, 2010).DNP-DPI- Project -Literature Reviews AssignmentType II Diabetes.For this project, Type II diabetes is the topic of exploration. It is described as an impairment of the body regulating and using glucose as a fuel source. Type II diabetes is a chronic condition where an excess amount of sugar is circulating in the blood stream (Mayo Clinic, 2019).Assumptions, Limitations, Delimitations Comment by Author: Review this section for past tense.DNP-DPI- Project -Literature Reviews AssignmentAs with all practice improvement projects, assumptions, limitations, and delimitations must be addressed. Assumptions are considered self-evident truth (Grand Canyon University, 2021). They are statements that are deemed plausible by other individuals and peers who read the project. The first assumption is that the participants will self-report honestly to the best of their recollection. To minimize social-desirability bias, the primary investigator will compare the participant’s answers with other data (laboratory values for glucose levels) (Leedy & Ormrod, 2020).DNP-DPI- Project -Literature Reviews AssignmentThe second assumption was that the primary investigator had adequately described the current situation at the project site. To ensure that fabrication and falsification of the project findings did not occur, the primary investigator observed the nurses during the patient visit to monitor the interactions. To ensure that the project results are not influenced by skewed statistical findings, an outside source was used to serve as a statistician. The third assumption was related to the inclusion criteria for the targeted population. Demographics and characteristics of the population were the same to meet their needs. Identifying the relevant inclusion and exclusion criteria is essential when conducting a quality improvement project, as these factors influence the external validity of the project (Patino & Ferreira, 2018).DNP-DPI- Project -Literature Reviews AssignmentLeedy and Ormrod (2020) stated that limitations are factors that the primary investigator has no control over. The first limitation is the primary investigator’s lack of control over the environment related to the novel coronavirus pandemic (COVID-19). The pandemic has affected the method in which the project will be implemented. The primary investigator will not interact with the participants during the project. Instead, five registered nurses were educated to implement the project. The pandemic has increased many patients’ fear related to one-on-one interaction with their primary care providers. The primary investigator does not know if there is a possibility with the new variant (Delta-variant) if the project will be modified to virtual monitoring to minimize the participant’s risk of COVID-19 infection.DNP-DPI- Project -Literature Reviews AssignmentThe second limitation is conducting the project (four weeks versus longer) (cross-sectional versus longitudinal). A cross-sectional project allows for a snapshot of a specific moment (Leedy & Ormrod, 2020). A longitudinal project would have allowed the primary investigator to provide a richness of data regarding the topic. The primary investigator could identify and convey the findings related to the participants’ behaviors, patterns of change, experiences, and reduce recall bias (Coolican, 2014). Furthermore, this type of project would allow the primary investigator to test whether the variables were casual or the result of other differences (Leedy & Ormrod, 2020).DNP-DPI- Project -Literature Reviews AssignmentDelimitations are choices the primary investigator made, describing the boundaries placed on the project. One project delimitation noted is the inclusion criteria of the participants. Patients with diabetes, ages 35 to 64, are included in the project. Since this project’s focus is to explore medication adherence among diabetes patients, which is a concern at the project site, it has narrowed the field to learn about other patients and their compliance issues. The second delimitation is where the project was conducted, an urban area located in the southeastern region of the United States, thereby impacting the generalizability of its findings.DNP-DPI- Project -Literature Reviews AssignmentSummary and Organization of the Remainder of the ProjectThe aging population is growing at an increasing rate in the United States, hence snowballing the number of individuals taking medications to manage their Type II diabetes. Kvarnstrom et al. (2018) emphasized that for Type II diabetics, it is essential that proper and effective medication adherence be maintained. For home healthcare patients, 45% of this population fail to maintain glycemic control < 7% (Polonsky & Henry, 2016). This is attributed to poor medication adherence (Polonsky & Henry, 2016). Healthcare providers are a critical component in making a difference by helping patients learn and maintain medication adherence.DNP-DPI- Project -Literature Reviews AssignmentThe quality improvement project will use a quantitative methodology. The rationale for using this method is to collect numerical data that can be statistically analyzed. A quasi-experimental design will answer the clinical question to determine if the outcome impacted the medication adherence rates. The project will be guided by Orem’s self-care deficit theory and Roger’s diffusion of innovation model (Rogers, 2003).DNP-DPI- Project -Literature Reviews AssignmentChapter 1 provided detailed support for utilizing the MAP resources to improve medication adherence among diabetic patients of the project site. A quantitative, quasi-experimental design was used to explore the impact of the MAP intervention on improving medication adherence among Type II diabetes patients of the selected project site. Other portions of the chapter included advancing scientific knowledge using Orem’s self-care deficit theory and Roger’s diffusion of innovation model. A detailed description was given related to the project’s significance, project’s methodology, and design. The last few sections of the chapter comprised the definition of terms, assumptions, limitations, delimitations, and a summarization of the chapter.DNP-DPI- Project -Literature Reviews AssignmentChapter 2 presented a detailed summary of the literature collected related to the project’s clinical question. Information about the theoretical framework and change model is detailed. The chapter comprises five sections, which highlight information about literature obtained from 2016 to 2021. The information presented provides readers in-depth knowledge and the importance of each chosen section.DNP-DPI- Project -Literature Reviews AssignmentChapter 3 offered research methodology details that the primary investigator employed. The information presented in the chapter included the selected research design, the target population, and the sample size. Furthermore, data collection tools (specifically the MAP’s resources) and data analysis procedures are discussed. The reliability and validity of the project instruments are detailed. Lastly, ethical considerations for collecting data are addressed.Chapter 4 presented the project’s findings, which were analyzed using chi-square analysis. Results regarding the descriptive and inferential data analyses will be offered. Furthermore, a brief discussion of project-related findings is delivered. The information will be presented using graphics, figures, and tables. Chapter 5 delivered the conclusions and recommendations drawn from the project’s results. The impact of the findings, in terms of practical and theoretical knowledge, will be offered. Comment by Author: Please review Chapter one in its entirety for revisions to past tense.DNP-DPI- Project -Literature Reviews Assignment   Chapter 2: Literature ReviewThere is a global epidemic of diabetes mellitus (DM), and a large proportion of diabetic patients suffer from Type II diabetes (Rana et al., 2019). Adherence to prescribed medications is essential for the achievement of therapeutic success and reduction of diabetic complications (Rana et al., 2019). For Type II diabetic home health patients, this is vital in maintaining self-care and management of the disease. Unfortunately, approximately 30% to 50% of patients adhere to their medication regimen (Hennessey & Peters, 2019).DNP-DPI- Project -Literature Reviews AssignmentDiabetes is a lifestyle disease, which can be prevented or avoided by making lifestyle changes. Disease management can also occur through adhering to one’s prescribed medication regimen(s). Medication adherence is important since it can help to reduce the likelihood of diabetes-related challenges and complications. In the United States (U.S.), the problem is associated with increased morbidity and mortality rates, with approximately 125,000 deaths and 10% of hospitalizations annually (Hennessey & Peters, 2019). Furthermore, medication nonadherence costs the U.S. healthcare systems roughly $100 billion to $317 billion yearly (Kini & Ho, 2018). The purpose of this quantitative quasi-experimental quality improvement project was to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients in urban Texas over four weeks.DNP-DPI- Project -Literature Reviews AssignmentChapter 2 reintroduced the project’s subject matter, background, theoretical framework, and change model. Other segments include a review of literature on previous and current empirical research related to medication adherence in Type II diabetic home health patients. The chapter’s themes are related to patient-related factors (non-pharmacological and pharmacological lifestyle changes, patient beliefs). The sub themes were socio-economic factors (medication costs, health literacy, lack of social support), health system factors (trust in the healthcare provider, complicated medication regimen), and interventions (patient education, motivational interviewing, and MAP resources). Comment by Author: Awkward revise.DNP-DPI- Project -Literature Reviews AssignmentThe primary investigator conducted a literature review utilizing peer-reviewed articles from 2016 to current. The inclusion criteria were articles written in English, topics specific to the project such as barriers to medication adherence, MAP resources, medication adherence, and Type II diabetes. The exclusion criteria were articles not written in English, more than six years, Type I diabetes, or involved children. Databases reviewed were PubMed, Google Scholar, CINAHL, Cochrane Library, EBSCOhost, and Grand Canyon University online library. The review revealed over 632,000 plus results; however, the primary investigator selected 30 articles for this chapter for this project. Comment by Author: This is not enough articles, you need to have at least 50 articles with 85% of these articles published within the last five years. You will need to add additional articles.DNP-DPI- Project -Literature Reviews AssignmentOne of the most problematic issues associated with home care for diabetes patients is adherence to medications. According to Bonney (2016), patients take their medication as prescribed only 50% of the time. Furthermore, patients are often reluctant to share medication compliance details, thereby resulting in health-related complications (Bonney, 2016). Type II diabetes mellitus is at an epidemic proportion globally (Centers for Diseases and Prevention Control, 2020). The incidence of the disease will continue to rise from 382 million individuals to 417 million by 2035 (Polonsky & Henry, 2016; Rana et al., 2019). Healthcare experts are becoming increasingly concerned because of the costs, morbidity, and mortality rates linked with the disease (Polonsky & Henry, 2016). One of the elements contributing to the problem is poor medication adherence (Rana et al., 2019). This is particularly true in-home health Type II diabetic patients. Medication adherence in adults with chronic conditions is roughly between 30% to 50% (Kini & Ho, 2018; Neiman et al., 2017). Furthermore, the healthcare system associated with medication nonadherence is costing the U.S. healthcare system $100 billion to $317 billion annually (Rana et al., 2019). Comment by Author: What is it for Type II diabetic patients. Need to tie in this statement with Type II diabetes.DNP-DPI- Project -Literature Reviews AssignmentAs adults in this country age, many are afflicted with chronic diseases such as diabetes (Type II). It is one of the main reasons for admission to home health agencies (Sertbas et al., 2019; Wong et al., 2020). Home health agencies have been in existence for over 30 years (Choi et al., 2019). These organizations will continue to grow and impact medical advances and technology (Wong et al., 2020). Hence, there is a need for healthcare providers to become familiar with strategies and barriers linked with medication adherence for this population. Many home health patients have difficulty adhering to their medication regimens. They often express difficulty adhering to the regimens, which reinforces the critical role of home healthcare providers (Wong et al., 2020). This is partly due to them not having knowledge and education related to the disease and proper self-management (Wong et al., 2020). Comment by Author: What is? Comment by Author: Who is them?DNP-DPI- Project -Literature Reviews AssignmentTheoretical FoundationOrem’s self-care deficit theory was selected to guide this quality improvement project. The theory was chosen because of its expectations that an individual must be self-reliant and responsible for their care (Orem, 1985). Dorothea Orem’s theory states self-care is an activity that a person engages in to maintain, restore, or enhance their health (Orem, 1985). The theory further states that nurses should not consider patients as inactive or sheer recipients of healthcare; instead, they should be considered reliable, responsible individuals who can make informed decisions and be active in their health care (Orem, 1985).DNP-DPI- Project -Literature Reviews AssignmentThis theory describes nursing as an action between two or more