DPI Project – Proposal Defense PowerPoint

Direct Practice Improvement Project Proposal

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

December 10, 2020

GRAND CANYON UNIVERSITY

Improving Medication Adherence in Diabetic Patients in Home Health Care Settings

by

Bola Odusola-Stephen

Proposed

December 10, 2020

DPI PROJECT COMMITTEE:

Mary Guhwe, DNP, Manuscript Chair

Bamidele Jokodola, RN, MSN, FNP, CMSRN, DNP, Committee Member

Full Legal Name, EdD, DBA, or PhD, Committee Member Comment by Author: Need to remove this as well as the footer

Abstract

Home-based healthcare is useful in managing some conditions as it is cost-effective and is known to improve the quality of life and longevity of patients. Home-based care is known to improve the mortality of patients due to the mental well-being associated with home-based care such as independence, mobility and the comfort of family and home. While beneficial, it can also be detrimental to patients if mishandled resulting in fatalities and complications in patients. Even though home-based care is popular and cost-effective, the adherence to medication by patients is unknown thus this project hopes to find out if educating patients undergoing home-based care improves their medication adherence. The project also aims to find out if family-led strategies lead to better medication adherence in home-based diabetes patients. Attachment and social cognitive theories will be used as the theoretical framework for this study. The project will be conducted in Urban Texas and will include 50 patients undergoing home-based care. Medical records of diabetes patients undergoing hospital-based care will also be reviewed for comparison. A standard questionnaire as well as the Morisky Medication Adherence scale (MMAS-8) will be used to collect data from patients. Data will be analyzed using excel and SPSS. Descriptive statistics and inferential statistics will both be used in analyzing data, Factor analysis will be used to analyze the data from the MMAS-8 tool. Comment by Author: The DPI template has the correct format for the abstract. Please refer to that and adjust your abstract. For the proposal you obviously will not have the results yet but you can complete the rest of the abstract requirements using the correct format Comment by Author: Make sure you have a change theory as part of your theories. As I mentioned previously, you do not need both the attachment and social cognitive theories but it is difficult to pin point which as you have not yet clearly identified what your intervention is for the project

Table of Contents Table of Contents Chapter 1: Introduction to the Project 1 Background of the Project 5 Problem Statement 6 Purpose of the Project 7 Clinical Question(s) 9 Advancing Scientific Knowledge 11 Significance of the Project 13 Rationale for Methodology 14 Nature of the Project Design 15 Definition of Terms 17 Assumptions, Limitations, Delimitations 20 Summary and Organization of the Remainder of the Project 23 Chapter 2: Literature Review 25 Theoretical Foundations 27 Review of the Literature 29 Theme 1 31 Theme 2 32 Summary 36 Chapter 3: Methodology 40 Statement of the Problem 41 Clinical Question 42 Project Methodology 44 Project Design 46 Population and Sample Selection 48 Instrumentation or Sources of Data 51 Validity 52 Reliability 53 Data Collection Procedures 54 Data Analysis Procedures 56 Potential Bias and Mitigation 59 Ethical Considerations 62 Limitations 64 Summary 66 References 68 Appendix A 70 Appendix B 72 Appendix C 74

2

Revised 4/21/2020 by: Dr. Suzette Scheuermann (Please remove this footer)

Chapter 1: Introduction to the Project

Improving Medication Adherence in Diabetic Patients in Home Health Care Settings Comment by Author: You have numerous formatting issues throughout the proposal that need to get fixed. My advise is to use a new template and re-enter your information in the new template as the template is already formatted for you in APA format

It is important that there should be proper and effective medication to the patients that are living with diabetes especially those that are under home -based care. More than half of the population does not take the medicine as it has been prescribed and this in most cases is resulting in costly health care challenge. The poor medication taking habits and the lack of adherence to the medicine creates complex problems. It is important that those who are under home care based should work hard to ensure that the patients are taking medications as they are supposed to be so that they do not develop more complications as a result of not adhering to medication. There are key interventions that should be identified, and effective measures made from this. Comment by Author: Why? Comment by Author: Citation? This whole section has numerous sections that need citations. I have given you feedback previously that you need some assistance with writing/editing. Please see DC network for resources. Comment by Author: The healthcare workers? Probably better to name the group you are referring to avoid confusion with the patients

Some medical situations inevitably require home healthcare services, this is important since it can help especially a person who is aging manage diabetes. Home –based care is also important in managing health issues, which are chronic in nature and also important in assisting people to live independently. Home-based care is also helpful in a person who is recovering from medical setback. Some patients that are under home care based may be unable to recover as well because in some instances they may not get the correct guidance as compared to when they are in the hospital. Comment by Author: See comments about citations above

The project is about the strategies and the methods that home-based care patients should follow to improve their health especially in adhering to medication to ensure that they get maximum benefits of their home-based care. This is because it has proven to be a challenge to follow the right medication strategies when the person is under home-based care. Comment by Author: This is not correct. Please see previous feedback about this. Your DPI project should be translating evidence into practice and not generating new knowledge/research. Please also refer to the DPI template for all the components you need in your various sections of the proposal. It is important to avoid missing any items but also so you can stay focused in your writing and be clear

Background of the Project

Home-based healthcare has been around since 1909 (Choi et al., 2019). It was perceived as a cheaper way to take care of patients who would have the benefit of enjoying the comfort of home and save money that would be have used up in paying hospital bills. In the early 20th century, home-based healthcare was mainly practiced due to adversities, in that the patients practiced it due to insufficient funds to afford proper health care. It was also practiced due to hardships in accessing medical care (Choi et al., 2019). In the present times, however, it is practiced out of choice, after a patient has weighed their options. Some of the situations where a patient can choose to practice home-based healthcare are when a patient is elderly and prefers to get home-based care instead of hospital care since at home, they would be more independent than they would be in a hospital. Home-based care is ideal when the condition can be managed without admission to a hospital such as in patients who have diabetes or those with hypertension (Szanton, et al.., 2016).

There is also a high rise of lifestyle diseases and conditions, such as diabetes. These chronic disease conditions require that a person engages in self-care behaviours at home to keep the situation controlled and prevent complications. Diabetes, for example, requires a patient to keep checking their glucose level. Many patients who are under home-based care do not have sufficient knowledge of the requirements that diabetes treatment entails. They do not practice medication adherence, causing more health complications due to unmanaged health conditions. Home-based care can increase the mortality and morbidity of diabetic patients if it is handled correctly by ensuring that diabetes patients have sufficient knowledge of what is required of them in terms of adherence (Neupane, et al, 2017). Comment by Author: This statement is incorrect. How does home correctly rendered home based care increase mortality and morbidity?

This proposed project is looking to tackle an increase in the fatality rate of diabetic patients practicing home-based healthcare. Most of the fatalities are caused by medical non-adherence, caused by a lack of sufficient knowledge of home-based care related to diabetes and other conditions. Patients at home are unaware of the requirements for medication, dosages, and required follow-up. Comment by Author: Citation? Also, I gave you feedback on this. This is not the aim or purpose of your project. Need to really adjust this and edit for clarity and scholarly writing

Problem Statement Comment by Author: This needs significant editing. You need templated language that clarifies what your problem is. I have given feedback multiple times previously and you have it in the DPI template as well.

Even though home-based care has certain advantages such as increasing the mortality of patients and the mental well-being of patients, it also has challenges in its implementation and successful outcomes. The adherence rate of home-based care patients is unknown and the implementation of strategies to aid in adherence is also unknown. It is important to measure these strategies and also to evaluate the adherence success rate of home-based care patients as this could make the difference between life and death for the home-based care patients.

The quality improvement project aims to find out how many patients have the required knowledge about their medical conditions and how to manage them. This includes learning about the vital medication, the importance of medicine, and the expected outcome if they do not adhere to the medical recommendations regarding diabetes and other conditions. The intervention for this problem can be done before a person is given a go ahead of having home-based care. Patients should first be given knowledge and the tips that are required on adherence to medication so that their health can continue improving and not to deteriorate as happens in many people who undergo home-based care. The nutritionists will be in charge of the diet education while nurses and practitioners will be responsible in offering general healthcare education regarding diabetes and the right lifestyle changes have to be taken into account. Nutrition education will examine the types of foods to be consumed, amount and frequency with which they should be taken. Lifestyle education changes will examine the healthy life activities that diabetic patients ought to be involved with. Medication adherence will be measured using self-report questionnaires that will be given to patients and health care providers during data collection. The tool will involve asking patients questions about the missed doses within a specific period of time. For accuracy purposes, the patients will be asked about medication adherence in the last three days because asking for more than three last days will be difficult for the patients to recall.

Purpose of the Project Comment by Author: This needs significant editing. You need templated language that clarifies what your problem is. I have given feedback multiple times previously and you have it in the DPI template as well.

The purpose of the project will be to determine medication adherence amongst home-based diabetes patients in Urban Texas. The project aims at determining the level of knowledge about diabetes and home healthcare requirements in 50 diabetes patients in Urban Texas. The project will focus on ways to reduce fatalities in diabetes patients under home-based healthcare. Many diabetes patients suffer due to medication non-adherence. This means that they do not follow the guidelines in managing their condition at home by the physician.

The main reason for medical non-adherence is the lack of knowledge of what they should do at home as healthcare measures to ensure they continue to improve their health. This could be due to home nurses’ failure to sensitize the patients on proper medication adherence or lack of proper follow-up through home visits.

The main aim of the project is to evaluate the implementations of some strategies which are important when it comes to defining clearly impacts that are present in case a person is on home-based care and the implications of not adhering to set times of taking medication

By conducting this project, the medical field can devise ways of ensuring that the useful information on diabetes management at home reaches everybody in Texas and other parts of the country. This should be incorporated in all systems like schools, workplaces, hospitals, and homes.

Clinical Questions Comment by Author: Put your PICOT question in this section and use that as your clinical question. Then add all the other information needed in the section based on guidance from the DPI template

Does Medication Adherence Education Increase Medication Adherence?

The project will focus on medication adherence of diabetes patients who are undergoing home-based care. The variables measured in this project will be adherence to medication and the outcomes of adherence or the lack of adherence in the patients and how this impacts home-based care. The project also hopes to understand the differences that are present in adherence to medication in diabetes patients undergoing home-based care as compared to those undergoing hospital-based care.

