Measuring the Impact of Nurse Practitioners on the outcomes of Care for Diabetic Patients in Primary Care

This research proposal aims to measure the impact of nurse practitioners on the outcomes of care for diabetic patients in primary care settings. It explores the role of nurse practitioners in managing diabetes and improving patient outcomes.

Running head: Proposal
Measuring the Impact of Nurse Practitioners on the outcomes of Care for Diabetic Patients in
Primary Care.

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Table of Contents
Introduction:....................................................................................................................................2
Background:.....................................................................................................................................2
Statement of the problem:................................................................................................................4
Hypothesis:......................................................................................................................................6
Research rationale:...........................................................................................................................7
Research question:...........................................................................................................................7
Aim and objectives:.........................................................................................................................8
Summary:.........................................................................................................................................8

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Introduction:
Diabetes is a worldwide epidemic with an alarming increase in diagnosis of the condition
in various countries. The global burden of diabetes is increasing with an estimated 1.6 million
deaths caused by diabetes in 2016.As the number of people diagnosed with diabetes has
increased with time, it is estimated that by 2045, prevalence rate of diabetes is likely to reach 693
people (World Health Organization 2018). This would mean large of patient visit for diabetes
related problem and huge pressure on the primary care setting. Primary care setting is the first
point of care for community people diagnosed with diabetes or at risk of diabetes. Shrivastav et
al. (2018) revealed increasing demand for the primary care professionals as they deliver clinical
care to 90% of individuals with diabetes. Hence, as the diabetes population increasing,
evaluating the contribution and role of nurse practitioners in successfully managing patients in
primary care is necessary. This would help to improve the provision of integrated care and
reduce the problem of general practitioners (GP) shortage in primary care. As recent evidences
shows that potential of nurse led clinics in primary care, conducting research to measure the
impact of nurse practitioners on influencing diabetes related outcome in primary care is
necessary. The main purpose of this research is to examine the impact of nurse practitioners (NP)
on quality and outcomes of diabetes care in community.
Background:
Diabetes is a type of disease condition that is associated with range of complications that
endanger health and survival of people and significantly increases the risk of medical
expenditure due to high health care cost. It is a major cause of mortality and disability globally
(Krug, 2016). Some of the major issues for people living with diabetes is they lack access to

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necessary medication or information. Other issues present in primary care that influence health
outcome of people living with diabetes is that large number of individuals receive their primary
care from non-physician clinician due to decrease in number of primary care physician and rural-
urban disparity in physician distribution (Kuo et al. 2015). Primary care physicians play a major
role in meeting psychosocial, medical and educational needs of people with diabetes. However,
they fail to achieve optimal glycemic level in diabetic patient because of high patient load,
patient diversity, language differences and failure to initiate therapy. However, Richardson et al.
(2014) gave the evidence that NPs can improve clinical outcomes of diabetes patient in primary
care practice as they have the skills to initiate, change and adjust medications. Hence, their
involvement in primary care setting can be vital to improve the quality of care and glycemic
target of patient.
As Richardson et al. (2014) revealed the potential of NPs in providing appropriate care to
diabetic patient, using robust design to measure the impact of NPs in improving HbA1c level,
BP, cholesterol level can help to rationalize the need for recruitment of more number of NPs in
primary care. This research will also favour adaptation of new models of care. Current researcher
regard for nurse-led model of care as an appropriate method for effective management of
diabetes . Clinical trials done in 2006 have revealed nurse can provide high quality primary care
compared to that of primary care medical staffs (Murrells et al. 2015). However, this finding
cannot be directly used to increase nurse’s involvement in primary care for diabetes as this has
not been done in diverse setting. As there is lack of evidence regarding the nurses contribution in
influence quality of diabetes care in a routine basis, using strong research design to rationalize
the need for substituting GPs with primary care nurse in primary care setting is necessary. The
significance of research on this topic is also understood from the fact currently there is growing