individuals (RenpenningcN et al., 2003). Furthermore, it assumes that a successful patient with self-care understands it is a primary element in health prevention and illness (RenpenningcN et al., 2003). The theory fits the project because the healthcare providers are in supportive educational roles, which assists the patient when they are ready to learn or cannot complete a task without guidance (Orem, 1985). In addition, the theory relates to healthcare providers assisting patients in their self-care and management to improve their function at a home level (RenpenningcN et al., 2003). The theory has been used in multiple studies regarding patients with chronic diseases (Afrasiabifar et al., 2016; Borji et al., 2017; Khademian et al., 2020).DNP-DPI- Project -Literature Reviews AssignmentThe change model that will be used is the diffusion of innovation developed by Rogers (2003). There are five components of the theory are a) knowledge, b) persuasion, c) decision, d) implementation, and e) adoption (Rogers, 2003). The model is defined as a social process, which occurs among individuals in response to knowledge regarding a new strategy for improving their health (Dearing & Cox, 2018). It is a process communicated within a specific timeframe (for this project, four weeks) (Dearing & Cox, 2018). This change model can provide the primary investigator with methods to share and educate regarding a new diabetic prevention strategy (Lien & Jiang, 2016). The model has been utilized in various fields to help healthcare providers understand and translate new concepts, treatments, disease knowledge, and educational methods (De Civita & Dasgupta, 2007; Lien & Jiang, 2016). For this project, the primary investigator using the MAP resources provide the participants a new approach to be integrated into the daily practices to improve quality of life and diabetic outcomes. Utilizing these methods will help the project advance by helping the healthcare providers to implement a standardized method in evaluating the patient’s medication-taking behaviors.DNP-DPI- Project -Literature Reviews AssignmentReview of the LiteratureDiabetes is prevalent in the United States and globally (Rana et al., 2019). It is one of the primary diagnoses for being admitted into home health care (Sertbas et al., 2019). Hence, the usage of home health services has become increasingly popular because it allows patients to remain in a comfortable atmosphere and decrease hospitalizations (Sertbas et al., 2019). There are many studies regarding older adults and diabetes, but minimum regarding home health care patients with diabetes (Sertbas et al., 2019). The review of literature is based on themes centered on patient-related factors, socioeconomic factors, and interventions.DNP-DPI- Project -Literature Reviews AssignmentPatient-related FactorsThe World Health Organization (2017) stated patient related factors encompass an individual’s resources, knowledge levels, belief system, perspectives, and expectations. These factors can vary dependent on the non-pharmacologic and pharmacologic lifestyle changes that the person maintains (Nduaguba et al., 2017). Type II diabetes management involves not just medication adherence but observance to monitoring diet and exercise, follow-up, and self-care (Nduaguba et al., 2017).DNP-DPI- Project -Literature Reviews AssignmentMedication adherence. Comment by Author: Not the proper format for your subtheme heading. Please review APA 7th edition.Medication adherence is a term that refers to one taking medication as prescribed by their healthcare practitioner (Ahmed et al., 2018). Healthcare providers must ensure that the prescriptions provided to patients are suitable to the individual’s conditions. While medication adherence is important, there is a plethora of literature available that expresses the prevalence of medication non-adherence among patients. Various factors continue to impact medication adherence, which includes, but are not limited to, fear, costs, misunderstanding, too many medications, lack of symptoms, mistrust, worry, and depression (American Medical Association [AMA], 2020). To prevent medication non-adherence, providers can seek to understand the needs of patients and provide them with resources that can aid in overcoming non-adherence.DNP-DPI- Project -Literature Reviews AssignmentAhmed et al. (2018) emphasized that the quality of healthcare can be influenced by the body’s ability to respond to the treatment. A study conducted by Rana et al. (2019) was related to exploring medication adherence to prescribed treatments as a crucial factor for hospitalized Type II diabetic patients in a Bangladesh hospital. The quantitative, descriptive cross-sectional study involved 112 Type II diabetic patients recruited from medical and endocrinology wards. Much of the sample size age was 57.46, 60.7% were male and married. The patient’s medication adherence was measured using the 7-item MCQ scale modified by Ahmad et al. (2013). Data were analyzed using SPSS-21. Descriptive statistics were used to measure the participants’ demographics. An independent sample t-test and one-way ANOVA with post hoc comparisons were used to evaluate the relationships between the variables (p =.05).DNP-DPI- Project -Literature Reviews AssignmentThe results from the Rana et al. (2019) study showed 72.3% of the participants forgot to take their medications, 96.4% chose not to take the medication or miss a dose when feeling better. Most of the patients, 81.3%, did not take their medications with them when traveling. The mean scores of the MCQ were 26.46 (SD =1.58). The study’s results concluded that the level of medication adherence among Type II diabetic patients was suboptimal (Rana et al., 2019). The authors recommended that more attention needed to be given to varied age groups related to medication adherence.DNP-DPI- Project -Literature Reviews AssignmentLee et al. (2017a) conducted a quantitative study to determine the medication adherence among Type II diabetic patients in an Asian community. This cross-sectional study involved 382 Asian participants from a primary outpatient care clinic in Singapore. The patient’s medication adherence was measured using a five-item Medication adherence report scale (MARS-5). A low medication adherence score was <25. The sample size was predominately female, with a mean age of 62 years. Using univariate analysis, the results showed 57% of the participants had a low medication adherence score, which was attributed to them being married or widowed, taking fewer than four medications daily, and poor glucose control. The study concluded that younger patients were susceptible to low medication adherence scores (Lee et al., 2017).DNP-DPI- Project -Literature Reviews AssignmentAlthough the studies were conducted in different settings (primary care and hospital), the results demonstrated a need for healthcare providers to focus on different age groups and their reasons for not adhering to their medication regimen. The studies were cross-sectional, which indicated the authors were unable to evaluate the participant’s habits and trends. This could have changed if they could assist the patients with barriers they faced during the studies.DNP-DPI- Project -Literature Reviews AssignmentThis topic was chosen because inefficient medication adherence is complex, with a variety of contributing causes; hence, there is no universal solution (Rodriguez-Saldana, 2019). For a patient to succeed with medication adherence, the healthcare provider must understand the underlying reasons that are barriers that could be removed or diminished. Teaching the patient new strategies that are patient-centered will help them achieve the new normal.DNP-DPI- Project -Literature Reviews AssignmentNon-pharmacological indicators. There are many medications used for the effective management of diabetes (Raveendran et al., 2018). Effective non-pharmacological therapy should be explored with all Type II diabetics. The measures could include nutrition and exercise. Nutrition interventions are critical in a person with diabetes maintaining an optimal glucose level (80-120mg). The dietary pattern that must be encouraged is consuming fruits, vegetables, low-fat dairy foods, whole grains, and minimal red meat (Asif, 2014). Khazrai et al. (2014) study emphasized that food intake is associated with obesity. However, it is not just the volume of food but the quality of one’s diet. High ingestion of red meat, sugary items, and fried foods contributes to insulin resistance and Type II diabetes (Khazrai et al., 2014). People with diabetes should be educated regarding consuming fruits and vegetables in protecting them since they are high in nutrients, fiber, antioxidants, and a protective barrier against diseases (Khazrai et al., 2014). Comment by Author: This is the proper heading format for a subtheme.DNP-DPI- Project -Literature Reviews AssignmentThis topic was selected because educating Type II diabetic home healthcare patients regarding their dietary habits is an integral part of diabetes care. Failure to incorporate healthy eating habits along with medication adherence can lead to severe complications of the disease. Healthcare providers must teach home healthcare patients dietary guidelines according to their food selection, cultural, and personal preferences to change their eating patterns.DNP-DPI- Project -Literature Reviews AssignmentPharmacological factors.Type II diabetic patients typically take multiple medications for their condition and other comorbidities (Kirkman et al., 2015). Following one’s medication regimen and treatment improves patient outcomes, reduces healthcare costs, hospitalizations, and mortality (Kirkman et al., 2015). A retrospective study conducted by Kirkman et al. (2015) determined patient, medication, and prescriber factors that influenced diabetic patients and medication adherence. A sample size of 200,000 participants (from 50 states, including the Virgin Islands) was extracted from a pharmacy database (Medco Health Solutions). The participants’ eligibility was based on the medication, benefits, and prescription history. Each patient was followed for one year from the medication date to post-implementation of the study.DNP-DPI- Project -Literature Reviews AssignmentMedication adherence was described as a medication possession ratio > 0.8 (Kirkman et al., 2015). Logistic regression analyses were conducted to evaluate factors independently linked with adherence. The results demonstrated that 69% of the participants were adherent. Other findings illuminated that adherence was associated with one’s age (older), male, higher education and income, and the use of the mail order versus retail pharmacies. Individuals with a new diagnosis of diabetes were less likely to be compliant with their medication regimen.The authors concluded that demographic, clinical, and system-level factors influenced the participants’ medication adherence regimen (Kirkman et al., 2015). The authors emphasized that younger individuals, newly diagnosed and had minimal medications to take, were at a higher risk for non-adherence. Individuals who used mail-order pharmacies resulted in higher medication adherence due to lower out-of-pocket costs (Kirkman et al., 2015).DNP-DPI- Project -Literature Reviews AssignmentPatient’s belief system.One’s culture influences a patient’s beliefs regarding medications, which ultimately affects their medication adherence (Lemay et al., 2018). This remains a challenge for healthcare providers in helping patients to understand the significance of medication adherence (Shahin et al., 2019). A study conducted by Shahin et al. (2019) used a systematic review to determine the importance of an individual’s cultural belief influenced medication adherence. A total of 2,646 articles were selected from various databases such as PubMed, CINAHL, EMBASE, and PsychINFO. Twenty-five of them met the inclusion criteria. The studies focus on diabetes or hypertension.DNP-DPI- Project -Literature Reviews AssignmentThe study results from Shahin et al. (2019) revealed personal and cultural factors linked with medication adherence. Ten articles (40%) demonstrated an individual’s perception of the illness, five (20%) were affiliated with health literacy, four (16%) cultural beliefs, three (12%) self-efficacy, and five (20%) knowledge illness (Shahin et al., 2019). Shahin et al. (2019) study concluded that one’s cultural influences affect their perception of the importance of medication adherence. Healthcare providers must understand their patients’ pre-existing perspectives of diabetes before offering new information. This is an opportunity for healthcare professionals and patients to have a dialogue to diffuse misconceptions related to the patient’s perceptions. The authors suggested that future research should identify the religious beliefs associated with disease knowledge and medication adherence.DNP-DPI- Project -Literature Reviews AssignmentHealthcare providers and the relationships with patients.Patients usually consider their healthcare providers (HCPs) as the most dependable source of data regarding their health condition and treatment. Patients are highly likely to effectively follow the treatment plan when they are involved in having a good relationship with their HCP due to the confidence and trust that has been built over time. Relationship building in healthcare is a vital aspect in the day to day lives of healthcare practitioners due to the nature of their job, which necessitates that they maintain long-term relationships with their patients for enhanced medication and treatment outcomes (Heston, 2018).DNP-DPI- Project -Literature Reviews AssignmentTrust is critical to developing, specifically since patients can experience improve health-related outcomes when they value relationships with their HCPs. Patients who have trust in their HCP often believe that their provider has a high level of competence and truly cares about their health-related outcomes (Heston, 2018). Mistrust develops when the patients