The data will be collected from both patients and health care providers engaged in home-based care programs. The aim is to find out to what extent medication adherence is utilised and what strategies are in place to ensure that patients adhere to their medication. The project will also seek to understand if the patients have sufficient knowledge on medication adherence. The following questions will guide this quantitative project: Comment by Author: This is research. Remember only limit your project to translating evidence into practice. Be very clear about what your problem is , what your intervention is and what your outcome is. Then you can be a good position to edit your manuscript. If you continue to edit the manuscript without clarity on those things it will be difficult for you

1. Does education on diabetes increase medication adherence in diabetic patients in home healthcare?

2. Do family-led strategies lead to better medication adherence in home-based diabetic patients?

Advancing Scientific Knowledge

This quality improvement project will help ensure that there is sufficient information available for the public regarding diabetes and the recommended home healthcare requirements to manage the condition. Seeing that there are so many patients without the necessary information regarding diabetes and how to manage it, there is a need to diversify the sources of information on diabetes and manage it. Comment by Author: Citation?

Sensitizing the population on the importance of adherence to medical recommendations and finding alternatives for expensive home healthcare facilities will solve problems even in the future, ensuring that the fatality rate in-home healthcare drops significantly. Adherence to medication by diabetes patients has been shown to improve their lives and reduce the development of more complications and premature death of patients (Delameter, 2006). This project will improve the overall quality of life for both the patients and their caregivers. This quality improvement project is also a gateway to more sensitization to people. The information can be shared in institutions. Future generations will also benefit from the knowledge on how to implement effective home-based care strategies to improve medication adherence and reduce diabetes related fatality rates. Comment by Author: How is this related to your project since these patients are home health patients?

The project will fill the literature gap on adherence to medication by diabetes patients undergoing home-based care. This project aims to provide all the necessary information to all Texas people to people all around the world. This information should be accurate and certified medically so that it will help reduce fatalities among diabetic patients in home healthcare settings.

Significance of the Project

This project is significant in current times. With the rise in chronic diseases, many people are opting for home-based care and not getting their treatment from a healthcare facility and thus they must know the importance of medication adherence even at home. Also, with the COVID-19, many people are undergoing more home-based due to congestion in hospitals and to also reduce the risk of spreading COVID-19 to other patients (Choi, Choi, & Shon, 2019). This DPI project provides a scope upon the general level of knowledge about diabetes and home healthcare. By focusing on medication adherence, the fatalities in home-based management can be reduced thus making the project very important to the management of diabetes at home. Though the project focuses on diabetes patients, it gives insight into the gap in a lack of knowledge on medication adherence for home-based care for other conditions as well including hypertension, heart disease and presently COVID-19. Other scholars interested in projects of this nature regarding other conditions will know the factors to consider and what to expect. Comment by Author: You need to make more of an argument for this as this is not the focus of your project so need to develop this argument further. You immediate impact for the project is improve medication adherence which improves control of the condition and prevents complications

After following through with content on the different ways of adhering to medical recommendations, other researchers can come up with ways to provide more information on current conditions to ensure that there is enough information guiding patients on the care measures required for a healthy life. Some situations that need looking into in the future are hypertension, and COVID-19, which are very urgent currently. Comment by Author: This is not what your project is about so need to edit

Rationale for Methodology

The DPI project employs quantitative methodology. This is where I will employ questionnaire as a way of collecting information. The data collected will be quantitative in nature to establish the medication taking behaviours of the patients under home-based care. In addition to the questionnaire developed, the Morisky Medication Adherence Scale (MMAS-8) will be used to determine how effectively the patients are adhering to medication. The MMAS-8 is a tool developed and widely used to determine patients’ adherence to medication in different conditions. It is a tool that eliminates bias from the patients and health care providers by asking questions in a method that avoids ‘yes-saying’ by patients. Numerical data is important as it focuses on trying to reduce the number of diabetes fatalities in home-based healthcare. Comment by Author: Can not use first person in scholarly writing. Pleas edit Comment by Author: You can not develop your own questionnaire/instruments for your project. You will need t utilize an already evidence-based instrument/questionnaire Comment by Author: Citation?

According to Creswell &Creswell (2017), a quantitative methodology is best suited for projects that require data in numerical form. This is to know the interventions that are happening to those who are under home based care to ensure that the strategies are working, and mortality rate of such people are reduced.

The information is then analyzed using quantitative methods and represented in charts and graphs. The conclusion on the findings is then drawn from the analysis of data, after which recommendations are thought of and implemented to curb the problems in scope.

Nature of the Project Design

This project will adopt the quasi-experimental design in that it deals with a random population that will be targeted will be all the stakeholders that have interacted with those patients that are in health care basis, and the DPI research project does not happen in a controlled environment. This design is more cost-effective than the actual experiment project design. In this project, the sample population is diabetes patients in Texas. The questionnaires, both the MMAS-8 scale and the questionnaire developed by the researcher, provide insights into the information intended for collection, thus providing accurate findings. Another mode of data collection used in this project surveys involves the diabetic patient or their caregiver to answer some questions related to diabetes, medical adherence, and home healthcare. Comment by Author: This is not really true. There is no requirement for randomization in quasi experimental design Comment by Author: The writing here needs editing for grammar and flow. Also please see prior feedback about removing any references of research a it pertains to the project. Comment by Author: Citation? Comment by Author: Only use evidence based instrument which you have provided as the MMAS so do not include caregiver interview etc that pertain to research

The project will use the data collected through the course time allocated. A detailed analysis of the data will be done, the date represented for interpretation, after which solutions to the research problem will be solved and tackled. It is a very descriptive project aimed at unravelling some of the truths that are not too obvious to develop solutions that are well needed in the current times. Comment by Author: If you are going to discuss data analysis then you need to just state what specific statistical tests you will run and what specific data you will analyze. This section is very vague and unclear as there are lot of research related statements

The research designs will help in the smooth process of data collection, analysis, and conclusions, which will help draft the recommendations for a healthy life for diabetic patients in Texas and possibly in the world who practice home-based healthcare.

Definition of Terms

Medication adherence:

This is the extent to which a patient, caregiver, or home nurse follows the recommended guidelines on managing a medical condition.

Home-based healthcare

Refers to the medical care given to a patient in the comfort of their home instead of going to the hospital.

Facilities

A thing, place, or person necessary to make the home healthcare process for a person with diabetes easier for both the patient and the caregiver.

Diabetes

A medical condition that is characterized by high sugar levels in the blood. It can be managed with drugs and insulin.

Assumptions, Limitations, Delimitations

This project assumes that medical non-adherence by diabetes patients’ is caused by a lack of sufficient knowledge on the matter. Education in the area as well as providing information on managing diabetes from home will solve the problem. It is also assumed that after education, the patients will automatically practice medical adherence because the knowledge will be easy to understand and the benefits of adhering to medication will be outlined to patients thus, they should be able to implement the knowledge. It also assumes that many people practicing diabetes home healthcare cannot afford the required facilities and equipment for treatment and care which is why they chose home-based care in the first place. Additionally, this project assumes that all patients and their caregivers are literate. Therefore, they can understand the physician’s diabetes and home healthcare recommendations for a long healthy life. Comment by Author: This is not correct as home health is not based on financial limitations bur rather other factors Comment by Author: Why are you assuming literacy when there is literature evidence that the average patient education material needs to be at the 5th grade level?

The project is limited because it focuses on only diabetes home-based care and does not consider patients undergoing home-based care who have different conditions. The project is also limited to an urban location and thus Texas state only and further limited to Urban Texas thus excludes rural Texas patients who may have different needs or challenges related to medication adherence. The project will also be limited to medication adherence of home-based care patients and does not cover other aspects such as mental health and health related quality of life of the patients. The project also includes all diabetes home patients, even those who are not necessarily ill and who are only practicing home-based care due to old age. In this case, the data may be a little imbalanced since it may record diabetes fatalities of patients who succumb to old age as a medical non-adherence fatality. Comment by Author: This is not a limitation as your population is diabetic patients in home health

Delimitations in this project include the project areas namely adherence and diabetes patients. The project will only collect data from diabetes patients and will only be interested in their medication adherence. The project study area is also only being conducted in an urban Texas area in the South East Unites State thus it will exclude patients from other states as well as rural rural locationsTexas.

The findings of the project will be applicable to medication adherence in patients with other conditions who are undergoing home-based care. They will also be applicable to all patients with diabetes throughout the country who are in the home-based care program to help them better adhere to medication and reduce the number of fatalities associated with the home-based health care programs.

Summary and Organization of the Remainder of the Project

Chapter one provides support for the assessing of interventions and their effectiveness especially those that are in home-based care, (Creswell & Creswell, 2017). This will bring about changes in the quality of life for people practicing diabetes home-based care not just currently during the COVID-19 pandemic but also in the years to come. People need to know the importance of medical adherence since it provides a chance to improve a patient’s quality of life. Chapter two will review literature both theoretical and empirical on the variables home-based healthcare, diabetes and also medication adherence to give the project a literary and empirical framework on which it will be based.

Chapter three will discuss the research methodology employed in the project. This will include research design, the target population, sample size, data collection tools, data analysis, reliability and validity of research instruments and ethical considerations when collecting data. Chapter four will present research findings and discussion of the findings. This will include both descriptive and inferential data analysis as well as discussions of the findings. Chapter five will present conclusions and recommendations drawn from the project.

Diabetes patients should also be enlightened on maintaining a healthy lifestyle and managing the condition at home (Choi et al., 2019). The data collected will make it easier to spot the problem and the gap, and therefore come up with ways to bridge it. One way to bridge the gap and reduce home-based healthcare fatalities of patients with diabetes is by providing adequate information on the management of diabetes at home. All the people involved in the home healthcare provision process should be sensitized to the significance of medical adherence. Comment by Author: See previous feedback on this

The projects also include data collection, where the data is presented and analyzed. The data gives insight into the situation, enabling ease of discussion of solutions and recommendations to increase medication adherence in home-based healthcare, which will reduce fatality rates of diabetic patients in home-based healthcare.