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interest in using nurse to expand the capacity of primary care workforce. This interest is seen
because of current problem likes ageing and prevalence of chronic disease which is increasing
the demand of primary care services (Laurant et al., 2018).
The need for nurse to assume greater role in diabetes management in clinical care is
necessary because of global shortage of health care workforce in relation to patient population.
Physician shortage is common problem in primary care because of disparities in availability of
GP in rural and urban areas, changes in the working culture and trends in retirement. Martínez-
González et al. (2015) argues that finding newer solutions such as granting full practice and
greater role to nurse to overcome work shortage. One of the advantages of involving nurses in
primary care is they are the largest group of qualified and competent health care professionals
and they are less expensive compared to physicians. Hence, this research will be critical in
providing valid evidence regarding the impact of nurse in promoting control of glycemic, BP and
cholesterol level. Evaluation of NP’s action in the achievement of this outcome will increase
interest of policy makers and health care managers in substituting physician and integrating
nurses in the primary care. The research can also help to understand how nurse can be effectively
integrated in primary care setting to improve health and quality of care for people with diabetes.
Statement of the problem:
The rationale for research in this area is understood from several problem present in the
health care setting currently. Current challenges in primary care setting are the high demand of
diabetes patients in primary care and lack of equal access to care for people living with diabetes.
Primary is a vital setting for newly diagnosed diabetes patients and patients at risk of diabetes to
receive care and support for management of the condition. Primary health care professionals play

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a major role in screening, providing lifetime advice and improving their health behaviour.
However, the quality of care for people with diabetes is seriously affected because of several
disparities in primary care management of diabetes. Buja et al. (2014) gives the insight that with
the increase in ageing population, the demand for care is rising because of the prevalence of
chronic disease like diabetes. In such situation, the role of the primary care team is to effectively
organize and coordinate patient care. However, this does not occur because of disparities in the
availability of GPs in primary care. Norful et al. (2017) suggest that physician shortage is a
critical issue in primary care as it increases strain on the health care system. Hence, investigation
about the impact of nurse on diabetes management is critical to shift from traditional model of
care and adapt new model of care to overcome challenges in disease management.
As per the traditional model of care, single physician is involved in the management of
patients with diabetes. They are assigned to provide care to a sub-group of population in the
community. However, the ratio of GPs may not be accurate in all setting to handle huge influx of
patients with diabetes related issues. Hence, to alleviate this burden present in primary care,
researching on nurse’s competency in diabetes management is critical facilitate acceptance of
nurse-led model of care in primary care setting. As NPs are capable of delivering high quality
care, getting validated data related to their influence of diabetes patient’s outcome would help to
alleviate challenges in care delivery (Norful et al., 2017). Although physicians provide care to
diabetes patients in large numbers, individual NPs are likely to achieve same clinical outcome
for diabetes patient compared to GPs. As the rate of NPs is expanding in developed countries,
using strong research design to evaluate NPs competency in diabetes management would
facilitate achieve optimal health outcomes for patient with diabetes.

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Reviewing skills of NPs is also necessary because of evidence of inconsistent practice
related to diagnosis, management and care uptake for diabetes. Jingi,, Nansseu and Noubiap
(2015) reports that primary care physicians are at the forefront of diabetes. Hence, they should
be highly competent in providing high quality care and preventing complications in diabetes
patient. However, the inconsistencies in care outcomes have been found due to overwhelming
patient load and limited consultation time. The investigation regarding the evaluation of
physician’s work in providing diabetes care revealed they do not spent adequate time with
patient during consultation because of great volume of work. To resolve this issue, involving
nurse in primary care is necessary so that workforce shortage issue can be addressed and NPs can
use their skills to appropriately support patients to reach their treatment goals and lead a high
quality of life.