attain unrealistic, inconsiderate, or insensitive advice from their HCPs, as well as feel emotional distance from them.DNP-DPI- Project -Literature Reviews AssignmentHealth literacy.Health literacy is described as one’s ability to obtain, communicate, process, and comprehend basic health information and navigate health services to make an informed decision (Sawkin et al., 2015). Medication adherence is broadly identified as a patient’s ability to follow a prescribed medical treatment (Sawkin et al., 2015). Researchers Glanz et al. (2015) have explored the impact of low health literacy rates on patient compliance with medications and health-related advice. The authors stated that approximately 35% of American adults possess basic or below basic health literacy levels (Glanz et al., 2015).DNP-DPI- Project -Literature Reviews AssignmentChima et al. (2020) conducted a systematic review to evaluate the impact of health literacy and medication adherence. Literature searches were performed using Ovid Medline, CINAHL, EMBASE, Scopus, and PsycInfo. The inclusion criteria for the articles were conducted in the United States, 18 years or older with a diagnosis of Type I or II diabetes, medication adherence was an outcome variable, quantifiable measure reported, and was a full text journal article. Articles were graded using Joanna Briggs Institute Critical Appraisal Checklists, which is appropriate for the respective study designs identified. Thirteen articles were retained in the review, most of which used a cross-sectional design.DNP-DPI- Project -Literature Reviews AssignmentThe results demonstrated four of the 11 studies found a positive association between health literacy and medication adherence (Chima et al., 2020). Two of the four studies had methodological shortcomings. The authors concluded there was some evidence that health literacy is linked with medication adherence among diabetic adults in the United States. Recommendation for future research to design and execute longitudinal studies to determine a deeper relationship between the variables (health literacy and medication adherence (Chima et al., 2020).DNP-DPI- Project -Literature Reviews AssignmentGiven inadequate literacy rates, among members of the general population, world practitioners continue to create unique strategies that can be used to reduce lacking health adherence among patients with diabetes. Improved literacy is a theme that should be of the utmost priority, specifically since it creates the foundation for long-term sustained profitability. Furthermore, as patients can understand the importance of medication compliance, adherence to medication regimens improves (Glanz et al., 2015).Using universally implemented and published resources that can improve medication adherence is important. Tools and resources can be utilized by HCPs to identify patients who are not taking their prescribed medications. Prescriptions need to be taken seriously for exceptional results and for the continued well-being of patients who have critical illnesses like diabetes.The use of simple language by HCPs, as well as by medication manufacturers, can encourage providers to meet patients where they are and utilize teach-back techniques to ensure a patient’s understanding of his/her prescribed medication regimen. Teach-back methods have been utilized to enhance medication adherence among many types of non-adhering patients. Most of the time 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 death. This is a key issue that has left most of the people victims of non-adherence (National Academies of Sciences, Engineering, and Medicine, 2018).Huang et al. (2020) conducted a cross-sectional study aimed to identify patient factors linked with diabetes medication adherence and health literacy levels. One hundred and seventy-five participants were involved in the study and recruited from two family medical clinics. All the participants were over the age of 20, diagnosed with Type II diabetes, taken one oral diabetic medication, and understood English. The authors evaluated the participants’ health literacy levels using the Newest Vital Sign, a six-item questionnaire, and an eight-item Morisky Medication Adherence Scale.The results showed a self-reported status of (β = 0.17, p = 0.015) and medication self-efficacy (β = 0.53, p, 0.001), which were positively associated with diabetes and medication adherence (Huang et al., 2020). Health literacy was neither associated with diabetes medication adherence (β = −0.04, p = 0.586). The authors concluded that health literacy measured using the Newest Vital Sign did not correlate with medication adherence or glucose control among Type II diabetics. They recommended that healthcare clinics develop interventions to improve their patients’ self-efficacy of medication to improve the medication adherence rates (Huang et al., 2020).Reading instructions and making a patient understand what is written on a medicine bottle or package should never be taken for granted as it is key for determining how patients will effectively or ineffectively adhere to the given drugs for treatment and disease control purposes. For the medical practitioner to be aware and sure that what they have explained to the patients has been delivered safely and appropriately, there is the need for a verification test. The patients as well as their identified support individuals need to be asked to explain in their own words stating what they have understood from everything the practitioner has 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, it should be used often.DNP-DPI- Project -Literature Reviews AssignmentConcerns associated with the issues of side effects can be challenges to medication regimen adherence, especially when the given advantages associated with taking the medication are not properly comprehended. To minimize the potential concerns that are associated with the side effects of drugs, since this can be identified as one of the reasons why patients may opt to not adhere to 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 in the prescription process.DNP-DPI- Project -Literature Reviews AssignmentThere have been issues of people and patients dying or experiencing negative and disturbing side effects when it comes to them taking the medication prescribed by their doctors. These cases have always been used as examples to explain the reason why people have been reluctant to take medications for prolonged periods. When an individual has a critical illness, it is not uncommon that he/she needs to take the prescribed medication for a long period, as this can result in improved medication efficiency. Lacking understanding of medication-related details has caused patients to withdraw from their prescribed medication regimen, which is due to lacking knowledge and prolonged side effect issues that are associated with their medication (Institute of Medicine [IOM], 2011). DNP-DPI- Project -Literature Reviews AssignmentFor example, when offering metformin, to enable adherence to the drug there is a 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. It is also vital to offer brief explanations about medication side effects and benefits due to time limitations. If a patient cannot have additional time with his/her provider, then other members of the health care team should aid in answering their questions and provide additional education. Education can be in the form of printed handouts, websites, or a teaching module that should be readily available for use with the identified patient. Comment by Author: I am not sure where your synthesis paragraph is for this theme? Please identify by beginning your synthesis paragraph with In summary …. You will need to provide citations throughout your synthesis paragraph to substantiate your statements from the literature reviewed for this theme.DNP-DPI- Project -Literature Reviews AssignmentSocioeconomic FactorsSocioeconomic-related factors that affect medication adherence include one’s location of residence, medical costs of treatment, and finances (Yeam et al., 2018). Other factors that could influence medication adherence are low health literacy, education level, lack of social support, living conditions, and medication costs (Hennessey & Peters, 2019). Health care providers must conduct a thorough assessment before providing a patient the prescription and consider any of the factors as mentioned above.DNP-DPI- Project -Literature Reviews AssignmentMedication costs. Comment by Author: Not appropriate formatting for your subtheme heading.Kang et al. (2018) conducted a quantitative, longitudinal study to examine factors that affected cost-related medication nonadherence. Cost-related medication nonadherence (CRMN) is defined as taking medication then indicated or prescribed due to costs (Kang et al., 2018). Unknown sample size noted, but the Behavioral Risk Factor Surveillance System data for 2013–2014 was used to identify individuals with diabetes and their CRMN. Weighted multivariable logistic regressions were used, and analyses were conducted using the Survey suite of programs in Stata SE version 14. The survey weights were used to obtain population-level estimates and subpopulation methods to estimate standard errors for the subgroup’s analyses (Kang et al., 2018).DNP-DPI- Project -Literature Reviews AssignmentThe results demonstrated that CRMN among American adults was 16.5% (Kang et al., 2018). Individuals with an annual income of < $50k and without health insurance had the highest rates of CRMN. Insulin users had a 1.24 times higher risk of CRN than those not using insulin. Factors influencing CRMN were diabetes care and lifestyle factors, depression, arthritis, and asthma (Kang et al., 2018). Health insurance was the most significant factor for the participants < 65 years of age and depression for respondents > 65 years (Kang et al., 2018).DNP-DPI- Project -Literature Reviews AssignmentThe authors (Kang et al., 2018) concluded that one’s annual income and health insurance status were the most significant factors for younger adults, while depression was for older adults > 65 years. When the younger and older groups were combined, it showed the largest impact of CRMN affecting individuals < 55years of age and having higher rates of non-medication adherence (Kang et al., 2018). Recommendations were for healthcare organizations to develop policies, resources, and support systems that address the factors to help improve CRMN.DNP-DPI- Project -Literature Reviews AssignmentSocial Support.Various factors impact medication adherence. However, Linni et al. (2015) emphasized that social support must be considered a core component in interventions that improve the management of Type II diabetic patients. The social support theory has three components a) subjective support (emotional experience and fulfillment of the individual being respected and understood; b) objective support (direct material help from the social network in the communities; c) support utilization (various support strategies from family, friends, and colleagues) (Linni et al., 2015; Shao et al., 2017).DNP-DPI- Project -Literature Reviews AssignmentA quantitative study conducted by Linni et al. (2015) determined whether social support was linked with medication adherence in patients with Type II diabetes. The study was conducted in a Beijing hospital with a random sampling of 412 participants with Type II diabetes. The adult patients’ assessment of their social support was retrieved from medical records and self-reported surveys (Social Support Rate Scale 14-item questionnaire). The support scale measured objective, subjective, and support utilization. The Chinese version of the Morisky Medication Adherence Scale, eight-item, was translated for the participants to complete. Three hundred and thirty participants completed the self-report measure medication adherence six months after the initial data collection.DNP-DPI- Project -Literature Reviews AssignmentA t-test demonstrated a significant difference in social support between the low and high medication adherence groups (t = -2.11, p= 0.036) (Linni et al., 2015). A regression analysis was used to determine the subscales of the support, which presented statistical significance and association with medication adherence (β = 0.29, p = 0.011), rather than another two subscales of subjective (β = −0.02, p = 0.80) and objective support (β = −0.04, p = 0.33) (Linni et al., 2015). The authors concluded that social support was a critical factor in improving medication adherence in diabetic patients. It must be impressed on this population to have open attitudes to receiving help from friends, family, and outside organizations.DNP-DPI- Project -Literature Reviews AssignmentA quantitative, longitudinal study conducted by Shao et al. (2017) determined the impact of social support and medication adherence among 532 Chinese patients from an outpatient and inpatient endocrine clinics. The authors used the ten-item Social Support Rating Scale for data collection related to social support. It measured the three components of social support (objective, subjective, and support utilization). A six-item self-efficacy scale was used to measure (emotional control, communication with physicians, symptom management, role function, and perceived adaptability to chronic diseases). Shao et al. (2017) developed a 13-item adherence scale that was divided into three subscales a) Do you take the medicine every day according to the doctor’s advice? b) Do you take the dosages according to the doctor’s advice? c) Do you take the medication on time?DNP-DPI- Project -Literature Reviews AssignmentData were collected and entered EpiData 3.1 software (Shao et al., 2017). A Pearson’s correlation coefficients were calculated to evaluate the pairwise associations between the social support scores, self-efficacy, and adherence (Shao et al., 2017). The descriptive data showed the participants were mostly older females. The coefficients for the three components were statistically significant demonstrated the