Chapter 2: Literature Review

Diabetes is a medical condition that is characterized by high sugar levels in the blood. It can be managed with drugs and insulin. Blood sugar serves as the major producer of energy in the body. Any condition interfering with blood sugar levels and mechanisms would bring about disruptions to the normal body activities. Optimal diabetes control usually needs patient associated engagement in various types of self-care associated activities, including the adherence of patients to the identified medication associated regimens along with adjustments to various lifestyle associated modifications and even the monitoring of the blood glucose associated levels, (Jajarmi, et al, 2019).

Since diabetes is a lifestyle disease, it can be easily prevented and avoided by making lifestyle changes. Managing the disease can also be made easier by making lifestyle changes as well as adhering to medication. This is important since it will help in avoiding of many challenges and complications that may arise from diabetes. one of the most problematic issues associated with home care for the patients suffering from Diabetes is Adherence to medications. According to Bonney (2016), patients usually take their identified medication as is prescribed solely 50% of the time. This along with the reluctance to be involved in the sharing of the details associated with medication taking behavior have been identified as less than optimal by healthcare providers. This project hopes to shed light on medication adherence and how it affects the quality of home-based care in diabetes patients. It hopes to understand the role of educating patients on medication adherence in improving their adherence to medication and also understand the impact of improved adherence on the patients.

This chapter provides both a theoretical and empirical framework through which the medication taking behaviors of diabetes patients undergoing home-based healthcare is investigated. The chapter is divided into theoretical and empirical sections. The theoretical section reviews two theories namely attachment theory and social cognitive behavior theory. In the empirical section, literature from previous studies and projects is reviewed and study gaps are identified in them which differentiate the reviewed projects from this project. The DPI project utilized databases as well as literature sources which have been systemically searched for the identified systematic reviews that report various aspects associated with diabetic adherence. A total of eighteen18 systematic reviews were realized as well as utilized in the advancement of the DPI conceptual framework. In overall, there was a total of six key sub-themes and many other subthemes for the project and that emerged which are all focused on thoroughly to enhance the comprehension of the DPI. Each of these key sub themes are discussed comprehensively along with in in-depth study. Most of the identified interactions were considered to be within the patient associated elements which usually not only interact with other kinds of theses but are also within the same theme. Comment by Author: I gave you feedback on this previously, you can not only have systematic reviews in your literature review. You need to revisit this Comment by Author: The writing is unclear here and needs editing for grammar and flow

Background

Non-adherence to diabetic medications in patients that are being treated from home usually leads to poor recovery along with ineffective treatment associated outcomes and even an increment in the healthcare associated costs is usually reported (Bosworth, 2015). A variety of elements that are usually related with the identified medication associated adherence have also been highly studied. However, it is vital to understand that a comprehensive framework along with a clear disease specific conceptual framework associated model which is involved in the capturing of all the probable elements has not been fully established. The main aim of the project is to assess the effectiveness of the interventions that have been put into place so as to ensure that there is improved home based care.

The demographics along with the cultural beliefs of the patients were considered to be the most notable elements of the given interactions with other types of categories as well as themes. The intricate network as well as the various interactions regarding the elements that have been identified between the distinct themes as well as within the individual types of themes usually reveal the identified complexity associated with the issue of adherence of medication especially those that are diabetic.

Theoretical Framework Comment by Author: One of your theories needs to be a change theory. As previously indicated, it is difficult to see the link between attachment theory and medication adherence. Not yet clear on your intervention so hard to say if it aligns with that or not. The social cognitive theory I can see how it aligns with your project.

According to Liu & Butler (2017), medication adherence is considered to be the largest challenge that healthcare workers and patients are facing in their daily lives. It is often considered to be a critical issue, which usually deserves higher level of attention. Inspiration along with the act of supporting patients to take their identified medications as prescribed can be a great issue. The Direct Practice Improvement (DPI) project utilizes two key theories to explain the relationship between medical non-adherence to patients and how medical adherence can be enhanced among the diabetic patients through improved interventions. Comment by Author: The writing here needs editing for flow and clarity

Attachment theory

The first theory is the attachment theory. This is defined as being a psychological, evolutionary, and ethological associated theory in relation to the aspects of relationships between individuals. This is a famous theory that had been used in the healthcare practices for a long time thus will be a suitable framework to be used in this case that entails creating the best interventions made for enhancing medical adherence with the diabetic patients.

The most vital tenet concerning the attachment theory is usually considered to be that young children usually need to advance a relationship with at least a single primary caregiver for the identified normal social and emotional advancement. The theory was designed by the prominent psychiatrist and psychoanalyst John Bowlby. Within this theory, the term attachment is usually utilized to refer to an affection bond or tie that is between a person and their attachment figure who in this case is usually considered to be the caregiver (Liu & Butler, 2017).

Some types of bonds may be considered to be reciprocal such as those occurring between two adults, however, the bond between a child and a caregiver are usually on the basis of the need of the child for safety, security and even protection. This is usually considered to be essential in both infancy and childhood phases of life. This given theory usually proposes that children are involved in the creation of attachment to their careers instinctively for the key associated purpose regarding survival along with the untimely as well as genetic replication.

The biological purpose for the use of this theory is the facilitation of survival while the psychological aim about the theory is to offer security thus making it a suitable theory to use. Attachment theory is considered to not be an exhaustive description associated with human relationships nor is it considered to be synonymous with love or affection, however these can be utilized in indication of the fact that bonds still exist. In the child to adult types of relationships, the child is usually referred to as the attachment while the caregiver is usually defined as being the reciprocal equivalent who in this case is called to be the care giving bond (In Hunter & In Maunder, 2016).

The modern attachment theory is usually focused on three key principles which entail bonding as an intrinsic human need along with regulation associated with emotion as well as fear to improve vitality and in the promotion of addictiveness along with development. Common attachment behaviors as well as emotions are usually displayed in most of the social primates including humans and are considered to be adaptive. The long-term associated evolution possessed by these types of species usually involves selection for the identified social behaviors which enable people and group survival more likely.

The commonly observed types of attachment behavior in toddlers staying near the familiar individuals are based on safety advantages in the identified environment both in early adaptation and our current world. Bowlby perceived the identified environment associated with the early adaptation as being the same to the current and also similar to the hunter-gatherer communities. There is a survival advantage in the identified capacity to effectively sense possibly dangerous conditions like the issue of unfamiliarity, loneliness, and rapid approach. In the identified internal models is entailed the regulation, interpretation and the prediction of attachment associated behavior in the identified self and the attachment figure.

The advancement of attachment is considered to be a transactional process. Particular attachment associated behavior usually starts with the predictable apparently innate behaviors in the infancy stage of life. They usually alter with age in various ways that are usually determined partly by the identified experience as well as partly by the various sit-upon elements. As the various attachments get altered throughout life, they do so in techniques that are shaped by the identified relationships.

In accordance with Hunter & Maunder (2016), there are two key reasons why the attachment theory is considered as being effective to be utilized in the following DPI. First and foremost, the theory acts as a solid foundation for the enhanced comprehension regarding the identified development of ineffective coping techniques as well as the underlying dynamics associated with the emotional difficulties of the person. Clinicians can help those people that have attachment anxiety and avoidance in the comprehension of the manner in which previous experiences with their caregivers or their significant others have helped in shaping their identified coping patterns to their various experiences of distress.

Secondly, the clinicians can help the people who have attachment anxiety and avoidance to find the best alternative way to meet their various needs. Most of the individuals who usually seek help want to learn the way in which they can employ different strategies for coping with the various dysfunction in their daily lives along with effectively modifying their various dysfunctional or even inappropriate coping techniques. This is an essential aspect since the caregivers need to form attachment first before delivering the advice and interventions to the diabetic patients on how they can adhere to their medications. It is important to note that for effective outcomes to be realized in these diabetic patients, there is the need to ensure that all the basic needs of the patients are effectively met as well as other types of strategies that are considered effective for changing the individual maladaptive techniques used in conjunction with the theory (In Hunter & In Maunder, 2016).

Social Cognitive Theory

The other vital theory that can be utilized in the facilitation of the DPI project is the social cognitive theory. Social cognitive theory is a famous theory that is usually utilized in the explanation of the manner in which human behavior is associated with dynamic, reciprocal, and progressive types of interaction that exist between the person and the given surrounding (Bosworth, 2015). The common types of theoretical basis associated with the cognitive theory is considered to be learning since it usually posits that the identified human behavior is effectively learned. Therefore, the Social Cognitive Theory (SCT) is famous because it often proposes that identified behavior aspects are an outcome of the cognitive processes which individuals usually develop via the social acquisition associated with knowledge.

According to Bosworth (2015), the theory usually bases its focus on the identified concept regarding behavioral capability which usually states that prior to any individual acting in a certain situation, the individual needs to have knowledge on what they need to do and the manner in which they need to do it. Bandura’s conceptual model regarding the reciprocal associated determinism is often utilized in addressing all the personal determinants associated with health. He postulated that an identified person or individual is engaged in a cognitive, vicarious, self-reflective, and even a self-regulatory process to attain a given goal. He went further to state that individuals usually effect alterations in themselves via their identified actions in anticipatory and proactive ways through the exercising of control over their given behavior via their well thought types of procedures and even motivations (Bosworth, 2015).

Bandura asserted that without having any kind of aspirations individuals usually course through life unmotivated and uncertain regarding their specific capabilities. Nonetheless, he also stated that people who take part in health promoting behavior have self-belief which enables them to fully take part in control over their thoughts, feelings, and actions. Therefore, the individuals who usually take part in self-control associated with health associated habits is involved in the reduction of key health associated risks leading to healthier and highly productive lives (Bosworth, 2015). In accordance with Bandura, although the prominent SCT usually acknowledge that the associated knowledge regarding the health associated risks along with the given benefits associated with treatment are considered to be necessary in the performance of health associated behaviors, this is in itself not adequate. Comment by Author: Need Citation Comment by Author: Comment by Author: This reads award, please edit

Self-influences are regarded as necessary in the attainment or the various alterations which will lead to the desired health associated outcomes in the identified patients. This concept is usually referred to as self-efficacy. The two types of cognitive processes which are involved in influencing behavior in the identified SCT are usually referred to as the self-efficacy and outcome expectations (Bosworth, 2015)

In accordance with Hadler (2020), the social cognitive theory is considered to be essential during healthcare workers’ counseling regarding various patients that have chronic medical illnesses like HIV and even diabetes. It can be utilized in the offering of help to the given patients in the learning of the vital information associated with HIV and AIDS as well as the related health issues like adherence. Support groups for people who have this could also utilize this social cognitive associated theory along with various behavioral techniques to effectively empower patients to effectively negotiate the various issues that are around medication adherence along with the establishment of effective supportive types of relationship which are efficient in strengthening the ability of the patient to stick to medication plans.