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Hypothesis:
The research hypothesis is that nurses can promote control of glycemic, BP and
cholesterol level in patients with diabetes coming to seek care in primary care setting. This
hypothesis has been made because NPs have required qualification and knowledge to understand
the etiology of diabetes and implement relevant methods to plan effective care plan for patient.
Bartol (2012) gives the evidence that NP are effective in improving clinical parameters of
diabetes patient because they are expert in diagnosing and prescribing treatment. They have the
skills to administer treatment, teach self-management to patient and maintain close
communication between visits.
Research rationale:
There are many rationale behind conducting research on the topic ‘impact of NPs on
outcome of care for patient with diabetes’. Firstly, evidence regarding barriers faced in diabetes
care delivery in primary care setting such as shortage of GP, poor consultation time, heavy
workflow and inconsistent practices suggest the need for involvement of NPs in management of
diabetes patients (Jingi,, Nansseu and Noubiap 2015). Secondly, several controversies
surrounding the need to shift from traditional care model to nurse-led care model and substituting
nurse with that of GPs to reduce to the strain on the primary care system makes research on this
topic necessary (Azami et al., 2018). The main rationale behind using NPs as a health care
professional group to influence health outcome of diabetes patient is that they have the required
clinical skills to maintain optimal health of patients and they can address the shortage of
workforce in primary care setting as they are available in large numbers. Hence, to reduce the

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burden of primary and improve cost effectiveness during care delivery, investigating impact of
NPs in achieving glycemic, Bp and cholesterol level control for patient is necessary.
Research question:
The Research question for the topic is that:
What is the impact of nurse practitioners on outcomes of care for patients with diabetes in
primary care center?
In this question, the research population is diabetes patients in primary care centre, the
outcome are diabetes related outcome of patient (glycemic, Bp and cholesterol level control) and
intervention includes impact of nurse practitioners.
Aim and objectives:
The aim of the research study is to measure the impact of nurse practitioners on care
outcomes (glycemic, Bp and cholesterol level control) of patients with diabetes in primary care
setting. The key objectives of the proposal are as follows:
 To measure the outcome achieved by nurse practitioners while delivering care to diabetes
patients in primary care such as (glycemic, Bp and cholesterol level control).
 To evaluate the impact of nurse in promoting health of diabetes patient in primary care
and improving their self-management skills
 To recommend the steps needed to completely integrate nurses in primary care setting.

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Summary:
To conclude, the research proposal gave an insight into the prevalence of diabetes and the
burden of health care system due to increase in diagnosis of diabetes. This research proposal
aims to investigate about the role of NPs in influencing care quality and outcome of patient with
diabetes. The paper provides an overview about the background information related to the task,
the problem related to the research topic and the rationale for conducting research in this area.
The research question and key objectives gives direction regarding the intended outcome of this
research.
Part 2: Literature review
Introduction:
This section will provide an insight into the review of research literature on the topic and
provide a critical summary of current findings in relation to the role of a nurse practitioner in
influencing care of diabetes patient. The gaps in past work and limitations in research
methodology will provide a guide to understand the best approach or methodology that needs to
be chosen to measure the impact of NP in influencing care outcome for diabetes patients in
primary care setting. The literature review starts with a discussion on the search strategy used to
search for research papers, the key databases used and the final list of papers obtained after the
search process. The section also provides summary of research findings with discussion on gaps
and implications of the finding for current research and for management of diabetes in primary
care setting.
Search strategy:

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To search for relevant research literature on the topic, the databases that were used
includes CINAHL and PubMed database. The key reason for choosing this database for literature
review is that CINAHL is an effective research tool for nursing and allied health professionals as
it provides broad content coverage from nursing specialties, general health medicine and
pathology. On the other hand, PubMed provides access to millions of articles for biomedical
literature like MEDLINE, life science journals and online books. Hence, these databases
increased the likelihood of getting peer reviewed, high quality research papers that extends
current knowledge regarding what current research says about the skills and roles of NP in
influence outcome of diabetes patients.
The key search terms that was used for literature search includes ‘nurse practitioner’,
‘diabetes care’, ‘diabetes outcome’, ‘nursing practitioner skills in diabetes management’ and
‘role of NP in diabetes care’. These were the primary search terms or key terms for literature
search. The search was also refined by the combining it with Boolean operators like ‘AND’ and
‘OR’. For example, the key words were combined in the following ways to get more relevant
research papers related to the topic:
 Nurse practitioner AND diabetes management
 Nurse practitioner AND outcome of diabetes patient
 Nurse practitioner AND diabetes care in primary setting
 Nurse practitioner role AND diabetes outcome
Inclusion and exclusion criteria:
The inclusion criteria and exclusion criteria for the selection of research papers were as
follows:

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 Publication date: Only those papers were included in the literature reviews which were
published within 5 years (2015-2019). Those published before 2015 was excluded.
 Type of resource: As the main purpose was to find out the role of NP in providing
holistic care to diabetes patients, all types of research papers including primary research
papers and literature review were included.
 Language: Only those research papers were taken which were published in English
language
 Research population: The main research sample or population for each study must be NP
and diabetes patients as the research topic centres around the contribution of NP in
influencing care outcome of diabetes patient.
 Research outcome: All the included research papers must give an insight into the skills of
NP in influencing health outcome of diabetes patient.
Search summary:
Based on search for papers in selected database, a total of 80 articles were found relevant
to the topic. After identification of the papers, the number of papers obtained for screening was
obtained after looking for duplicates paper or papers with similar authors. Based on this criteria,
12 duplicates papers were removed and 68 articles were screened based on inclusion and
exclusion criteria. Based on this criterion, 40 records were excluded as they did not fulfill all the
inclusion criteria. The remaining 28 articles were assessed finally by reviewing the full-text
articles. Based on this process, the final papers included for review included 6 papers and the rest
20 were excluded as the full paper revealed lack of focus on diabetes management or focus on
other disease management.
Literature review:

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The review of the 6 papers gave a significant insight into the skills and potential of nurse
practitioners in promoting health and positive health outcome of diabetes patient. The
retrospective cohort study by Kuo et al. (2015) gave an insight into the processes and cost of care
for diabetes patient when cared by nurse practitioner versus primary care physician (PCP). The
sample population with diabetes were taken from a national sample of Medicare beneficiaries
who received care from either a NP or PCP. The key outcomes that were measured included eyes
examination, LDL-C screening, HbA1c test and frequency of provider visits. The statistical
analysis of the processes of care between diabetes patients cared for by NPs and PCPs revealed
participants in the NP group were less likely to have an eye examination or HbA1C test.
Participants in this group also had lower adherence to medication compared to PCPS. The
findings leaves behind some gaps as the results are not consistent with other research papers. For
example, research study by Condosta (2012) revealed that NPs order more number of HbA1 test
than PCPs. However, some positive findings that were obtained for care delivered by NPs was
that diabetes patients cared for by PCPs were more likely to be referred to cardiologist,
endocrinologist and nephrologist. The high consultation rates with NPs were also consistent with
past research too.
Although the study by Kuo et al. (2015) is relevant to the research topic as it explores the
role of NPs in providing care to patients with diabetes, however one gap found in this paper is
that focus more on processes of providing care than comparing the outcomes obtained for
diabetes patients. Hence, instead of focusing on number of eye testing or HbA1c test done, the
main focus should have been to explore improvement in HbA1c level for diabetes patient. This
would have helped to understand the impact of NPs in influencing outcome of diabetes patient.
Another limitation of the research by Kuo et al. (2015) is that selection bias may have influenced