goodness-of-fit indices (χ2 = 2 47, P = 0 12; GFI = 0 99; AGFi = 0 98; CFI = 0 98; and RMSEA = 0 05) (Shao et al., 2017).DNP-DPI- Project -Literature Reviews AssignmentBoth studies, Linni et al. (2015) and Shao et al. (2017) utilized an adequate number of participants for their quantitative studies. They used the same support rating scale, which validated their findings. The key difference is that the studies were conducted in various settings (hospital and endocrine outpatient/inpatient clinics). In conclusion, the studies validated the role of social support in managing Type II diabetic patients. Hence, it must be considered as a key component in any intervention a healthcare provider develops to improve self-managing and glycemic control (Linni et al., 2015; Shao et al., 2017). Comment by Author: Is this your synthesis paragraph?DNP-DPI- Project -Literature Reviews AssignmentInterventionsUsing tools and instruments that are considered effective and appropriate is vital in supporting adherence in different ways and in achieving self-efficacy among the various patients. Positive family and social support are vital aspects associated with adherence to the issue of diabetes management (Rodríguez-Saldana, 2019). The engagement of family members can enhance self-care activities for patients suffering from diabetes, including eating effective and healthy foods, keeping fit, monitoring blood glucose, and adhering to medication.DNP-DPI- Project -Literature Reviews AssignmentA web-based portal is an innovative resource that can be used to assist patients. This web-based portal can improve medication reconciliation processes among patients and providers. The web-based portal can help patients with various regimens navigate challenges. Furthermore, this medication information, available through the portal can help individuals understand medication requirements, as the portal often helps to clarify and verify inaccuracies. The web portal aims to enhance medication adherence and prevent the improved use of the medication (Forman & Shahidullah, 2018). DNP-DPI- Project -Literature Reviews AssignmentWhen patients can verify information in their electronic medical records to ensure proper medication adherence, this can enhance patient well-being. The EMR provides an accurate list of a patient’s medications and provides detailed medication information (e.g., type of drug, what the drug is used to treat, frequency of drug use, etc.). 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 (Eskola et al., 2017).DNP-DPI- Project -Literature Reviews AssignmentMedication Adherence Project (MAP).The MAP resources were introduced, developed, and implemented by the New York City Department of Health and Mental Hygiene in response to clinicians and pharmacists working in primary care practices (Starr & Sacks, 2010). It serves patient populations impacted by several chronic diseases (Starr & Sacks, 2010). The resources provide practical tools to help practitioners communicate with patients related to medication adherence. It consists of a training course and toolkit that was piloted and assessed by doctors, nurses, pharmacists, medical assistants, nutritionists, and healthcare educators (Starr & Sacks, 2010).DNP-DPI- Project -Literature Reviews AssignmentThe objectives of the tool are to acquaint healthcare providers with the obstacles associated with medication adherence with individuals who have chronic diseases:Other aspects include a) evidence-based solutions that improve adherence, b) educate healthcare providers to engage in conversations regarding medication taking, c) help practitioners to combine the tool into the clinical practices and quality improvement methods, and d) help providers train their peers to use the resources effectively (Starr & Sacks, 2010).DNP-DPI- Project -Literature Reviews AssignmentPatient-Centeredness Care.Patient-centeredness entails ensuring that all the identified interventions described in the first theme are focused on the individual patient who is being helped to effectively adhere to the given medication during home care settings. Patients who have been diagnosed with various critical illnesses and have been asked to go home for home-based care have been associated with poor adherence to the medications they are given when they are discharged from the hospital (Steinberg & Miller, 2015).DNP-DPI- Project -Literature Reviews AssignmentPractice recommendations, whether they are focused on evidence or expert opinion, are intended to offer the desired guidance on an overall approach to care (da Costa et al., 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 must make treatment recommendations for any patient who would be considered to not have effectively met the eligibility criteria for the studies on which the given guidelines were based.DNP-DPI- Project -Literature Reviews AssignmentPatient Advocacy.Advocacy is a vital aspect in healthcare since it addresses the needs of the patient who need the utmost help and care, thereby allowing them to go back to their previous health state (D’Onofrio et al., 2018). Advocacy is an aspect that can be referred to as active support, as well as engagement, that aims to effectively develop a cause as well as a policy (Mollaoglu, 2018). Furthermore, advocacy is usually needed to enhance the lives of individuals suffering from diabetes. The various issues that diabetic patients experience, such as obesity, physical inactivity, and societal challenges reinforce the need for advocacy (Firstenberg & Stawicki, 2017).In summary, these topics were selected because they contributed to helping the healthcare provider understand the challenges noted for this population. This contributes significantly to the challenge’s healthcare providers face in caring for Type II diabetic patients. Comment by Author: Where is your synthesis paragraph for this theme?Summary Comment by Author: Your summary should include a synthesis of all three of your themes i.e. a synthesis of your literature review.The prevalence of Type II diabetes is affecting one in ten Americans (Ahmed et al., 2018). The disease is expected to continue rising higher by 2030 (Lin et al., 2018). Medication adherence for Type II diabetic home health patients is critical in decreasing the poor patient outcomes associated with the disease. Medication adherence with Type II diabetic patients remains a challenge for many healthcare professionals. Education for the healthcare providers and the patients can make a difference in this population’s lives.DNP-DPI- Project -Literature Reviews AssignmentChapter 2 discussed reintroduced the topic and presented the theoretical framework and change model to guide the project. Other sections include the literature review related to patient-related, socio-economic, and health system factors.A summary of the chapter was provided with an introductory sentence that previews Chapter 3.Chapter 3 reinstated the selected topic. Other segments presented the project’s methodology, design, population, and sample selection. A description of the MAP resources and the electronic medical record (EPIC) are provided. The validity and reliability of the instrument was demonstrated along with the data collection and analysis procedures, potential bias. The last few sections discuss the ethical considerations, limitations, and a summary that leads into Chapter 4. Comment by Author: You are short on the number of articles that you need. I am counting approximately 29 articles. You need at least 50 and 85% of these need to be within the last five years.DNP-DPI- Project -Literature Reviews AssignmentChapter 3: MethodologyMedication adherence is a critical component in minimizing adverse patient-related outcomes among individuals with chronic illnesses (Type II diabetic patients). Ahmed et al. (2018) stated medication adherence for this quality improvement project refers to the extent to which a home healthcare patient can correctly take their medications in the absence of their health care providers. Individuals looking to adhere to their medical regimens must follow all instructions provided by their physicians (Bellou et al., 2018)DNP-DPI- Project -Literature Reviews Assignment. Comment by Author: DeleteIn the United States, one in ten people have type II diabetes (Ahmed et al., 2018). The prevalence of the disease is expected to increase by 2030 because of the growing number of older adults and the aging of the population (Lin et al., 2018). Due to the growth of home health services, there is now a need for education regarding medication adherence. Approximately 45% of patients are not able to maintain their glucose levels (Polonsky & Henry, 2016). Poor medication adherence is associated with higher financial obligations for patients, hospitals, and insurance companies. Polonsky and Henry (2016) emphasized that adverse outcomes cause frequent hospitalizations and lower quality of life for patients and their families. Comment by Author: In the home health care setting?DNP-DPI- Project -Literature Reviews AssignmentChapter 3 reestablished the selected topic. Other sections of the chapter include the statement of the problem, clinical question, project methodology (quantitative), and project design (quasi-experimental). The chapter described the population and sample selection, the instrumentation (MAP resources), validity, reliability, and data collection procedures. The last few segments included the data analysis procedures, potential bias, ethical considerations, limitations, and a summary.DNP-DPI- Project -Literature Reviews AssignmentStatement of the ProblemIt was not known if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients. The targeted population was Type II diabetic patients in an urban healthcare facility in urban Texas. The primary investigator collaborated with the facility’s stakeholders; it was noted that medication adherence among the patients was lacking. The information was obtained from the electronic medical records (Cradle Solutions)DNP-DPI- Project -Literature Reviews Assignment, which showed that ten percent of the diabetic patients were not adhering to their medication regimen. Comment by Author: DeleteFactors that influence poor medication adherence are numerous and include poor knowledge or awareness of the disease, medication costs, and lack of understanding of the medication treatment, which reinforced the project’s purpose (Heath, 2019; Sharma et al., 2020). Healthcare providers play an essential role in assisting patients with medication adherence. The primary investigator will introduce a standardized strategy for the facility’s healthcare providers to assess the patients’ medication adherence using MAP resources (Starr & Sacks, 2010).Using a standardized method will help to solve the facility’s problem with medication adherence rates. It will also help improve the healthcare providers’ knowledge levels and awareness regarding the barriers associated with medication adherence. Complying with the new guidelines developed by the Centers for Disease Control and Prevention (2020) could help patients control their glucose levels, minimize healthcare costs, hospitalizations, and potential infections.DNP-DPI- Project -Literature Reviews AssignmentClinical Question Comment by Author: Again review your entire document for the need to change to past tense.The clinical question that will direct the primary investigator’s answer is: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients in urban Texas? The independent variable is the MAP resources. The dependent variables are the medication adherence rates. The data collection process will not begin before approval is received by Grand Canyon University IRB. The primary investigator developed informational flyers for the nurses to give their patients during their home health visits. The staff answered questions related to the project regarding risks, benefits, and purpose while instructing that participation is voluntary. A convenience sample will be used because of the easy access to the participants for the primary investigator.DNP-DPI- Project -Literature Reviews AssignmentThe primary investigator collected data (four weeks) prior to implementation of the project. The data will be collected from the electronic medical records using Cradle Solutions for the impact of the MAP resources and medication adherence rates. In the first week, the primary investigator will educate the staff to use the MAP resources. Once the staff begins to implement the tool, post-medication rates will be assessed post-four weeks. The data was inserted into a Microsoft Excel 2016 codebook developed by the primary investigator. It was exported into SPSS-27 and analyzed by using a chi-square test. The five-item demographic survey will collect the descriptive statistics of the home healthcare patients. The questionnaire comprised of (age, gender, years with Type II diabetes, oral or insulin, and education). Comment by Author: Need to provide a discussion on the level of measurement of your variables i.e. nominal, ordinal, interval ….. See the manuscript template.DNP-DPI- Project -Literature Reviews AssignmentProject MethodologyA quantitative methodology was used for this quality improvement project. According to Creswell and Creswell (2018), a quantitative methodology is appropriate for projects that use data in its numerical form. For this project, the data was presented using figures, graphs, charts, and tables. This allowed the readers to compare the medication adherence rates pre-implementation and post-implementation of the project. Comment by Author: Please do not cut and paste much of this section is verbatim of what is in Chapter 1.DNP-DPI- Project -Literature Reviews AssignmentA qualitative methodology was considered but not used, although they are beneficial. It explores the patient’s experiences, perspectives, and lived experiences regarding a phenomenon (Creswell & Creswell, 2018). Data collected using this methodology is semi-structured interviews, one-on-one interviews, and focus groups (Creswell & Creswell, 2018). The