All these are associated with improved adherence as well as effective clinical results. Issues that are around the disclosure associated with the underlying conditions that some patients are subjected to are considered to be skills which could be effectively taught in the identified support groups and which could cause improved medication adherence. The reason why these two theoretical frameworks are used in this situation of diabetic patients who do not adhere to medications is because special intervention is needed to convince diabetic patients to adhere to medications and this will be installed in them as knowledge for behavioral change that will influence a positive change that will cause the patients to adhere to their medications.

Review of the Literature Comment by Author: You are missing any citations in these few paragraphs as indicated before. You need citations to support your assertions or thoughts. Remember that the hall mark of the DNP scholarly journey is translating evidence into practice so all aspects of the project need to have literature support

Medication adherence is considered to be the largest challenge that the healthcare workers as well as their patients are facing in their daily lives. It is often considered to be a critical issue which usually deserves higher level of attention. Inspiration along with the act of supporting of patients to take their identified medications as has been prescribed can be a great issue. The cognitive associated perspective on the identified health associated behavior is usually on the identified assumption that our thoughts along with beliefs usual influence our personal emotions and behavior.

It is important to note that the key focus of people working in the healthcare facility with diabetic patients, consider them as critical patients in the manner in which the identified patients are entailed in the conceptualization of the different health associated threats along with is involved in the appraisal or the elements which are involved in facilitating adherence or even serving as barriers to effective treatment of people.

Although adherence to antiretroviral therapy is considered a predictor of effective clinical associated outcomes among diabetic patients, it is a crucial challenge, and strict adherence is usually considered not to be usual

Medication adherence :  Comment by Author: Please see DPI template for appropriate formatting of your headings and subheadings i.e differentiating between themes and subthemes

This refers to the art of taking medication in the right way as prescribed by healthcare practitioners. This is done in most cases by people in the hospital, and these are health care practitioners. This is through giving prescriptions as they are supposed to. For home-based diabetic patients, they might be missing the opportunity to have a physical person monitoring their recovery process. For those that are home-based, the process is done by those present in that very time. However, their adherence and track of the body changes can play a significant role (Ahmed et al., 2018). Comment by Author: The writing here is not clear, please edit

What can be done to enhance Medication adherence?

To handle the issue of medication adherence among the diabetic patients who have had an issue with the adherence to medication needs to come up with a variety of strategies that have been attained from scholarly reviews as well as journals for purposes of well researched data on the concept. Appropriate types of medications are usually considered to be the identified cornerstone regarding the prevention as well as disease treatment yet according to numerous research carried out, there is solely about half of the individual patients who adhere the instructions of their prescribed medication (Bosworth, 2015). This usually causes a common as well as a costly public health associated challenge especially for the healthcare system in the US.

Since the aspect and issue of inappropriate as well as inefficient medication adherence is considered to be a complex change with a variety of contributing causes, there is no universal solution (Rodriguez, 2019). The following theme breaks down into three subcategories which form the basis of the sub-themes associated with this theme. The sub-themes are used to offer comprehensive analysis of all the vital types of interventions which are considered to be effective at enhancing medication Adherence among the diabetic patients but were also considered to be potentially scalable that is they are easy to implement in any given scenario in even large population (Bosworth, 2015). Key traits that make these interventions effective are discussed throughout the DPI. The information offered under each sub-theme is vital in enhancing proven as well as low rescue and even the cost-effective solutions to enhance Medication Adherence.

Strengthening the Relationships with Patients

Patients usually put into consideration their identified HCPs the major along with most dependent source of data regarding their health associated condition along with the treatment, and they are usually considered to be highly likely to effectively follow the treatment types of plan when they are involved in having good relationship with their HCP due to confidence and trust that has been built over time. Relationship building in healthcare is considered to be a vital aspect in the day to day lives of healthcare practitioners due to the nature of their job which necessitates that they all maintain long term relationship with their patients for enhanced medication as well as treatment outcomes (In Heston, 2018).

Trust is usually developed throughout time with the same types of HCP in any kind of mutual relationship between them and the identified specific patients. The patients in these cases usually consider that their identified HCP possesses the highest level of competence along with actually cares about their identified health. Mistrust usury develops when the given patients attain unrealistic as well as inconsiderate and even insensitive advice from their identified HCPs as well as feel some kind of emotional distance from them.

Medication Nutrition Education Therapy 

Appropriate nourishment assumes a vital function in infection counteraction and treatment. Numerous patients comprehend this connection and seek doctors for direction, diet, and diligent work. Nonetheless, real doctor practice is regularly deficient, intending to the nourishment parts of infections, for example, malignancy, adiposity, and diabetes. Doctors do not feel significant, specific, or sufficiently set up to give nourishment guiding, which might be identified with problematic information on fundamental sustenance science realities and comprehension of potential sustenance intercessions. Truly, nourishment training has been underrepresented at numerous clinical schools and residency programs.

This usually makes it hard for the desired coordination as well as level of friendship that is needed for the effective as appropriate manage the issue of diabetes to be attained. When the caregivers are considered to be not friendly as well as not welcoming, it becomes hard to convince the patients on taking their medicine, yet they have a negative perception and attitude towards their care giver (In Mahmoud, 2019). The identified patients who are usually engaged in some meaningful types of partnerships are usually considered to be highly receptive to the various messages that have been delivered by their identified health care associated team.

As an outcome, the given patients usually tend to be in possession of some kind of anti-ballistic perceptions regarding the identified severity of the disease along with the benefits that come with the treatment of the disease and how medical adherence can attend to enhanced efficiency along with results in the healthcare work with the diabetic patients. Therefore, in this case, the factors that are entailed in impacting medication adherence are referred to as the severity of the diabetes illness along with the advantages associated with the treatment.

It is a vital theme which helps in understanding that the different types of patients that have close relationship with their caregivers are associated with high likelihood of following medications prescribed to them (In Sherman & Bednash, 2015). Any patient who is considered to be engaged in an identified partnership or even relationship with the caregiver is usually considered to be highly likely to be entailed in disclosing their various clues which helps the identified HCPs in the employment of numerous personalized models to offering support to medication adherence efforts. Attaining a careful comprehension is considered essential in the comprehension or the needs of patients via appropriate patient- provider types of Communication which are vital in the employment of the practical approaches to enhancing medication adherence as has been suggested throughout this DPI.

How and Why to Adhere to Medications

An estimated American adult of about 35 percent is considered to possess basic as well as the below-basic health associated literacy. This has been recognized globally and is associated with causing their incapability to read as well as write and understand any kind of message that is indicated on the prescribed medicines or the treatment sheets. Health literacy had been considered to be a vital aspect in the receiving of any kind of services. First and for foremost, it helps in helping the identified diabetic patients to not miss out on any fine detail needed for them to put into consideration and has not been written carefully thus can seek clarification on such aspects unlike if one cannot read not clarify on anything. Literacy is the ability to read as well as be able to understand the different aspects that people highlighted them to them (Glanz& Viswanath, 2015).

For these same reasons, the world practitioners have been involved in the coming up with different strategies that can be used in the reduction of health literacy levels among taunts that have diabetes. It is vital to put this theme into consideration and should be a first priority since it is what makes the basis along with the foundation of having long term sustained profitability rates as they will be able to explain themselves to the identified people that will help them in making sure that they adhere to all their given medication.

It is always vital to adopt the universally implemented as well as published precautions that are made against the identified medication non-adherence as well as the low health associated literacy. This is famous for its nature of purpose. It is always utilized to offer effective encouragement of the various identified HCPs to carry out an assumption that the given patients are not being involved in taking their identified medications as they are prescribed to. Prescriptions need to be taken seriously for them to offer exceptional results and for the continued well-being for the patients who have critical illnesses like Diabetes.

The use of simple language by HCPs as well as medication manufacturers is another vital way, they can be utilized to help in teaching back types of techniques. These methods have been utilized in the enhancement of adherence among many types of non-adherence medication patients. Most of the times people opt to not take their medication as they cannot read all the instructions written on the medicine and are afraid that they will die especially in the cases that they mistake those drugs for poison or some drug that may look like a famous poison causing deash. This is a key issue that has left most of the people victims of non-adherence (National Academies of Sciences, Engineering, and Medicine (U.S.), 2018).

Reading instructions and making a patient understand what is written in a medicine bottle or package should never be taken for granted as it is key for determining the manner in which patients will effectively or ineffectively adhere to the given drugs for treatment and disease control purposes. So that the identified medical practitioner can be aware and sure that what they have explained to the patients has been delivered safely as well as appropriately, there is the need for them to do a verification test. The patients as well as their identified support individuals need to be effectively asked to offer an explanation in their own words what they have understood from everything the practitioner have told them regarding their health along with drug management and intake. This teaching back method is vital in offering additional data on the key topic of interest thus should be used often.

Concerns associated with the issues of side effects can be considered to be challenges to the aspect of medication associated regimen adherence especially when the given advantages associated with taking the identified medication are not properly along with effectively comprehended. To minimize the identified potential associated concerns that are associated with the side effects of drugs since this can be identified as one of the reasons why these patients may opt to not adhere to the medications in fear that they will experience the side effects and be greatly inconvenienced, there is the need for HCPs to offer the relevant data regarding the common types of side effects when they are entailed in the prescription process.