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the rate of eye testing and HbA1c test. There was no heterogeneity in the study population too as
those patients were taken who were taking diabetes medication. This findings gives the
implication to conduct longitudinal study to understand how care delivery by NPs lead to
improvement in diabetes related outcome.
The research study by Jutterström et al. (2016) is significant as it focuses on evaluation
of diabetes patient outcomes instead of the process of care delivery. The main aim of the
research was to evaluate the impact of self-management support led by nurse in improving HbA1
level in patients with type 2 diabetes. As fluctuation in metabolic level is a major challenge for
diabetes patient, investigating the potential of nurse in improvising this outcome is significant.
The study was done using randomized controlled study method and three groups included in the
study included the group intervention, the individual intervention or the internal control group.
The patienst were randomized to any of the three groups listed by random numbers. The key
intervention that the nurse provided included initial workshop focussing on patient’s
understanding of illness followed by role plays in which one nurse led the session and other
acted as patients. The lesson focussed on improving self-efficacy of self-management. Total six
sessions were provided for 45-90 minutes and the themes varied for each session. The primary
outcome measured after 12 months follow-up included participant’s HbA1c level.
The statistical analysis of the results obtained by Jutterström et al. (2016) revealed
significant improvement in HbA1c level for group intervention group compared to individual
intervention. For control group, the HbA1c level was close to baseline. The overall conclusion
was that nurse-led self-management group was effecting in influencing outcomes both for group
intervention and individual intervention. The main reason cited for this positive outcome was
integration of illness resulting in enhanced self-management. Collins and Rochfort (2016)

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argues that skills like patient centred care, quality improvement and collaboration is necessary to
better manage chronic illness. However, compared to the key objectives for this literature review,
the gap that was found in this research is that the research was not done in a primary care setting.
Secondly, it was a single centre study that limited generalizability of the research findings.
Furthermore, the main intervention in this study was only self-management support. However, in
primary care setting, nurse may have broader role such as assessing risk, medicine management
as well as self-management education. Hence, all these factors were not explored, this papers
gives idea regarding the elements that can be included while planning new research on topic.
Despite this limitation, the study gives positive insight into the role of nurse in supporting
patients with diabetes in primary care.
The study by Murrells et al. (2015) used retrospective observational research design to
examine whether consultation provided by nurse can improve HbA1c level for diabetes patient
or not. The data for patients were derived from electronic health record and workforce input was
measured by the consultation process. This involved direct contact with patient either through
home visit or telephonic conversation and measurement of percentage of consultation involving
nurse and total time spent in consultation annually. The main outcome measure for this study
was achievement of glycaemic control. The retrospective analysis of research data revealed that
nurses were successful in increasing their activity compared to HP. The data was examined from
the period between 2002 and 2011 and the important result was increase in diabetic review
undertaken by nurse. This was also associated with significant increase in glycaemic control.
Despite this result, the applicability of this research outcome is limited by the fact it is
restrospective analysis and limited to general practice of UK only. Hence, results from this study
cannot confirm the same process and outcome for diabetes management in primary care setting

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led by nurse. This limitation suggest the need to conduct research in local settings and consider
the capacity of primary care setting in recruiting more number of nurses and improving care
outcomes of diabetes patient. The result has implications for improvement in nursing workforce
required in general setting. However, it does directly define the contribution of nurse in
influencing diabetes care outcome.
Although the multi-disciplinary team plays a vital role in influencing diabetes care, this
research focus on examination contribution of nurse in diabetes outcome due to barriers in
provision of care delivered by primary care staffs. The review of past studies suggests many
favourable outcomes for patient when care is delivered by nurses. For this reason, there is a
strong argument to shift physician with nurse in primary care setting to provide diabetes care.
One of the research paper that strongly advocates for the integration of nurse specialist in
diabetes care is the research by Riordan et al. (2017). Cross-sectional survey based research
design was used to examine survey diabetes nurse specialist (DNS) regarding the clinical role,
multidisciplinary working and barriers and facilitators to service delivery. The survey was done
with 25 DNS out of which six were advanced nurse practitioners, two clinical nurse managers
and two with qualification in performing the role of DNS. The survey response regarding role
indicated that aspects of patient management and role for each nurse differed by setting and
majority of them liased with other professionals while providing care. They revealed that service
delivery was enhanced by multi-professional collaboration and barriers to integration includes in
appropriate referral. This paper is significant in developing understanding regarding the
preparedness of hospital in integrating nurse in diabetes care. However, no outcome related to
diabetes care has been outline, it leaves behind many gap in findings. It gives evidence regarding
the benefits of integrated care model in influencing care outcome of diabetes patient (Seidu et al.