primary investigator aims not to understand the home health participants’ emotions, behaviors, or experiences related to medication adherence.DNP-DPI- Project -Literature Reviews AssignmentA quantitative methodology supported the project because it permitted the primary investigator to remain objective in providing the project’s findings (Leedy & Ormord, 2020). Furthermore, the methodology allowed the primary investigator to summarize the data that could support generalizations for a larger or similar population. The methodology is less costly with easy replication for future quality improvement projects to obtain the same results.DNP-DPI- Project -Literature Reviews AssignmentProject Design Comment by Author: As above, please review for some of the statements are verbatim of what is in chapter 1, do not cut and paste.Quasi-experimental designs are utilized to compare data before and post-implementation of an intervention (Price et al., 2017). The design is frequently used in a controlled environment. For this project, the design was chosen because it is cost-effective versus an experimental project design (Schweizer et al., 2016). A quasi-experimental design allowed the primary investigator to analyze the impact of MAP resources on medication adherence rates.DNP-DPI- Project -Literature Reviews AssignmentAn experimental design was not considered because the primary investigator was not seeking to conduct the project under a controlled environment (Leedy & Ormrod, 2020). This design observes the independent variable (MAP resources) and the dependent variable (medication nonadherence rates). It is a simple design that is performed in various physical and natural settings (Leedy & Ormrod, 2020).A correlational design was considered but not appropriate for the project because the primary investigator was not seeking to understand the relationships occurring among the variables (Creswell & Creswell, 2018). This design is typically descriptive relying on a hypothesis (Leedy & Ormord, 2020c). The primary investigator did not seek the relationships between the independent variable (MAP resources and education intervention) and the dependent variable (medication adherence rates).DNP-DPI- Project -Literature Reviews AssignmentThe targeted population were home health patients ages 35 to 64 years old. The selected site serves approximately 100 patients annually. The inclusion criteria are males and females diagnosed with Type II diabetes, oral medication or insulin, and home health patients. The exclusion criteria comprised of individuals with language or cognitive deficits and diagnosed with Type I diabetes. Five registered nurses helped to implement the project. They were individuals who work full-time and had been employed over a year.DNP-DPI- Project -Literature Reviews AssignmentThe data collection process began once approved by Grand Canyon University IRB. Recruitment occurred from informational flyers given to the patients during their home health visits with the providers. The nurses answered questions regarding the project’s risks, benefits, and purpose and be instructed that the participation is voluntary. The primary investigator used a convenience sample because of the access to the participants.DNP-DPI- Project -Literature Reviews AssignmentData was collected four weeks prior to project implementation from the electronic medical records (Cradle Solutions) (medication adherence rates). In the last portion of the first week, the primary investigator educated the healthcare providers regarding using the MAP resources. The staff began implementing the tool, and the post medication adherence rates will be assessed four weeks post-implementation. The primary investigator documented the data in a Microsoft Excel 2016 codebook developed by self. Once completed, it was exported into the SPSS-27 and analyzed using a chi-square analysis. A five-item demographic questionnaire was used for descriptive statistics of the population. The survey included (age, gender, years with Type II diabetes, oral or insulin, and education).DNP-DPI- Project -Literature Reviews AssignmentPre-intervention and post-intervention data were obtained using the MAP resources. The questions analyzed were: (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?” In addition to the questions, home healthcare providers will ask the patient “Are you taking your medications?” Any information attained from the question and due to probing, observation of patient’s medications, and patient-related medication adherence was documented in the project site’s EHR. The data was analyzed using an independent t-test to determine the statistical significance.DNP-DPI- Project -Literature Reviews AssignmentThe electronic medical record that was used to collect data is Cradle Solutions a software for home health companies. It serves the specialized needs of home health care providers that give a web-based point-of-contact information entry and management (Cradle Solutions, 2021). It is compliant with HIPPA security features for billing, reporting, administrating, and managing patient information (Cradle Solutions, 2021). Liss et al. (2020) emphasized that electronic health records can be used for quality measures as a snapshot or calendar year. The primary investigator obtained the measurement of the medication adherence rates and align it with new protocols and guidelines developed by the facility.DNP-DPI- Project -Literature Reviews AssignmentPopulation and Sample SelectionThe specific population addressed were adult home health patients ages 35 to 64 years old. The primary investigator chose this population because of the prevalence of Type II diabetes rising in children, adolescents, and young adults in the United States (12:100000) (Centers for Disease Control and Prevention, 2020; Kao & Sabin, 2016; Reinehr, 2013). The selected site serves approximately 100 patients annually, and 30 patients are diagnosed with Type II diabetes. The inclusion criteria are males and females diagnosed with Type II diabetes, oral medication or insulin, and home health patients. The exclusion criteria are individuals with language or cognitive deficits and diagnosed with Type I diabetes. Five female staff nurses were trained to help implement the quality improvement project. They were registered nurses, worked full-time, and had been employed with the facility for over one year.DNP-DPI- Project -Literature Reviews AssignmentThe geographic location of the project is in an urban area of Houston, Texas. The county statistics showed that approximately 17.6% of the population have Type II diabetes (Houston, 2021). During 2016-2018, 20.2% of the population was hospitalized due to diabetic complications (Houston, 2021). There are over 700 000 Medicare participants in a three-county radius, which is higher than the national average (Understanding Houston, 2021). Data further showed that preventable hospital stays occur in older adults 65 and above (Understanding Houston, 2021). This suggested a trend to overuse the hospitals as a primary source of care (Understanding Houston, 2021). Comment by Author: Delete, too specific. Comment by Author: Delete, does not add to your argument.DNP-DPI- Project -Literature Reviews AssignmentDuring the informed consent process, the principal investigator explained to the nurses the purpose, risks, and benefits of the project. The participants were informed that participation was voluntary, and they could withdraw at any time without repercussions to their careers or personal lives. The project participants were not compensated. The primary investigator did not use the participants’ names or other identifying information during the project to protect the participants’ identities. For security reasons, each participant was assigned a random number. The primary investigator adhered to the University’s Institutional Review Board guidelines and the recommendations of the Belmont Report (justice, respect for persons, and beneficence) (U.S. Department of Health & Human Services, 2018).DNP-DPI- Project -Literature Reviews AssignmentHard copies of the data were stored on a flash drive at the home office of the primary investigator (in a locked cabinet). Data files will be stored on the primary investigator’s laptop, which is digitally protected. The data will be stored for three years according to Grand Canyon University procedures (June 2024). Upon completion of the project and meeting all requirements, the primary investigator will shred the information using Iron Mountain shredding services and ERASER software on the laptop. Comment by Author: Need to present your G power analysis in this section.DNP-DPI- Project -Literature Reviews AssignmentInstrumentation or Sources of DataThe instrument used in the project was the MAP Toolkit and Training Guide resources, which includes (1) the questions to ask poster, (2) adherence assessment pad, and (3) my medications list. The questions to ask poster encourages patients to ask the provider about their medication. For this project, the nurses will review the medications with the Type II diabetic patients. Six questions will be asked (1) Why do I need to take this medicine, (2) Is there a less expensive medicine that would work as well, (3) What are the side-effects and how can I deal with them, (4) Can I stop taking any of my medicines, (5) Is it okay to take my medicine with over the counter drugs, herbs, or vitamins, and (6) How can I remember to take my medicine? Comment by Author: CitationThe second section, the Adherence assessment pad, explored the barriers to the patient’s maintaining medication adherence. The questions include (1) makes me feel sick, (2) I cannot remember, (3) too many pills, (4) costs, (5) nothing, and (6) other.DNP-DPI- Project -Literature Reviews AssignmentThe third component is my medication list. It provides detailed information in chart form, which is discussed between the patient and the healthcare provider. It comprises of (1) name and doses of my medicine, (2) this medication is for my diabetes, (3) when do I take and how much (options include: morning, noon, evening, or bedtime), and (4) I will remember to take my medicine (a blank that will be filled in).DNP-DPI- Project -Literature Reviews AssignmentThe source of data for this project was the electronic medical record. The facility uses Cradle Solutions, software for home health companies. It serves the specialized needs of home health care providers that give a web-based point-of-contact information entry and management (Cradle Solutions, 2021). It is compliant with HIPPA security features for billing, reporting, administrating, and managing patient information (Cradle Solutions, 2021). Liss et al.DNP-DPI- Project -Literature Reviews Assignment(2020) emphasized that electronic health records can be used for quality measures as a snapshot or calendar year. The primary investigator will measure the medication adherence rates and align them with new protocols and guidelines developed by the facility. Comment by Author: DeleterValidityValidity conveys how accurately a method is measured (Creswell & Creswell, 2018). If the method measures what it should and the findings correspond closely, it is considered valid. There are four types of validity are constructs, content, face, and criterion (Creswell & Creswell, 2018). For this project, construct and face validity is applicable to the instrument. A group of professionals developed the tool, which consisted of physicians, pharmacists, nurses, and medical assistants (Starr & Sacks, 2010). It was based on their years of work experience in their perspective fields. The toolkit’s improvements were adjusted and in alignment with the CDC and other healthcare governing bodies.DNP-DPI- Project -Literature Reviews AssignmentAltman et al. (2018) stated hospital electronic health records are frequently being used in research studies. Many studies report validity using Cohen’s kappa, which measured performance and specificity (Altman et al., 2018). In another study conducted by Goulet et al. (2007), a robust correlation was found (between .86 and .99) for measures obtained from data and compared in a manual review. Comment by Author: From the EHR?DNP-DPI- Project -Literature Reviews AssignmentReliabilityReliability refers to the consistency of instrument measuring something (Creswell & Creswell, 2018). If the same results occur regularly by using the same procedures under the same conditions, the measurement is reliable (Creswell & Creswell, 2018). For this project, the MAP toolkit reliability was confirmed by inter-rater reliability (Starr & Sacks, 2010). The observers noted the same results associated with using the instrument, which aligned with the literature findings regarding collecting data for medication adherence rates.DNP-DPI- Project -Literature Reviews AssignmentA study conducted by Harrell (2017), occurred over 90 days, where weekly medication adherence rates were assessed. Seventy-eight percent of the patients prior to the study’s implementation did not adhere to their prescribed medication regimen. Post three-months of the project, 56% of the patients improved regarding medication adherence rates. For this project, test-rest reliability will be noted, because the nurses will be using the MAP toolkit over time (two different times) (Creswell & Creswell, 2018).DNP-DPI- Project -Literature Reviews AssignmentElectronic medical records are considered a reliable and valid source for data collection. A study conducted by McGinnis et al. (2009) examined EMR and written records. The results demonstrated the EMR-based data validity was shown to be moderate to excellent, with Pearson r correlations ranging from .875 to .99 for EMR and documentation records (McGinnis et al., 2009). Electronic medical records are considered a reliable source of data, as emphasized by Goulet et al. (2007), found strong agreement (Kappa between .86 and .99) and high sensitivity and specificity (≥.95) for quality measures based on electronically abstracted structured data compared with manual review.  