There have been issues of people and patients dying or experiencing very negative and disturbing side effects when it comes to them taking the desired drugs by their doctors. These cases have always been used as forms of examples to explain the reason why people have been reluctant to take the medications for prolonged periods. For most of the critical illnesses, the medication is usually made to be taken for a long time for increased efficiency. This has caused many to withdraw from the medication due to the prolonged side effect issues that is associated with it (Institute of Medicine (U.S.), 2016).

For instance, when offering a prescription or the metformin, there is the need to inform patients that are suffering from diarrhea during their time of prescription to anticipate that the loose bowel issues will be over in about a week if the drug is continued to enable the adherence of the drug. It is also vital to offer brief expansions due to the issue of time limitations along with engaging other members regarding the health care associated team in the provision of more additional education can be essential. This can be in the form of printed handouts as well as websites and in the use of teaching module which should be readily available for use with the identified patients.

In summary, the level of medication illiteracy among Americans is assumed to be high. This significantly contributes to the difficulties faced by patients when they are required to follow instructions. There is need for practitioners to take time and educate the patients on the right measures to take. Learned patients will have better understanding of the actions to take, and which can positively impact what they are after.

Tools for Building Patient Self Efficacy as well as Support Adherence

Using tools along with instruments that are considered effective along with appropriate is vital in supporting adherence in different ways and in achieving self-efficacy among the various patients. Positive family along with social support are considered to be vital aspects associated with adherence to the issue of Diabetes management (In Rodríguez, 2019). If vital, the engagement of the family members can enhance self-care activities for the patients suffering from Diabetes, including the eating of effective and healthy foods as well as keeping fit and in monitoring the identified blood glucose and even adherent to medication.

An innovative method that entails patients in the identified medication associated reconciliation process through a given web portal to undertake the verification of their various regimens along with the clarification and the verification of any types of inaccuracies after the identified hospital discharge has been received to enhance Medication adherence as well as in the decrement of the potential adverse drug associated events (In Forman & In Shahidullah, 2018).

In this case, there may be higher roles for the engagement of patients with their identified electronic medical types of records so that they can appropriately verify along with help in the maintenance of accuracy associated with their medication list to undertake the reflection of their actual taking of drugs. Also, the use of screening tests is vital in understanding how well patients are taking their drugs. If there is no consistency in medication taking then motivation aspects should be utilized to enhance Adherence (European Medical & Biological Engineering Conference & Nordic-Baltic Conference on Biomedical Engineering and Medical Physics, 2018).

In summary, the utilization of tools and instruments simultaneously plays an essential role in upholding medication adherence. Having a supporting and positive minded family also plays an essential role in supporting self-efficacy of the patients. Innovation should be incorporated in searching for medications. This will be advantageous because of the contemporary rapid advancement in technology.

Diabetes Care Concepts

When dealing with patients that have been considered to be reluctant in taking their medication, it is vital that the various care concepts in diabetes patients is understood. It helps in the effective integration of all the Interventions that have been mentioned in theme 1 for enhanced efficiency in the overall improvement of diabetic patients concerning adherence to medications that she been prescribed to them to help them in quick recovery and in the management of the illness for a longer term.

The following theme offers comprehensive knowledge as well as in depth illustrations on the distinct components associated with the clinical control regarding patients have been diagnosed with diabetes. The review offers effective clinical practice associated guidelines which have been considered to be the key to the enhancement of the population associated health, however for the identified optimal outcomes as well as diabetes care ought to be individualized for every identified patient.

Patient-Centeredness

Patient centeredness entails ensuring that all the identified interventions described in the first theme are focused on the individual patient who is being helped in having effective adherence to the given medication during home care settings. Patients who have been diagnosed with various critical illness and have been asked to go home for home-based care have been associated with lack or poor adherence to the medications they are given when they are discharged from the hospital. It is a global issue that has raised consent for the need to understand how to go about it for enhanced feasibility in treatment of illnesses (Steinberg & Miller, 2015).

Practice recommendations whether they are focused on the identified evidence as well as expert opinion are usually intended to offer the desired guidance on an overall approach to care (In Costa & In Alvarez-Risco, 2018).  The science as well as the art associated with medicine usually come together when the identified clinician is experiencing or has experienced some sort of situation whereby, they have to make treatment associated recommendations for any patient who would be considered to not have effectively met the eligibility associated criteria for the studies on which the given guidelines were based.

Recognition of what an individual needs is vital, and it can be achieved through the use of the studies that offer standards for when as well as the manner in which to adapt the given recommendations. Since the Patients that suffer from Diabetes usually possess highly increased risk for the identified cardiovascular illness, a patient centered approach needs to entail a plan that should be utilized in the reduction of the various cardiovascular risk through offering the address of the identified blood associated pressure along with the identified lipid control and even in smoking associated prevention and even creation and other aspects (Major Topics in Type 1 Diabetes, 2020).

Diabetes Across the Life Span

An increment in the identified proportion associated with patients that suffer from diabetes are usually considered to be mostly the adults (In Balogh & Institute of Medicine (U.S.), 2015). For the less salutary reasons, the identified incidences associated with type 2 diabetes is considered to be highly increasing in the creating in the children as well as the young adults. Patients that possess the type 2 diabetes as well as those that have type 1 diabetes are considered to be having good lives even in their older age which is regarded as a stage of life whereby there is minimal evidence from the identified clinical traits to be used in the guidance of therapy (Bonney, 2016). All these toes of demographic alterations are usually involved in highlighting another key challenge to the high-quality diabetic patients care. In this case, the identified need is usually considered to be the enhancement of the coordination between clinical teams as well as patients in the effective transitioning via the dysfunction phases enticed in life span (In Corcora & In Roberts, 2015).

Advocacy for People with Diabetes.

Advocacy is a very vital aspect in healthcare since they deal with patients that need their utmost help as well as care for them to go back to their previous health state (In D’Onofrio & In Sancarlo, 2018). Advocacy is an aspect that can be referred to as an active support as well as engagement to effectively develop a cause as well as a policy (Mollaoglu, 2018). Furthermore, advocacy is usually needed to enhance the loves of individuals suffering from patients. Given the various issues in diabetic patients such as the high toll that the issue of obesity as well as physical inactivity and even the various alterations that take place in the society determinants at the identified root regarding these issues can be solved using Advocacy (Stanislaw & Michael, 2017).  Comment by Author: Bola, there are significant formatting as well as content and writing issues with your literature review. Please take the time to review examples of DPI projects in DC network as well as the template before our teleconference to discuss all of these changes. You definitely also need writing/editing assistance as it is really difficult to get your point across if the writing has mechanical errors etc We will need to discuss your literature review during our teleconference Comment by Author:

Summary

Medication associated adherence among most of the critical illness patients such as those suffering from Diabetes as illustrated in the project is considered to be a key challenge for the identified patients that have chronic diseases like Diabetes. Optimal adherence to the identified prescribed medications can be entailed in the decrement of complications along with enhancing clinical outcomes and in saving healthcare associated costs. The following DPI has been comprehensive through the review of diabetic patient care concepts issue of non-adherence along with the time to look deeper for the issue of non-adherence as well as the manner in which to undertake the evaluation of the identified patients appropriately along with effectively in a clinical setting along with has offered practical solutions to helping in the improvement of the medication associated adherence (Major Topics in Type 1 Diabetes, 2020).

Medication adherence is considered to be the largest challenge that the healthcare workers as well as their patients are facing in their daily lives. It is often considered to be a critical issue which usually deserves higher level of attention. Inspiration along with the act of supporting of patients to take their identified medications as has been prescribed can be a great issue, however it is considered to possess the capability to possess the highest effect on their identified long term associated health as the well as on the economic well-being regarding the healthcare system of the nation.

The identified theories point to the possibility of solving the problem of poor medication taking behaviors by the use of attachment and social learning. The theories point out that medication taking is learnt and can be enhanced through the use of cognitive behavior change. The theories also point out that attachment between a health care provider and patient can form the basis of positive interaction between them leading to trust which then enables the health care provider to ingrain adherence into their patients. Comment by Author: This did not really come out doing your discussion of the attachment theory and this is why my feedback was that it does not really align with your project. Remember that you only need two and one has to be a nursing theory. In addition a change theory is needed since this is a change you are making based on evidence.

The empirical review point to the complications caused by lack of medication adherence in diabetes patients. It also highlight possible ways in which health care providers can help patients better adhere to medication through strategies such as advocacy and patient centeredness. Overall, medication adherence is important to the treatment and effective management of diabetes in patients and health care providers can play a vital role in ensuring that diabetes patients learn the importance of adherence. Comment by Author: This summary section still needs work. Remember that the summary needs should:• Synthesize the information from all of the prior sections in the literature review and use it to define the key strategic points for the project.• Summarize the gaps and needs in the background and introduction and describe how it informs the problem statement.• Identify the theories or models describing how they inform the clinical questions.• Use the literature to justify the design, variables, data collection instruments or sources, and population to be evaluated. • Relates the literature back to the DPI-project topic and the practice problem.• Build a case (argument) for the project in terms of the value of the project and how the clinical questions emerged from the review of literature.• Explain how the current theories, models, and topics related to the project will be advanced through your project.• Summarize key points in Chapter 2 and transition into Chapter 3.This section should help the reader clearly see and understand the relevance and importance of the project to be conducted. The Summary section transitions to Chapter 3 by building a case for the project, in terms of project design and rigor, and it formulates the clinical questions based on the gaps and tensions in the

Chapter 3: Methodology

Medication adherence is important to minimize the impact of chronic illnesses and reduce emergency visits to hospitals. Medication adherence refers to how well a patient in home-based care can take their medication correctly in the absence of health practitioners as prescribed by the doctor (Ahmed et al., 2018). It requires the patient to totally adhere and comply with all the medical instructions given. The number of people with diabetes diagnosis in the United States of America is too large and a most of them are living with underlying conditions which increases their risks being under medication. The challenges faced in keeping such large patient numbers on hospitals has necessitated the introduction of home-based care programs (Brown & Bussell, 2018).