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2017). However, it does not show whether nurse can achieve glycaemic control for patients or
not.
Apart from retrospective observation and cohort studies, two systematic review papers
were also obtained that revealed about the skills of nurse in influencing outcome of diabetes
patient. Tabesh et al. (2018) investigated about the impact on nurse prescribers on glycaemic
control in type 2 diabetes. The significance of this research is that it is based on the opinion that
nurse needs to take broader roles in diabetes management such as with skills in prescribing and
providing education to patient (Hirschman et al., 2015). With the possibility to advance nursing
role, the study aimed to evaluate the effect of nurse prescribers on diabetes patient outcome. The
systematic review of research papers revealed diverse findings for each paper as nurses followed
different algorithm or protocols for prescribing medications. Although the study did not provide
string evidence regarding the role of nurse prescriber in achieving glycemic control for patient, it
reveals possibility of equal outcome for nurse when compared with physician prescriber role.
The significance of this research paper is that enlightens the scope of adapting nurse-model of
care and shifting from traditional model of care to improve management for diabetes patients.
Hence, this research can be further utilized to address the gaps in its research design and use
robust methods to explore whether nurse led clinical are feasible for influencing quality of care
and outcomes of patient with diabetes or not.
Another meta-analysis by Daly, Tian and Scragg (2017) investigated about the effect of
nurse-led randomized controlled trials in cardiovascular risk factors and HbA1c in diabetes
patient. It revealed all RCT trials were nurse led intervention was compared with usual care for
diabetes patient. The meta-analysis revealed small improvement in HbA1c level and serum
triglyceride levels. Many patients reduced the rate of smoking too. The reduction in blood

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pressure was also significant. However, no reduction in body mass index or serum cholesterol
was seen. Hence, this study gives a positive indication that nurses can play an independent role
in diabetes management. However, as the improvement achieved was very small, there is a need
to modify process by which nurses are recruited to provide primary care to patient. These
changes in the roles allocated to them might help to achieve favourable outcomes for patient.
Theoretical framework:
The research will be guided by a research framework. The framework that is found most
relevant to the research question and the study objectives includes the Donebedian model as it is
a conceptual framework that favours critical evaluation of health services using the three
categories of structure, process and outcomes. As the main purpose is to measure quality of care
delivered by nurse, use of this theoretical framework will support proper examination of all
factors that influence management of care for diabetes patient (Voyce et al., 2015)
Conclusion:
To conclude, the literature review revealed several advantages of nurse participation in
diabetes care. Overall, the study gives positive evidence regarding the integration of nurse in
primary care for diabetes management. However, limitation in research design such as use of
retrospective research method, lack of analysis of all diabetes related outcome such as HbA1c
level, pressure and cholesterol for diabetes patient and single centre study suggested conducting
research with modified methodology. This findings and gaps obtained will be utilized to plan
research methodology for this research proposal and include all those measures that give full
answer to the research question.
Part 3: Methodology

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Introduction:
Research methodology in a research process defines the specific procedure adapted to
identify, collect and analyse information about a research topic within a specific setting. This
section will define the research methodology that will be adapted to measure the impact of nurse
practitioner in influence quality of care and health outcome for diabetes patient in care setting.
The overview of the research methodology and research design will define the approach that will
be taken to collect data from NPs in specific setting in Saudi Arabia. The methodology chapter
will also define the types of research tools that will be used in collecting data and the analysis
method that will be used to critical examine and review research data. The paper will define the
target population of interest for this study along with specific sampling technique adapted to
recruit research participants in the research process. The ethical consideration that will be
considered during the research process will also be defined.
Type of research method:
As the main of this research is to analyse the impact of NPs in improving outcome of care
for diabetes patient particularly in relation to glycemic, blood pressure and cholesterol level
control, quantitative research methodology is considered appropriate to get answer to the
research question. Quantitative research methodology will be appropriate for this research
because the research aim is focussed on collecting objective data related to outcome of care for
diabetes patient in primary care setting and not subjective data related to perception or
experience in care for diabetes patient. Hence, as this research has a narrow focus, quantitative
method is ideal to collect measurable data related to HbA1c level, blood pressure and cholesterol
level in diabetes patient. McCusker and Gunaydin (2015) argue that review of research aim helps