DNP-DPI- Project -Literature Reviews AssignmentData Collection ProceduresThe data collection process began once approved by Grand Canyon University IRB. Recruitment occurred from informational flyers given to the patients during their home health visits with the providers. The nurses answered any questions regarding the project’s risks, benefits, and purpose and be instructed that the participation is voluntary. The primary investigator used a convenience sample because of the accessibility to the participants. The goal was to attain approximately 34 participants.Five home healthcare nurses were trained to implement the project. Training sessions was offered twice so that the nurses working on the weekends could participate. The primary investigator offered two 60-minute Zoom training sessions. During these sessions, the primary investigator provided information regarding using the MAP toolkit and resources. A 10-minute PowerPoint presentation was included during the 45-minute training session, along with a MAP toolkit binder for each participant.DNP-DPI- Project -Literature Reviews AssignmentThe participants were educated by the nurses regarding the purpose of the informed consent and its contents. The participants were informed regarding the benefits, risks (minimal), and purpose of the project. The potential risk (minimal) was related to emotional circumstances such as the stigma of the disease, anxiety, or depression. The participants were instructed that if they felt increased anxiety, depression, or embarrassment during the project, they could withdraw without any reason, or the project will end for them immediately. They were directed to a primary care physician or professional who could further help them.DNP-DPI- Project -Literature Reviews AssignmentThere was a slight chance that the hard copies (demographic and MAP surveys could be lost. To ensure that this did not occur, the primary investigator used a digitally password-protected laptop to protect their privacy. The participants were informed that the data was kept in a password-protected folder on the laptop accessible only to the primary investigator. The nurses collected the signed informed consents and returned them to the primary investigator after their visits. The primary investigator collected them daily during the project.DNP-DPI- Project -Literature Reviews AssignmentThe primary investigator protected participants’ rights and welfare by adhering to the Belmont report principles of a) justice, b) respect for the individual, and c) beneficence (Office for Human Research Protections, 2016). Furthermore, the primary investigator adhered to Grand Canyon University’s IRB guidelines. By providing fair treatment to all participants, the primary investigator upheld the principles of justice. There was no exploitation of this population or manipulation of their health conditions or diseases by the participants. Participants were treated as autonomous individuals to demonstrate respect for them. All the participants were treated using ethical conduct by respecting their answers and decisions, thus protecting them from harm. Hence, this allowed the primary investigator to abide by the beneficence guidelines.DNP-DPI- Project -Literature Reviews AssignmentThe primary investigator worked with the information technology department, ensuring that the three MAP resources were incorporated into the Cradle Solutions documentation application. As part of week one, nurses provided the patients with informed consent, answered questions regarding the project, conducted a five-item demographic survey, and administered a pre-MAP survey. In the second to fourth week, the nurses examined the patient’s medication list and adherence (ten minutes). Each week, nurses documented medication adherence information in the patient’s electronic medical record.All nursing staff input was completed by the end of week four. The system was updated if the patient stated that they did not adhere to the medication regimen. The primary investigator collected post-test scores regarding medication adherence rates. To analyze the data, the results were entered into a Microsoft Excel 2016 codebook developed by the primary investigator. The data was exported to SPSS-27 and analyzed based on a chi-square test.DNP-DPI- Project -Literature Reviews AssignmentTo maintain the confidentiality of data, hard copies of the demographic and MAP surveys were stored in a locked cabinet in the primary investigator’s home, which is not accessible to anyone else. The Microsoft Excel 2016 codebook and SPSS results were saved on the primary investigator’s digitally password-protected laptop. The primary investigator installed an encryption program (TrueCrypt) to ensure additional security. In accordance with Grand Canyon University’s Institutional Review Board guidelines, the data will be kept for three years (June 2024). At that time, the primary investigator will clean the laptop data by using ERASER (a computer program) and Iron Mountain’s shredding services. Comment by Author: Delete. Comment by Author: Will need a citation t the end of the setntnce. Comment by Author: Delete or provide a citation. Comment by Author: Will need citations.DNP-DPI- Project -Literature Reviews AssignmentData Analysis ProceduresThe objective of this quality improvement project was to address the issue of medication adherence among Type II diabetic patients receiving home healthcare services. Information was obtained from the electronic medical records (Cradle Solutions), which indicated that ten percent of diabetic patients did not adhere to their medication regimens. The data for both the comparative and implementation patients were collected from the EMR after the four-week implementation period, and a PDF report was sent via encrypted email to the primary investigator. The dependent variable (medication adherence rate) was manually entered into a secure Microsoft Excel file (2016) for the comparative and implementation patients. All data collected was in numerical values. A unique identifier was assigned to each patient to facilitate data organization.DNP-DPI- Project -Literature Reviews AssignmentThe medication adherence rate is a nominal-level variable with two mutually exclusive options (adherent or non-adherent) for each patient. It was analyzed using a chi-square test, which is the most appropriate test for comparing two independent groups on a dependent categorical variable (Schober & Vetter, 2019). The patient groups are independent as patients in the comparative group (four weeks before implementation) were not matched for the implementation group. The project analysis employed a chi-square test, which aligned with the project design since the test compares group differences when the dependent variable is measured at a nominal/categorical level (Schober & Vetter, 2019).DNP-DPI- Project -Literature Reviews AssignmentThe clinical question that is guiding the project is: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients in urban Texas? Comment by Author: Please delete this as your clinical question is already mentioned above.DNP-DPI- Project -Literature Reviews AssignmentTo address this question, the medication adherence rate for 30-days before and 30-days after the implementation of MAP resources will be compared. To answer the clinical question, a chi-square test will be conducted. The chi-square test allowed for a comparison of the medication adherence rate for patients 30 days before and 30 days after the implementation, thereby answering the clinical question. The level of significance was set to .05, indicating a p-value of less than .05 would reveal statistical significance.DNP-DPI- Project -Literature Reviews AssignmentData were organized using a Microsoft Excel file (2016) containing a unique identifier for each patient. The quality department staff collected information regarding medication adherence and entered it manually into an Excel file as a categorical variable with numeric codes representing 0 for non-adherent patients and 1 for adherent patients. Data was imported into IBM SPSS version 27 after data entry was completed in Microsoft Excel. To ensure that the data was correctly prepared for analysis, a preliminary analysis of all variables was performed to identify any missing data or inaccuracies in the dataset. A frequency count was conducted for variables to ensure no missing data or values outside of the range of 0 to 1 for medication adherence rates.Potential Bias and MitigationThe internal validity is related to the extent the primary investigator can be confident that the cause-and-effect relationship found cannot be explained by other factors (Leedy & Ormrod, 2020). Thus, the conclusions of this project are credible and trustworthy (Leedy & Ormrod, 2020). The external validity of the project was affected by two factors: the maturity of the participants and the instrument (MAP resources). Participants’ maturity may be impaired by their recollection, poor memory, or follow-through. The outcomes of the project would vary over time, affecting the results. To reduce this occurrence, one method was to have the participant complete the survey at the best time for them. For example, if an individual is a morning person (have them take the survey in the morning versus the afternoon or late evening). The second factor is the instrumentation process (MAP resources). The primary investigator educated the nurses regarding providing the participants the same time (30 minutes) to ensure the same measures are used during the pre-implementation and post-implementation phases.DNP-DPI- Project -Literature Reviews AssignmentBias is defined as any tendency that prevents an impartial discussion of a clinical issue (Pannucci & Wilkins, 2010). This can occur at any stage of the research process, including study design, data collection and analysis, and publication (Pannucci & Wilkins, 2010). A possible bias may arise from the selection process. The primary investigator avoided bias by selecting individuals and using strict inclusion and exclusion criteria that were previously developed for the project. Participants were drawn from the specified population.DNP-DPI- Project -Literature Reviews AssignmentThe second bias is related to recall bias, a systematic error that occurs when participants do not accurately remember previous events or experiences (Creswell & Creswell, 2018). The project could be affected because the participants are self-reporting to the nurses using the MAP resources. To prevent this bias, nurses were trained to carefully teach each participant using the same method, thereby preventing their responses from being influenced (Creswell & Creswell, 2018).DNP-DPI- Project -Literature Reviews AssignmentEthical ConsiderationsThis project was conducted according to the University’s Institutional Review Board and Belmont report guidelines. According to Belmont (1979), there are three principles to be followed: respect for participants, justice, and beneficence (Office for Human Research Protections, 2016). The primary investigator and nurses demonstrated respect by listening to the participants, validating their feelings, and answering their questions regarding the education or project. The primary investigator occasionally observed the nurse’s interactions with the participants throughout the project. The participants were instructed that there are no repercussions to their personal or professional lives upon withdrawing from the project. Nurses and the principal investigator safeguarded the privacy and confidentiality of the participants by not discussing the project, the participants, or its findings with anyone not associated with the project or without their consent.DNP-DPI- Project -Literature Reviews AssignmentBeneficence was demonstrated by informing the participants that the primary investigator or nurses would immediately cease questioning if they felt emotionally injured. To participants who were affected by the questions or project, a psychological resource was provided. Participants were informed of the risks, benefits, and minimal harm that may occur to them, for example, loss of data, conflict with family and friends, and feelings of anxiety or depression.DNP-DPI- Project -Literature Reviews AssignmentAs stated in the Belmont Report (1979), justice refers to the allocation of burdens (Office for Human Research Protections, 2016). It was possible that the project would lead to unwanted stigma from the participants’ colleagues, family members, or friends. Each participant was treated uniformly following their wishes, so it did not affect the project’s findings. There could be a potential conflict of interest since the primary investigator works at the facility. To minimize the conflict, the primary investigator did not interact with the participants.DNP-DPI- Project -Literature Reviews AssignmentLimitationsThe project had several limitations, including the self-reporting of medication compliance by patients. To minimize this limitation, the primary investigator validated the self-reporting instrument (MAP resources) before utilizing it for data collection (Althubaiti, 2016). Furthermore, the patient’s self-reporting was compared to their fasting blood glucose levels, medical records, or reports from family and friends (Althubaiti, 2016).The second limitation was the potential impact of the COVID-19 pandemic on healthcare organizations. The new COVID-19 guidelines have had an impact on the current healthcare delivery model. Due to the pandemic, the primary investigator has redirected resources and ceased in-person training sessions for nurses. Recruitment has been limited to Zoom meetings and telephone interviews. The third limitation was the location and setting of the project. The findings of the project cannot be generalized to other home healthcare agencies with similar populations. The fourth limitation is the time required to complete the project (four weeks). A longer timeframe would help the primary investigator analyze the site’s