Various models and therapies are available for people with diabetes. The medication nutrition therapy determines the types of foods that patients with diabetes will be consuming at various stages of their treatment. It also calls for the education of these patients about nutrition (Brown & Bussell, 2018). The ongoing care management dictates that patients with diabetes need to receive care from multiple integrated teams. These two models help in maintaining home-based care for diabetic patients (Brown & Bussell, 2018). Pharmaceutical-led therapy cannot be ideal for home-based patients because the pharmacist will not always be there to ensure medication adherence. The role of family members in upholding the patient’s health is therefore vital. Various approaches have been designed to improve care in diabetic patients. The patient-centered communication approach focuses on the interest and preferences of the patient and identifies any barriers (Voortman et al., 2017). Chronic care models ensure that any form of care required by the patient is well taken care of.

This quality improvement project will be guided by the following question: To what degree does the implementation of family-led strategies impact medication (what) compared to pharmaceutical-led strategies among diabetic patients in home-based care in Texas over four weeks? Comment by Author: Remember that this section includes both a restatement of project focus and purpose statement for the project from Chapter 1, to reintroduce reader to the need for the project and a description of contents of the chapter. This is not your purpose statement

This chapter will be explaining the methodology of this project. Information such as the project design, selection of the sample, instrumentation, validity, and reliability, data collection procedures, data analysis procedures, ethical considerations, and limitations will be included in this chapter.

This chapter will be explaining the methodology of this project. Information such as the project design, selection of the sample, instrumentation, validity, and reliability, data collection procedures, data analysis procedures, ethical considerations, and limitations will be included in this chapter.

Statement of the Problem

It is not known to which extent are the interventions working so as to ensure that home-based care is having positive implications as it is supposed to as well as to what extent is the implementation of the strategies that are making the patients that are in the home-based care to adhere to the medications despite being out of the hospital set up. Diabetes home-based healthcare can be very effective since the patients are acting independently away from the health facility as and the necessary medical recommendations are adhered to Therefore, they can be of great importance to the patients as they can give ready support compared to doctors. Comment by Author: See prior feedback on the problem statement in chapter 1. Remember there are certain parts of your project that stay consistent regardless of where in the proposal they are. The purpose, problem statement , population, PICOT questions, data collection procedures etc are the same throughout

This is important since it will help in saving lives especially for those that are in this kind of medication.

The quality improvement project aims to find out how many patients have the required knowledge about their medical conditions and how to manage them. This includes learning about the vital medication, the importance of medicine, and the expected outcome if they do not adhere to the medical recommendations regarding diabetes and other conditions

The number of patients in the United States with diabetes diagnosis is very high. This, therefore, makes it impossible to accommodate all of them in hospitals (Brown & Bussell, 2018). This means further that most of these patients have to be placed under home-based care programs. In these programs, there are no medical practitioners to ensure that patients adhere to their medication. For diabetic patients in home-based programs, they miss the opportunity of having someone monitoring their recovery process. For instance, there will be nobody to remind them how to take their medication or stick to healthy diets (Norman et al., 2018).

According to Norman et al. (2018), family members are closer to the patient in home-based programs than the healthcare practitioners. For this reason, they can be of great help in offering support to diabetic patients as compared to doctors.

Clinical Questions

Prior studies have demonstrated that medication adherence for patients in home-based care has not been a smooth process. Evidence shows that this is usually because there is nobody to monitor the progress of these patients. There is usually nobody to remind them to take medication the right way or adhere to their dietary instructions (Wolff & Baker, 2019). However, there are chances of improvement in this. The implementation of family-based medical adherence strategies can help to enhance medication adherence among diabetic patients in home-based programs. A family-led health education intervention will be carried out by the health care providers who will educate patients on the disease and how-to manage it, medication they should be taking and also the importance of adherence. This will be done during follow up sessions with patients in home-based healthcare.

There are a number of Strategies and the outcome is strict medication adherence. A quantitative, quasi-experimental design approach has been chosen for this report. This approach will help to assess the effectiveness of family-led strategies in enhancing medication adherence among diabetic patients in home-based care as compared to pharmaceutical-led strategies. The project will be guided by the following clinical questions:

1.Does education on diabetes increase medication adherence in diabetic patients in home healthcare? Comment by Author: Use your PICOT question here

2. Do family-led strategies lead to better medication adherence in home-based diabetic patients?

The following table shows the characteristics of the variables involved.

Table 1

Characteristics of Variables

Project Methodology

A quantitative methodology is appropriate for use in this project because of the feasibility and clinical relevance associated with the practice improvement measurement. This will facilitate the discovery of the effectiveness of family-led strategies as compared to pharmaceutical-led strategies in medication adherence of diabetic patients in home-based care. It will get quantifiable and objective data related to the research question through the statistical analysis. This methodology was preferred rather than the qualitative methodology in this project because there will be a need to collect numeric data to assess the effectiveness of family-led strategies. The numerical data will be collected before and after the study. The results will then be compared and contrasted prior to making the necessary conclusions from the study. Qualitative data cannot be used to conduct this comparison. The quantitative methodology also allows for the numerical representation of the DPI findings so that specific and observable conclusions can be drawn. Descriptive statistics will be used to determine the relationship between the variables and to explain the differences in the two strategies and their impact (Queiros et al., 2017). Comment by Author: This will need editing as this is not research. There is still work to be done in this section re. clarifying exactly what variables you will quantitatively measure and how

The quantitative methodology aims to predict, control, or explain certain theories. To analyze data, this research methodology relies heavily on statistical analysis. According to Fain (2017), this research methodology focuses on objective measurements and analyzes the data collected through statistical, numerical, or mathematical analysis. It also uses computational techniques to manipulate preexisting statistical data. Usually, it is applied to test if or confirm whether certain theories and assumptions are true or false. According to Zaccagnini and Pechacek (2019), the two important foundational aspects of projects that use this research methodology are that they build on results and evidence from past research and that they usually form the basis for future research.

Project Design

This quality improvement project will use the quasi-experimental design as the principal evaluation method (Handley et al., 2018), while the design will assess how family-led strategies compare with pharmaceutical-led strategies in ensuring ensure medication adherence among patients with diabetes in home-based care programs. This approach will be used to determine if family-led strategies make a difference in medication adherence among diabetes patients in home-based care programs. Since this project aims to find out how the two interventions compare, measurement of numerical data will be necessary. An evaluation of the impact of each of the two strategies on medication adherence among diabetic patients in home-based care will also be conducted before and after the application of the strategy.

Family-led strategies among diabetic patients in home-based care have very notable differences with pharmaceutical-led strategies among patients in this care. The design of this project is a two-group pre- and post-intervention quasi-experiment design. The project design chosen for this project is a quantitative quasi-experimental design which will be used to assess the impact of family-led strategies on medication adherence among diabetic patients in home-based care programs. This research design is suitable for this project because the variables cannot be changed by the researcher (Handley et al., 2018).

Information on the gender and age of the patients identified for this project will be collected. A population of 50 diabetic patients has been identified for the project. The project research intends to use entire population as a sample diabetic patient in home-based care and the most valid and reliable instrument to be used in this project is questionnaires. Close- ended questionnaires will be utilized in this case. The project lead, in this case, is a comparison between the impact of family-led strategies and pharmaceutical-led strategies on medication adherence among diabetic patients in home-based care programs. Meanwhile, the pretest and posttest data that will be collected using questionnaires will be analyzed using the Statistical Package for the Social Sciences (SPSS) software.

An impact assessment of the strategies will be conducted before the implementation of the strategies and four weeks after the implementation of the strategies. This design will be applied to determine the relationship between the variables in the study. The project design chosen will facilitate the analysis of the comparison in the impact of family-led strategies and pharmaceutical-led strategies.

Population and Sample Selection

The population from which the sample to be used in this project is diabetic patients in home-based care programs in Texas. This sample is convenient because it includes participants who would be directly impacted by the interventions involved in this research. For this project, patients in home-based care who are interested in increasing their knowledge of medication adherence will be the participants. The population will comprise of diabetic patients aged 35 years and above. The population will comprise of patients who are not in a position of being admitted to hospitals. According to a Texas Medicaid and Texas Diabetes council report (2018), there were 8,700 inpatient hospital claims and 88,988 outpatient hospital claims made by diabetes patients in the year 2018. The figure that will be used as target population in this project is the 88,988 outpatient claims. The sample size will be determined using the Taro Yamane formula: Comment by Author: Do not use this number as your N. Your home health agency only sees a percentage of this number so use the volume of diabetic patients at your home health agency for this calculation

n=N/1+ N(e)2

Where:

n= sample size

N= target population (88,988)

e=error term in this case 10% (0.1)

Thus, sample size is determined to be 99.88 rounded off to 100 patients.

Before data is collected from patients, they will be asked to sign an informed consent form which will explain to them the purpose of the project and also assure them of their confidentiality should they choose to participate in the study. The informed consent form will be administered with care making sure that patients are not coerced or promised benefits for participation. Only patients who agree to participate and sign the informed consent form will be included in the project.

Instrumentation or Sources of Data

Data in this project will be collected through a pre-implementation and a post-implementation survey. Questionnaires and the MMAS-8 tool will be used in this project to gather information about the impact of the family-led strategy on medication adherence among diabetic patients in home-based care programs (Krosnick, 2018). Patients in home-based care programs will be given questionnaires to fill. There will also be questionnaires for family members offering direct support to these patients to fill. The questionnaires in this case will require ‘yes’ or ‘no’ responses. There will also be scaling questions in the questionnaire where participants will be required to assess certain information on a scale of 5 (1=strongly disagree, 2=slightly disagree, 3=neither agree nor disagree, 4=slightly agree, and 5=strongly agree). A questionnaire like this fit perfectly and it is the most effective for this project because it is easy to statistically analyze (Krosnick, 2018). The MMAS-8 questionnaire on the other hand will measure the medication adherence of patients and will be used in both pre and posts assessment.

The questionnaires will include two sections, the first section is where the socio-demographic information of the participants will be captured. This will include information on gender and race, while the other section will capture information about the impact of the respective intervention strategies on the medication adherence of the patients. It will involve getting data from the assessment, which will be compiled in a spreadsheet. The SPSS software will then be used to analyze the data so that conclusions can be drawn from it.