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to take choice regarding the type of methodology needed for research. Quantitative research
focus on gathering numerical data to explain a particular phenomenon for a set population group
and the objective measurement is done either by statistically analysis or numerical analysis of
data through survey or questionnaires (Creswell and Creswell 2017).
Research design:
The literature review method revealed many research being done using retrospective
cohort research design. However, the disadvantage associated with this method is that they are
subjected to biases because of differential loss to follow-up. Hence, to effectively evaluate the
contribution of nurse in influencing outcome of diabetes patient, it is planned to conduct a
retrospective pre-post research design. The main feature of this type of research design is to
collect both before and after information at the same time. This is an effective research design as
this research design helps to assess an individual’s skills, knowledge and awareness related to the
issue. This type of research design is relevant for the purpose of this study too as it can help to
evaluate whether pre and post intervention project in primary care clinic coordinated by NPs can
influence outcome of diabetes patient or not. Evidence suggests the utility of such program in
evaluation of a program related to quality improvement Geldhof et al. (2018). This research can
be regarded as a quality improvement initiative because this research is being conducted because
of problems in primary care setting in relation to management of diabetes.
The nurse practitioners will be involved in providing integrated diabetes care and
education to patients with diabetes in primary case setting of Saudi Arabia. The pre and post-
intervention quantitative measure will focus in measuring HbA1C level, lipid profiles and BP of

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patient. The pre and post-intervention outcome related to diabetes care outcome will be measured
in clinic and after 3 months post the intervention.
Research setting:
As the research aims to address the problem of diabetes management in primary care
setting, it is planned to conduct research in a primary care setting of Saudi Arabia. To enhance
the validity of research data, the research will focus on conducting research at two primary care
settings in Saudi Arabia, to ensure that the data is not influenced by specific centre characteristic.
While selecting the primary care setting, the focus will be to identify those setting where large
number of adult patient with type 2 diabetes comes to seek care.
Target population with category:
The target research population for the study will be adult patients with type 2 diabetes.
This will be examined by diagnostic details of patients. Other criteria that will be considered to
ensure that the relevant population group is selected includes excluding patient with anemia,
chronic kidney disease, pregnant women and those who has received blood transfusion within
the past 3 months. These groups of patients will not be taken as the above conditions can falsely
influence HbA1c level.
Sample size and sampling technique:
Purposive sampling technique will be identified to select people with type 2 diabetes
from target setting of Saudi Arabia. This will involve selecting research participants based on
inclusion and exclusion criteria. Purposive sampling is a technique that involves selecting
samples based on population characteristics and specific purpose of research (Etikan, Musa and

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Alkassim 2016). As this research is centred on investigation about quality of care outcomes for
diabetes patient when care is delivered by NP, it will be necessary to analyse diabetes patient
particularly in relation to glycemic control. Hence, the inclusion and exclusion criteria will focus
on excluding those patients who has conditions that can falsely affect HbA1c level. This
sampling technique will ensure sample is selected based on desired characteristics of sample
needed for the study. The advantage of using purposive sampling technique is that it can make
generalization from the sample easier and it helps to fulfil the key purpose of research. As the
research will be done in two centres, sample size calculation will be done to estimate appropriate
sample size that gives valid and reliable results in relations to the research objective.
Ethical consideration:
To ensure that the research is done ethically, the focus will be to fulfil all ethical
requirement needed to conduct the research process. The approval for this research will be taken
by the Research Ethics Committee of Saudi Arabia and this research approval form will define
the specific purpose, expected outcomes, sample population and key methodology that will be
used for the search process. Furthermore, during sample selection, participations will be included
in the research only after receiving informed consent from the participants. The informed consent
from will define research method, any possible risk during research and protection of
confidentiality of sample. This form of ethical conduct will ensure that the accountability,
transparency and confidentiality are maintained throughout the search process. According to
McKenna and Gray (2018), while planning any new methodological approach, analysing ethical
issues that could arise with research is important. It is a responsibility of all researchers to be
aware of all responsibilities in relation to ethical conduct and reporting of research process.