challenges, trends, and sustainability.DNP-DPI- Project -Literature Reviews AssignmentSummaryMedication adherence among Type II diabetic home health patients remains a critical factor in their quality of life. The purpose of this quantitative quasi-experimental project is to determine if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources when compared to current practice among Type II diabetic patients of a home healthcare agency in urban Texas over four weeks. A quasi-experimental design allowed the primary investigator to evaluate the impact of the MAP resources and educational intervention on the dependent variable (medication adherence rates).DNP-DPI- Project -Literature Reviews AssignmentBy utilizing a quasi-experimental design, the primary investigator was able to assess the impact of the MAP resources and educational intervention on the dependent variable (medication adherence rates). The medication adherence rates, and weekly glucose levels were collected before and after project implementation (four weeks). Data was collected by the primary investigator and stored on a digitally protected laptop. Hard copies were stored in a secure file cabinet at the primary investigator’s home office. Chapter 4 provided a summary of the topic, along with descriptive data of the participants. Other sections consisted of the data analysis procedure, project findings, and summary.DNP-DPI- Project -Literature Reviews AssignmentChapter 4: Data Analysis and ResultsIt was not known if or to what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients. The stakeholders have cited that medication adherence among diabetic patients is lacking. According to data obtained from the site’s electronic health record (EHR), home healthcare providers documented that ten percent of diabetic home healthcare patients are not adhering to their medication regimens.DNP-DPI- Project -Literature Reviews AssignmentA quantitative quasi-experimental project will be conducted to address the clinical question: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients in urban Texas? Data on medication adherence was collected for the comparative group and compared to an implementation patient group.DNP-DPI- Project -Literature Reviews AssignmentChapter 4 presented the descriptive data for the patient sample. The data analysis procedures are outlined, and the results are presented using narrative and chart format. The chapter concluded with a summary of the findings regarding the clinical question and the significance of the data analysis.DNP-DPI- Project -Literature Reviews AssignmentDescriptive DataThe quality improvement project used a quantitative, quasi-experimental approach for data collection. The targeted population for the project was from a home health care facility in urban Texas. The primary investigator used a G* power version 3.1.9.7, effect size 0.3, power 0.95, and df 0.5 to calculate the sample size needed for the project (N=220) for a significant level. The participants completed a five-item demographic questionnaire comprised of (gender, education level, race, age, and years as Type II diabetic). Comment by Author: Seems kind of high?DNP-DPI- Project -Literature Reviews AssignmentA total of 30 patients were included in the project, n= 15 in the comparative group and n= 15 in the implementation group. The descriptive data for gender, education level, and race are displayed in Table 1. It shows 10 males (66.7%) and five females (33.3%) in the comparative group and eight males (53.3%) and seven females (46.7%) in the implementation group. For education level in the comparative group, 2 (13.3%) graduate high school, 9 (60.05) had some college, 2 (13.3$) had an associate degree, 1 (6.7%) had a bachelor’s degree, and 1 (6.7%) had a doctorate degree. For educational level in the implementation group, 2 (13.3%) graduated high school, nine (60.0%) had some college, 1 (6.7%) had associate degree, and 3 (20.0%) had a doctorate degree. There were three Asian (20.0%), five (33.3%) Black, and seven (56.7%) White participants in the comparative group and there were two (13.3%) Asian, six (40.0%) Black, and seven (46.7%) White participants in the implementation group. Comment by Author: This is not what is reported in your abstract.DNP-DPI- Project -Literature Reviews AssignmentTable 1Descriptive Data for Gender, Education, and RaceVariable Comparative(n = 15) Implementation(n = 15)Gender n % n %Male 10 66.7 8 53.3Female 5 33.3 7 46.7Education Level   DNP-DPI- Project -Literature Reviews Assignment    Graduate High School 2 13.3 2 13.3Some College 9 60.0 9 60.0Associate Degree 2 13.3 1 6.7Bachelor’s degree 1 6.7 0 0.0Doctorate 1 6.7 3 20.0Race        Asian 3 20.0 2 13.3Black 5 33.3 6 40.0White 7 56.7 7 46.7 Table 2 displays the descriptive data for age and years with Type 2 Diabetes for project participants. The mean age for the comparative group was 49.94 years (SD = 11.67) and the mean age from 35 to 64 and the implementation group was 52.80 years (SD = 9.47) with a range from 35 to 65. The comparative patients had a mean of 3.47 years since diagnosis (SD = 1.19) with a range from 1 to 5 and the implementation group had a mean of 2.93 years since diagnosis (SD = 1.03) with a range from 1 to 5.Table 2Descriptive Data for Age and Years with Type II Diabetes Variable Comparative (n = 15) Implementation (n = 15)  M SD M SDAge 49.94 11.67 52.80 9.47Years with Type II Diabetes 3.47 1.19 2.93 1.03Note. M = mean; SD =standard deviationData Analysis ProceduresThe data analysis procedures included evaluating de-identified data of medication adherence rates four weeks prior and four weeks post-implementation of the project. The primary investigator abstracted a PDF report of the medication adherence rates for both the comparative and implementation groups. Raw data were input into a Microsoft Excel (2016) file (codebook). The independent variable was the MAP resource implementation (categorical), and the dependent variable was the medication adherence rates (yes/no). After data entry in Microsoft Excel was completed, data were exported to IBM SPSS version 27.DNP-DPI- Project -Literature Reviews AssignmentTo ensure data was prepared for analysis, a preliminary analysis of all variables was conducted to determine if the dataset has missing data or inaccurate entries. This included frequency counts for variables to check for missing data and values outside of the possible range of 0= no medication adherence and 1= medication adherence. A chi-square test was conducted to answer the clinical question. The chi-square test compares the association between two independent categorical variables (Schober & Vetter, 2019), which compared the medication adherence rate for patients 30 days before and 30 days after the implementation, thereby answering the clinical question. The primary investigator used a G* power version 3.1.9.7, effect size 0.3, power 0.95, and df 0.5 to calculate the sample size needed for the project (N=220) for a significant level. The sample size for this project did not meet the required sample for 95% power with N= 30.DNP-DPI- Project -Literature Reviews AssignmentThe significance level was set to .05. Therefore, a p-value of less than .05 would demonstrate statistical significance. The patient outcome-dependent variable was collected from the electronic medical records (Cradle Solutions) within the project site. The p-value (significance level) indicates the degree to which the null hypothesis is rejected or failed to be rejected. Researchers typically compare the p-value with a significance level of 0.05. If the p-value is less than 0.05, it implies that there is enough evidence to reject the null hypothesis. When the p-value is greater than 0.05, the null hypothesis is rejected. DNP-DPI- Project -Literature Reviews AssignmentElectronic medical records are considered a reliable and valid source for data collection. A study conducted by McGinnis et al. (2009) examined EMR and written records. The results demonstrated the EMR-based data validity was shown to be moderate to excellent, with Pearson r correlations ranging from .875 to .99 for EMR and documentation records (McGinnis et al., 2009). Electronic medical records are considered a reliable source of data, as emphasized by Goulet et al. (2007), found strong agreement (Kappa between .86 and .99) and high sensitivity and specificity (≥.95) for quality measures based on electronically abstracted structured data compared with manual review.  DNP-DPI- Project -Literature Reviews AssignmentOne identified potential error was related to the data is coverage error, which results in a difference between the sample size and the population measured (Qualtrics, 2020). To reduce the chances of this occurring, the primary investigator utilized a recruitment method accessible to all potential participants (such as word of mouth, text messages, and emails). The random error related to the quality improvement project is the measurements (Leedy & Ormrod, 2020). The error could occur after the primary investigator collects the data while being processed (Leedy & Ormrod, 2020). To minimize the chances of errors, the primary investigator hired a statistician to interpret the data patterns using statistical tests and perform data cleaning (Leedy & Ormrod, 2020).DNP-DPI- Project -Literature Reviews AssignmentResultsA chi-square test was conducted to answer the clinical question: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients in urban Texas? Comment by Author: Delete this has already been mentioned above. Only use the clinical question x 1 for each chapter.The results are displayed in Table 3. The chi-square was utilized as the independent variable (MAP resources) and the dependent variable (medication adherence yes/no) are categorical variables and a chi-square determines whether there is an association between categorical variables. There was an increase in medication adherence from the comparative (n = 10, 66.7%) to the implementation group (n = 11, 73.3%), X2 (1, N = 30) = .159, p =. 999. The p-value was greater than .05, which indicated that the increase in medication adherence was not significant. Thus, there was no evidence that there was a statistically significant difference in medication adherence rates between the comparative and implementation groups. An interpretation of the project’s results based on the chi-square test probability value indicated there was no association between the independent and dependent variables, and the data did not reject the null hypothesis at a significance level of 0.05.Table 3Medication Adherence Rates in the Comparative and Implementation Groups Variable Comparative(n = 15) Implementation(n = 15) X2 p-value  n % n %    Medication Adherence 10 66.7 11 73.3 .159 .999 The results of the chi-square test analysis supported the implementation of MAP resources to improve medication adherence as compared to current practice among Type II diabetic home healthcare patients, ages 35 to 64 of a home healthcare organization. The rate increased in the implementation group, although the p-value was not less than .05 indicating no statistical significance. Given these findings, the data analysis strengthened clinical improvement after the implementation of the MAP resources for improving medication adherence rates.Summary statistics were conducted for the knowledge test for the nurses before and after the MAP implementation. Figure 1 displays the mean knowledge % scores for the five nurses at pre and post implementation. As shown, the mean knowledge % score at pre implementation was 63% (SD = 5.70%) with a range from 55% to 79%. The mean knowledge % score at post implementation was 85.6% (SD = 7.02%) with a range from 78% to 95%.Figure 1Mean Knowledge Scores for Participants at Pre and Post Implementation SummaryThe purpose of this quantitative quasi-experimental project was to evaluate the impact of the Medication Adherence Project (MAP) resources on patient medication adherence rates for Type II diabetics patients. Data on medication adherence was collected from the site’s EMR for four weeks before the SBAR intervention and for four weeks after the intervention. Data on N= 30 patients was extracted from the facility EHR for a comparative sample (n = 15) four-weeks before implementation and an implementation sample (n= 15) for four-weeks after the implementation. A chi-square test was conducted to address the clinical question using IBM SPSS Version 27 with the level of significance set to p <.05. The results showed an increase in medication adherence from the comparative (n = 10, 66.7%) to the implementation group (n = 11, 73.3%), X2 (1, N = 30) = .159, p =. 