Validity Comment by Author: This section as well as the reliability section still needs some work. You will need to specifically discuss the validity and reliability of the evidence-based tool/instrument you are using. You can find this data in prior research done to validate the tool. Remember you can not make up your own instruments/questionnaires. You need to utilized evidence-based tools/questionnaires/instruments

The validity of the questionnaire will be established through the exploration of its social theoretical construction. The validity of closed-ended and scaling questionnaires has been confirmed through research. According to research, the test for the validity of these types of questionnaires would be a normal distribution curve. The research found the use of closed-ended and scaling questionnaires to be acceptable. According to research, these questionnaires are effective in linking existing knowledge to current findings. Questionnaires will be the only source of data in this research. Research on the validity of these types of questionnaires shows that existing theoretical, as well as empirical constructs, should be well represented in the questionnaires to increase their validity (Francis et al., 2017). For the standard questionnaire that uses Likert scale, Cronbach’s alpha will be used to determine the validity of the questionnaire items. The value of Cronbach’s alpha will be at 0.7 for the questions to be deemed valid. For the MMAS-8 questionnaire, factor analysis will be used to both asses the validity of the items as well as analyze the adherence levels of the patients.

Reliability

The reliability of this project, just like the validity of questionnaires impacts the research findings and consequently the conclusions drawn from the research to a great extent. Reliability is the extent to which a questionnaire produces similar results in different trials. Regarding the reliability of these types of questionnaires, reliability cannot be achieved unless the measurements are based on numerical values. Reliability is closely related to the objectivity of the research. Since this is quantitative research, the objectivity lies in the instrumentation used in the research. Research shows that there are several threats to the reliability of questionnaires in research. These include using unclear and complicated questions, the use of arbitrary and illogical codes, and giving unclear response options (Francis et al., 2017). To ensure that reliability of the standard questionnaire is met, the questionnaire will be given to a few experts in the diabetes management sector to determine if the questions are appropriate and if there are any internal inconsistencies in them. Their opinions will be incorporated into the final questionnaire. Use of the MMAS-8 questionnaire ensures reliability because it is a widely used and tested tool for collecting information on adherence.

Data Collection Procedures Comment by Author: Section still needs work. Remember this is basically a step by step recipe regarding how you will complete your project and collect your data. Use the words pre implementation and post implementation instead of pre test /post test. It is not clear exactly your intervention is and how it will be implemented so makes this section unclear

Informed consent will first be sought from the participants in this research. This will be after informing all the participants in detail what this project is all about. The participants will be provided with a letter explaining the purpose of the project and its benefit to them and the nursing profession. Participants will be notified how their data will be used and will be assured of confidentiality. Personal data regarding the patients and other participants will not be collected and their medication plans will not be affected.

The participants will be asked to complete a pretest and post-test survey which will be anonymous. Participants will be identified using numbers rather than names to protect anonymity. The pre-test will be conducted before the family-led health education strategy is introduced to patients. This will give baseline I formation on adherence. The post-test will be carried out after three months of constant reminders and follow up on the patients to evaluate of the intervention was successful. Post-test and pretest results will be identified in such a way that they correlate for easier and right analysis.

The data will be collected using a questionnaire that is already set by other stakeholders in the health sector so that the right information can be collected so that the research

Data Analysis Procedures

The data will be collected and analyzed using the SPSS software. Through descriptive statistics, the numeric and categorical variables in the questionnaires will be summarized. Comment by Author: How? On paper? Electronically?

Descriptive statistics will be used to describe the patient’s demographic information such as age, weight, gender, level of education and marital status. Central measures of tendency such as mean and standard deviation will be used to describe the population under study and also in the adherence-based questions. Comment by Author: Why do you need this information?

Common Factor analysis will be used to determine common factors amongst patients in regard to adherence and infer from the results which factors are common to all patients and which are least common. Comment by Author: Why do you need 3 different statistical tests for your data analysis? Try to determine what is the best way to analyze your data to answer your clinical question and pick a statistical test that best does that. You do not need more than one unless it is necessary

Logistic regression will also be used to determine the relationships existing between adherence and patients’ sociodemographic characteristics to determine how they interact or influence patient’s medication taking behaviors. Chi-square and Odds ratio will also be used to determine the effectiveness of the intervention in the post assessment phase of the project.

The analysis is important in quality improvement project will begin only after the nature and statuses of the patients and their caregivers are understandable. The SPSS software that will be used in this project will help to determine the relationship between the different variables in the research. It will establish the relationship between family-led strategies of intervention and medication adherence among diabetic patients in home-based care. It will also show how this compares to the impact of pharmaceutical-led strategies of intervention on medication adherence among diabetic patients in home-based care. This software will further be used to predict the possible application of the results drawn from this research. Comment by Author: This section still needs works as well to distinguish the project from research analysis

The data will be analyzed by comparing the results of the pretest and those of the post-test. The characteristic of this research design is to apply an intervention so that it can help to determine the relationship between two variables in the research. The quasi-experimental design that will be used in this project will help to analyze the impact of family-led strategies on medication adherence among diabetic patients in home-based care. It will also help to analyze how this impact compares to that of pharmaceutical-led therapies on medication adherence among diabetic patients.

Potential Bias and Mitigation

There exists a number of possible sources of bias throughout the project. However, the most important issues is formulating solution strategies on how the bias can be addressed. One potential source of bias is recall bias causes. This will emerge from the responses that the respondents will be required to provide. For instance, the diabetic patients will be required to respond to self-report survey based on the medication adherence. In such situations, the researchers normally rely on the information that has been issues out by the respondents, and majorly their memory. Based on the patients’ memory, the information might or might not be accurate, but the investigator will have to rely on it. Two mitigation strategies to recall bias are empathy and acknowledgement. The investigators should empathize with patients, assume their situations and circumstances, and try digging deeper to get an understanding possible causes why the information given out might be true or untrue. Acknowledging that there are possibilities of the problem to exists is important in a number of ways. This will help suppress the bias that might be available in respondents. Comment by Author: Great job as recall bias is pretty evident in self report surveys/tools. However the writing needs work and you need citations for your assertions

Ethical Considerations

An authorization letter has been obtained from the project site (appendix …). The project has also been submitted to the project site IRB exemption ( Appendix…..). The project will need to be submitted to GCU IRB for review. This project will get approval from the university. The participants will be informed on all aspects of the project including how the data will be collected, analyzed, and used. They will also be informed about the importance of this project to them and the nursing field in general. Written informed consent will then be sort from all the participants in this research. This quality improvement project will to the latter the principles and standards of ethical research (Fiesler, 2019). Comment by Author: This section still needs editing for the writing

The participants will answer the questionnaire questions anonymously and they will be assigned numbers will be used to identify participants to further protect anonymity. Also, the questionnaires will be handled with great care to ensure privacy. Data collected for the project will be kept on a password protected computer only accessible to the DPI investigator. The computers that will be used to compile and analyze data in this project will be secured with strong passwords to protect data. Aggregate dData will only be shared among people who are directly affected by the project. Personal information about the participants will not be collected in this research. The participants will be informed of the results of this project via the contact information they would have been provided in the questionnaires. After completion of the project, the questionnaires containing participant information will be disposed of safely (Fiesler, 2019). Comment by Author: Which people? Comment by Author: But previously you said you would collect some information regarding education status etc?

Limitations

The quantitative quasi-experimental approach that was chosen for this project is the best in determining the relationship between variables in this research and showing how the two main interventions compare. However, there are several limitations to this project. One of them is that the time frame set for this project may not be enough to show the impact of an intervention. Four weeks is a relatively short time to determine whether an intervention has had any impact or not. The second limitation is that the sample size set for this research project is also relatively small. This will make it difficult to generalize the results of this project. The fact that only diabetic patients will be participating in this quality improvement project also makes it difficult to establish whether family-led strategies can be effective among other patients with chronic illnesses and those who are in home-based care. The method of data collection chosen for this research could also be a limitation. Participants can give wrong information in their questionnaires which will affect the overall results of the study. Comment by Author: Great start, you need some citation to support your assertions

Summary

Medication adherence among patients with diabetes remains a crucial determiner of their well-being. The purpose of this project is to determine to what extent the implementation of family-led strategies would impact medication adherence when compared to pharmaceutical-led strategies among diabetic patients’ in-home care settings in Texas over four weeks. The problem that aims to be solved in this research is to bridge the gap in knowledge about the impact of family-led strategies on medical adherence among diabetic patients in home-based care programs as compared to pharmaceutical-led strategies. Moreover, the methodology that has been selected for this project is the quantitative methodology (Fain, 2020). A quasi-experimental design will be used in this quality improvement project. The design will facilitate the identification of the relationship between the variables in the research. Questionnaires will be used as the only method of data collection in this research. The validity and reliability of questionnaires for data collection in this research has already been established.

The pretest-posttest approach will be used to collect data in this research. Data will be collected before the application of the intervention and after. An analysis of the two sets of data will be used to determine the impact of the independent variables of this research on the dependent variable. The data gathered will be compiled in excel spreadsheets. The SPSS software will be used to analyze data in this research. This software will ensure that the dependent variables in the research are not manipulated.

To ensure that ethical research is conducted, this project will follow to the latter the principles and standards of ethical research. It will also ensure that written informed consent is sought from the participants prior to beginning the research. The anonymity of the participants and the privacy of data will be upheld at all costs. Among the limitations of this project is the small number of participants used in the research. The short duration of the project and the use of questionnaires as the only method of data collection are also limitations in the study. In chapter four, this project will present the data analysis and results. The chapter will also discuss the findings and results. Chapter five of this project will conclude the project and give directions for future use.

References

Bonney, W. (2016). Mobile health technologies – theories and applications. Rijeka: InTech. Retrieved from https://www.worldcat.org/title/mobile-health-technologies-theories-and-applications/oclc/965915046

Bosworth, H. B. (2015). Enhancing medication adherence: The public health dilemma. London: Springer Healthcare. Retrieved from https://www.worldcat.org/title/enhancing-medication-adherence-the-public-health-dilemma/oclc/1005831498

European Medical & Biological Engineering Conference, In Eskola, H., In Väisänen, O., In Viik, J., In Hyttinen, J., & Nordic-Baltic Conference on Biomedical Engineering and Medical Physics. (2018). EMBEC & NBC 2017: Joint Conference of the European Medical and Biological Engineering Conference (EMBEC) and the Nordic-Baltic Conference on Biomedical Engineering and Medical Physics (NBC), Tampere, Finland, June 2017. Retrieved from https://www.worldcat.org/title/embec-nbc-2017-joint-conference-of-the-european-medical-and-biological-engineering-conference-embec-and-the-nordic-baltic-conference-on-biomedical-engineering-and-medical-physics-nbc-tampere-finland-june-2017/oclc/1005134274

HADLER, A. N. D. R. E. W. S. U. T. T. O. N. S. T. E. P. H. E. N. O. S. T. E. R. B. E. R. G. L. A. R. S. (2020). WILEY BLACKWELL HANDBOOK OF TREATMENT ENGAGEMENT: Theory, research, and clinical practice. Place of publication not identified: WILEY-BLACKWELL. Retrieved from https://www.worldcat.org/title/wiley-blackwell-handbook-of-treatment-engagement-theory-research-and-clinical-practice/oclc/1130650913

In Balogh, E., In Miller, B. T., In Ball, J., & Institute of Medicine (U.S.). (2015). Improving diagnosis in health care. Retrieved from https://www.worldcat.org/title/improving-diagnosis-in-health-care/oclc/1001623571

In Forman, S. G., & In Shahidullah, J. (2018). Handbook of pediatric behavioral healthcare: An interdisciplinary collaborative approach. Retrieved from https://www.worldcat.org/title/handbook-of-pediatric-behavioral-healthcare-an-interdisciplinary-collaborative-approach/oclc/1062418920

In Corcoran, K., & In Roberts, A. R. (2015). Social workers’ desk reference. Retrieved from https://www.worldcat.org/title/social-workers-desk-reference/oclc/1030982838

In Costa, F. G., In Mil, J. W. F., & In Alvarez-Risco, A. (2018). The pharmacist guide to implementing pharmaceutical care. Retrieved from https://www.worldcat.org/title/pharmacist-guide-to-implementing-pharmaceutical-care/oclc/1053888074

In D’Onofrio, G., In Greco, A., & In Sancarlo, D. (2018). Gerontology. Retrieved from https://www.worldcat.org/title/gerontology/oclc/1084323462

In Heston, T. (2018). Ehealth: Making health care smarter. Retrieved from https://www.worldcat.org/title/ehealth-making-health-care-smarter/oclc/1099336057

In Hunter, J., & In Maunder, R. (2016). Improving patient treatment with attachment theory: A guide for primary care practitioners and specialists. Retrieved from https://www.worldcat.org/title/improving-patient-treatment-with-attachment-theory-a-guide-for-primary-care-practitioners-and-specialists/oclc/1005792343

In Mahmoud, S. H. (2019). Patient assessment in clinical pharmacy: A comprehensive guide. Retrieved from https://www.worldcat.org/title/patient-assessment-in-clinical-pharmacy-a-comprehensive-guide/oclc/1091029018

In Rodríguez, S. J. (2019). The diabetes textbook: Clinical principles, patient management and public health issues. Retrieved from https://www.worldcat.org/title/diabetes-textbook-clinical-principles-patient-management-and-public-health-issues/oclc/1106168761

In Sherman, S., In Hansen-Turton, T., In King, E. S., & Bednash, G. (2015). Nurse-led health clinics: Operations, policy, and opportunities. Retrieved from https://www.worldcat.org/title/nurse-led-health-clinics-operations-policy-and-opportunities/oclc/1034939410

Institute of Medicine (U.S.). (2016). A framework for educating health professionals to address the social determinants of health. Washington, DC: The National Academies Press. Retrieved fromhttps://www.worldcat.org/title/framework-for-educating-health-professionals-to-address-the-social-determinants-of-health/oclc/1021273933

Glanz, K., Rimer, B. K., & Viswanath, K. (2015). Health behavior: Theory, research, and practice. Retrieved from https://www.worldcat.org/title/health-behavior-theory-research-and-practice/oclc/1085343214

Liu, M., & Butler, L. M. (2017). Patient communication for pharmacy: A case-study approach on theory and practice. Retrieved from https://www.worldcat.org/title/patient-communication-for-pharmacy-a-case-study-approach-on-theory-and-practice/oclc/1017661990

Major Topics in Type 1 Diabetes. (2020). Place of publication not identified: InTech. Retrieved from https://www.worldcat.org/title/major-topics-in-type-1-diabetes/oclc/1096930284

Mollaoglu, M. (2018). Caregiving and home care. Rijeka: InTech. Retrieved from https://www.worldcat.org/title/caregiving-and-home-care/oclc/1039625354

National Academies of Sciences, Engineering, and Medicine (U.S.). (2018). Health-care utilization as a proxy in disability determination. Retrieved from https://www.worldcat.org/title/health-care-utilization-as-a-proxy-in-disability-determination/oclc/1030971027

Stanislaw, P. S., & Michael, S. F. (2017). Vignettes in Patient Safety – Volume 1. Retrieved from https://www.worldcat.org/title/vignettes-in-patient-safety-volume-1/oclc/1193045081

Steinberg, M. P., & Miller, W. R. (2015). Motivational interviewing in diabetes care. Retrieved from https://www.worldcat.org/title/motivational-interviewing-in-diabetes-care/oclc/1167659294

Choi, D., Choi, H., & Shon, D. (2019). Future changes to smart home based on AAL healthcare service. Journal of Asian Architecture and Building Engineering, 18(3), 190-199.

Creswell, J. W., & Creswell, J. D. (2017). Research design: Qualitative, quantitative, and mixed methods approaches. Sage publications.

Medina, M., Babiuch, C., Card, M., Gavrilescu, R., Zafirau, W., Boose, E., … & Boissy, A. (2020). Home monitoring for COVID-19. Cleveland Clinic journal of medicine.

Parker, M. L., Yip, P. M., DeCherrie, L. V., Escobar, C., Füzéry, A. K., Price, C. P., & St John, A. (2018). There’s No place like home: exploring home-based, acute-level healthcare. Clinical chemistry, 64(8), 1136-1142.

Ahmed, I., Ahmad, N. S., Ali, S., Ali, S., George, A., Danish, H. S., … & Cox, B. (2018). Medication adherence apps: review and content analysis. JMIR mHealth and uHealth, 6(3), e62. Retrieved from https://mhealth.jmir.org/2018/3/e62/

Brown, M., & Bussell, J. (2018). Medication Adherence: WHO Cares? Mayo Clinic Proceedings, 86(4), 304-314. Retrieved from https://doi.org/10.4065/mcp.2010.0575

Fain, J. A. (2020). Reading, understanding, and applying nursing research. FA Davis. Retrieved from https://books.google.com/books?hl=en&lr=&id=-Y__DwAAQBAJ&oi=fnd&pg=PT8&dq=Fain,+J.+A.+(2017).+Reading,+understanding,+and+applying+nursing+research.+FA+Davis.&ots=JHcH0p64cR&sig=3Rd1qARsV5AERkZ7TcrYTC9aFWA

Fiesler, C. (2019). Ethical Considerations for Research Involving (Speculative) Public Data. Proceedings of the ACM on Human-Computer Interaction, 3(GROUP), 1-13. Retrieved from https://dl.acm.org/doi/abs/10.1145/3370271

Francis, H. M., Osborne-Crowley, K., & McDonald, S. (2017). Validity and reliability of a questionnaire to assess social skills in traumatic brain injury: a preliminary study. Brain injury, 31(3), 336-343. Retrieved from https://www.tandfonline.com/doi/abs/10.1080/02699052.2016.1250954

Handley, M. A., Lyles, C. R., McCulloch, C., & Cattamanchi, A. (2018). Selecting and improving quasi-experimental designs in effectiveness and implementation research. Annual Review of Public Health, 39, 5-25. Retrieved from https://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-040617-014128

Krosnick, J. A. (2018). Questionnaire design. In the Palgrave handbook of survey research (pp. 439-455). Palgrave Macmillan, Cham. Retrieved from https://link.springer.com/chapter/10.1007/978-3-319-54395-6_53

Norman, G. J., Orton, K., Wade, A., Morris, A. M., & Slaboda, J. C. (2018). Operation and challenges of home-based medical practices in the US: findings from six aggregated case studies. BMC health services research, 18(1), 45. Retrieved from https://link.springer.com/article/10.1186/s12913-018-2855-x

Queirós, A., Faria, D., & Almeida, F. (2017). Strengths and limitations of qualitative and quantitative research methods. European Journal of Education Studies. Retrieved from http://oapub.org/edu/index.php/ejes/article/view/1017

Voortman, T., Kiefte-de Jong, J., Ikram, M., Stricker, B., van Rooij, F., & Lahousse, L. et al. (2017). Adherence to the 2015 Dutch dietary guidelines and risk of non-communicable diseases and mortality in the Rotterdam Study. European Journal of Epidemiology, 32(11), 993-1005. Retrieved from https://doi.org/10.1007/s10654-017-0295-2

Wolff-Baker, D., & Ordona, R. B. (2019). The expanding role of nurse practitioners in home-based primary care: Opportunities and challenges. Journal of gerontological nursing, 45(6), 9-14. Retrieved from https://www.healio.com/nursing/journals/jgn/2019-6-45-6/%7Ba5e68fe2-1e03-4962-af70-9dfea6d85e1e%7D/the-expanding-role-of-nurse-practitioners-in-home-based-primary-care-opportunities-and-challenges?fat=MJ9ZQQM69Y

Zaccagnini, M., & Pechacek, J. M. (2019). The Doctor of Nursing practice essentials: A new model for advanced practice nursing. Jones & Bartlett Learning. Retrieved from https://books.google.com/books?hl=en&lr=&id=_8enDwAAQBAJ&oi=fnd&pg=PP1&dq=The+doctor+of+nursing+practice+essentials:+A+new+model+for+advanced+practice+nursing.+Jones+%26+Bartlett+Learning.&ots=6bg8wXlxK2&sig=f2n-0wUQIg8KV9K0xcvuzZwxleg

Appendix A

10 Strategic Points Table