999. The p-value was greater than .05, which indicated that the increase was not statistically significant. The results do however support clinical improvement as the adherence rate improved after the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources. Comment by Author: Again, this is not what is shown in your abstract. Comment by Author: Why is it 15 and 15 above but 10 and 11 here?Chapter 5 offered a summation of the results and conclusions based on the findings showing increased medication adherence after the MAP resource implementation. The theoretical and practical implications of the results will be summarized. The chapter concluded with recommendations for future projects, including adult home health patients with Type II diabetes, concerning the project findings that support MAP resources to improve medication adherence rates. Chapter 5: Summary, Conclusions, and RecommendationsDiabetes impacts approximately one in ten Americans (Centers for Disease Control and Prevention, 2020). The prevalence of the disease continues to rise and is expected to grow by 0.3% annually until 2030 (Lin et al., 2018). This particularly troublesome for Type II home healthcare patients diagnosed with the disease. Polonsky and Henry (2016) emphasized that roughly 45% of this population fail in sustaining a normal glucose level. Poor medication adherence is associated with increased morbidity and mortality rates, finances, hospital readmissions, and diminished quality of life (Polonsky & Henry, 2016).This quality improvement project was developed to address a standardized method for healthcare providers to assess their patients’ medication adherence. A quantitative, quasi-experimental design contributed to the participants promoting self-reliance and increased knowledge levels in maintaining healthier glucose levels. Furthermore, the project improved the practitioner’s awareness of the need to evaluate their patient regarding medication adherence frequently. The project provided current information related to Type II diabetic patients and medication adherence, which validated other studies such as Heath (2019) and Sharma et al. (2020).Chapter 5 summarized the project related to Type II diabetic home health patients and medication adherence. Other segments comprised of the summary of the project’s findings and conclusions. The theoretical (Orem’s self-care deficit theory and Roger’s diffusion of innovation model), practical, and future implications were discussed. The last section consisted of recommendations for future projects and clinical practices. Summary of the ProjectThe clinical question that directed the project was: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients in urban Texas?A chi-square test was conducted for a comparison of the medication adherence rates for the patients 30 days prior and 30 days post-implementation. A level of significance was set to .05, which indicated a p-value of less than.05 would reveal statistical or non-statistical significance.A convenience sampling was used to recruit N=15 participants for the comparative group and N=15 for the implementation group. Five nurses were educated regarding the use of the MAP resources. A retrospective chart audit was done to evaluate the medication adherence rates before the project implementation. The chi-square test was utilized to determine the variations among the two groups for statistical difference.Summary of Findings and ConclusionA sample size of N=15 participants was compared utilizing a chi-square test with the significance level at p <.05. Two groups were compared comparative (n=15) and implementation (n=15). The number of medication adherence rates were evaluated four weeks pre-implementation and post-implementation of the project. The clinical question that was answered using the chi-square analysis was: To what degree the implementation of the New York City Department of Health and Mental Hygiene Medication Adherence Project (MAP) resources impact patient medication adherence rates when compared to current practice among Type II diabetic patients in urban Texas? There was an increase in medication adherence from the comparative group (n= 10, 66.7%) to the implementation (n=11, 73.3%), X2 [1, N=30] = .159, p= .999. The p-value was greater than .05, which indicated that there was statistical significance in the medication adherence rates. The project demonstrated that healthcare providers should check on their diabetic patients’ medication adherence frequently during each home health visit. Comment by Author: I am confused as to why your chi-square is on 10 pre and 11 post but you are stating that there are 15 and 15. Please check with a statistician to make sure that your statistics are correct.ImplicationsNursing is a practice discipline. Therefore, when a quality improvement project is carried out, it should focus on issues that directly affect nursing practice (Polit & Beck, 2018). With this project, the emphasis was on patient care and the potential clinical implications that affected the findings (Polit & Beck, 2018). The theoretical, practical, and future implications for this project are based on the data and the literature that preceded it.Theoretical ImplicationsOrem’s self-care deficit theory was selected since it aligned well with the clinical question within the project. The theory guided the primary investigator and the nurses during the conception and implementation of the project based solely on the self-care needs of Type II diabetic patients’ in-home health care. As a result of the theory, strategies that assisted participants in understanding their disease and maintain self-care were integrated into the project. Orem’s self-care deficit theory consists of three components: the self-care theory, the self-care deficit, and the nursing system (RenpenningN et al., 2003). The intervention focused on a) abilities and actions related to medication adherence, b) staff nurses coordinating resources for diabetic patients, monitoring the disease, assessing medication adherence using a patient-centered approach (Orem, 1985).The strength of Orem’s self-care deficit theory allowed the primary investigator to provide the nurses with increased awareness in understanding their patients while addressing barriers that could impact them in understanding and maintaining medication adherence. In Chapter 2, the literature review examined how patients could effectively manage medication adherence while contributing to previous literature that utilized the theory on Type II diabetic patients (Borji et al., 2017; Ebrahimi, 2015; Ghafourifard & Shahbaz et al., 2016). One strength noted in the project was the increased curiosity and desire to learn exhibited by the patients. This was related to the nursing staff using a patient-centered approach in addressing their medication adherence. The patients verbalized that they appreciated the extra time that the nurses spent with them regarding maneuvering the chronic disease.The project’s weakness was instructing the nurses to become familiar with Orem’s self-care deficit theory, which formed the foundation of the project. Orem’s theory can be utilized and implemented in other projects related to Type II diabetic home healthcare patients since the findings cannot be generalized. Additionally, the project was constrained by a very short time frame (4 weeks). If the project had been conducted over a longer period, the primary investigator might have been able to observe interactions between nurses and patients, trends, and obstacles that prevented an individual from maintaining medication adherence procedures.Practical ImplicationsPractical implications included the agency evaluating and developing patient-specific medication adherence guidelines using MAP resources and the Orem theory. Several nurses suggested that one of the home visits focus entirely on a patient’s current medication list and medication adherence. Another suggestion was for the primary nurse to send text messages to the patient’s cell phone to remind them to take their medication. The last practical implication of this study was that nurses should not confront the patients regarding medication adherence status but should instead develop interventions designed to meet their specific needs (Sansbury et al., 2014). As a result of strategies such as goal setting, behavior contracts, or having an accountability partner, medication adherence can be improved (Sansbury et al., 2014).Future ImplicationsAmong the future implications of the project is the possibility of other quality improvement initiatives investigating the rates of medication adherence among teenagers in home healthcare settings. This should incorporate medication adherence strategies specific to their age group. A second implication pertains to diabetic medications; home health patients should be encouraged to participate in phase three trials for new diabetic products to improve their compliance. These products are becoming available and provided to participants at monthly or longer intervals. As a result, some of the short-term barriers to medication adherence would be addressed (Polonsky & Henry, 2016).A second future implication of the project is the implementation of strategies for medication adherence that are tailored to the participant’s demographic characteristics (race, gender, age, personal preferences, culture, and social determinants) (Williams et al., 2014). Understanding and addressing the factors that affect the patient might facilitate better management of the disease (Williams et al., 2014). The use of a multi-systems approach to medication adherence can increase medication effectiveness, adherence, healthcare outcomes, and decrease healthcare costs (Williams et al., 2014).RecommendationsThe recommendations constitute a solid foundation for the nursing workforce by ensuring they are appropriately educated and ready to implement the practice (Institute of Medicine, 2011). To meet their patients’ future health care needs, they must act as change agents within the healthcare sector (Institute of Medicine, 2011). This home health agency will require time, finances, resources, and staff commitment to implement and maintain the recommendations. The following paragraphs discuss recommendations for future research projects and clinical practices.Recommendations for Future ProjectsAs a first recommendation, these projects should use a standardized assessment strategy to evaluate their patients’ medication adherence practices and behaviors. Patient engagement in decision-making is limited when medical records are inaccurate, or medication assessments are inadequate. It would be helpful if diabetic patients were informed about the importance of adhering to their medication regimens. Patients who exhibit a change in their behavior are the best indicators of medication compliance.The second recommendation is to conduct the project using a larger population size focused on caregivers of diabetic patients. Focusing attention on this sector would emphasize the emotional and family support to help the patient remain compliant. Since many Type 2 diabetic patients have friends, family, or caregivers in their circle, it would be significant to include them in the discussion and the importance of medication adherence. This would allow a deeper understanding of the subject and generalization of the findings on this population.The next step in moving this type of project forward is implementing and sustaining MAP resources by the home health agency for maximum impact on the patients. By using this tool, frequent hospitalizations will be decreased, medical expenses will be reduced, and health quality will be improved. The project must be tailored to fit the needs and demands of the home health agency to enhance the project’s sustainability.Recommendations for PracticeOne recommendation for current practices is for home health nurses to offer other options to help their patients remain medication adherence compliant. Kirkman et al. (2015) suggested via their project findings that encouraging patients to use mail-order pharmacies increases the patient’s chance of medication adherence. An analysis conducted by Medicare Part D showed an increase in medication adherence by diabetic patients (Kirkman et al., 2015). Another suggestion is the use of a medication events monitoring system to evaluate the patient’s medication adherence. The device would be incorporated into the patient’s packaging of the prescription medication (Lam & Fresco, 2015). It records the dosing events and stores the information with audiovisual reminders. The last option is to receive automated electronic reminders such as (text messages) using REMIND software from the visiting home health nurse.The second recommendation is for future clinic practices to establish and educate the nursing staff on cultural competency care. This type of nurse-patient relationship allows a stronger connection with the patient who feels comfortable expressing concerns and knowledge deficits because of a non-judgmental environment that helps them maintain medication adherence behaviors. Patients with Type II diabetes and their caregivers cope with Type II diabetes more effectively when they have effective communication (Aloudah et al., 2018).ReferencesAdministration on Aging. (2015). Medication management. www.aoa.gov/AoA_Programs/HPW/Med_Manage/index.aspxAfrasiabifar, A., Mehri, Z., Javad, S., & Ghaffarian-Shirazi, H. (2016). The effect of Orem’s self-care model on fatigue in patients with multiple sclerosis: A single blind randomized clinical trial study. Iranian Red Crescent Medical Journal, 18(8), e31955. https://doi.org/10.5812/ircmj.31955.Ahmad, N., Ramli, A., Islahudin, F., & Paraidathathu, T. (2013). Medication adherence in patients with Type 2 diabetes mellitus treated at primary health clinics in Malaysia. Patient Prefer Adherence, 7, 525-530. https://doi.org/10.2147/ppa.s44698.Ahmed, I., Ahmad, N. S., Ali, S., Ali, S., George, A., Saleem Danish, H., Uppal, E., Soo, J., Mobasheri, M. H., King, D., Cox, B., & Darzi, A. (2018). Medication adherence apps: Review and content analysis. JMIR mHealth and uHealth, 6(3), e62. https://doi.org/10.2196/mhealth.6432.Allen, M. (2017). The sage encyclopedia of communication research methods. SAGE Publications.Aloudah, N., Scott, N., Aljadhey, H., Araujo-Soares, V., Alrubeaan, K., & Watson, M. (2018). Medication adherence among patients with Type 2 diabetes: A mixed methods study. PloS One, 13(12), 1-6. https://doi.org/10.1371/journal.pone.0207583.Althubaiti, A. (2016). Information bias in health research: definition, pitfalls, and adjustment methods. Journal of Multidisciplinary Healthcare, 9, 211–217. https://doi.org/10.2147/JMDH.S104807.Altman, M., Colorafi, K., & Daratha, K. (2018). The reliability of electronic health recorddata for obstetrical research. Applied Clinical Informatics, 9(1), 156-162. doi.org/10.1055/s-0038-1627475American Medication Association. (2020, December 2). 8 reasons patients don’t take their medications. https://www.ama-assn.org/delivering-care/patient-support-advocacy/8-reasons-patients-dont-take-their-medicationsAsif, M. (2014). The prevention and control the type-2 diabetes by changing lifestyle anddietary pattern. Journal of Education and Health Promotion, 3, 1. https://doi.org/10.4103/2277-9531.127541DNP-DPI- Project -Literature Reviews Assignment

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