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Instruments and tools:
Pre and post retrospective chart review will be done by the analysis of HbA1c values, BP
values and LDL-C values for each patient before and post the inclusion of nurse in primary care.
The electronic medical record for each patient will be the main source for collecting this
information. The main goal will be to reduce HbA1c value to less than 8%, reduce blood
pressure to less than 140/90 mm Hg and maintain cholesterol value to less than 100mg/dL. The
chart review focussed on comparing pre and post respective data in relation to outcome for BP,
LDL-C and HbA1 value for patient. With a focus on evaluation of process of care too as per the
Donabedian theoretical framework, the research will also use the Audit of Diabetes Dependent
Quality of Life questionnaire to measure participant’s perception of the impact of diabetes care
in quality of life. Another benefit of using this tool is it is highly sensitive to change in treatment
outcome and it can provide reliable data.
Data analysis:
The analysis of data will be done by statistical analysis. For each of the three outcomes in
relation to HbA1c level, BP and cholesterol, a benchmark clinical value will be set. The
retrospective chart review will measure and compare the outcomes obtained for each outcome
before and after inclusion of nurse in primary care. Mean and standard deviations for outcome
will be evaluated and significance of the outcome will be obtained by review of p-value. The
advantage of this form of statistical analysis is that it is less time consuming and it facilitates
identifying all forms of patterns and correlations in research data. Another advantage of this
process is that if it is possible to check and re-check different variables at different time. Hence,

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such data can be easily representative of the target population and it increases the reliability of
the research process.
Analysis procedure:
The analysis procedure can be done using the SPSS (Statistical Package for Social
Sciences) software. The mean deviation and standard deviation in relation to each outcome can
be used to statistically analyse outcome variables and detect significant improvement in quality
of diabetes care when delivered by NPs. Bell, Bryman and Harley (2018) explains that it is the
most widely used research package that helps in analysis of data in different forms. It helps in
effective interpretation of result findings.
References:
Azami, G., Soh, K.L., Sazlina, S.G., Salmiah, M.S., Aazami, S., Mozafari, M. and Taghinejad,
H., 2018. Effect of a Nurse-Led Diabetes Self-Management Education Program on Glycosylated
Hemoglobin among Adults with Type 2 Diabetes. Journal of diabetes research, 2018.
Bartol, T. 2012. Improving the treatment experience for patients with type 2 diabetes: Role of the
nurse practitioner. Journal of the American Academy of Nurse Practitioners, 24, 270-276.
Bell, E., Bryman, A. and Harley, B., 2018. Business research methods. Oxford university press.
Buja, A., Gini, R., Visca, M., Damiani, G., Federico, B., Donato, D., Francesconi, P., Marini, A.,
Donatini, A., Brugaletta, S., Bardelle, G., Baldo, V., Bellentani, M., Valore Project 2014. Need
and disparities in primary care management of patients with diabetes. BMC endocrine
disorders, 14, 56. doi:10.1186/1472-6823-14-56

24Proposal
Collins, C. and Rochfort, A., 2016. Promoting self-management and patient empowerment in
primary care. In Primary Care in Practice-Integration is Needed. IntechOpen.
Condosta, D., 2012. Comparison between nurse practitioner and MD providers in diabetes
care. The Journal for Nurse Practitioners, 8(10), pp.792-796.
Creswell, J.W. and Creswell, J.D., 2017. Research design: Qualitative, quantitative, and mixed
methods approaches. Sage publications.
Daly, B., Tian, C.J.L. and Scragg, R.K.R., 2017. Effect of nurse-led randomised control trials on
cardiovascular risk factors and HbA1c in diabetes patients: a meta-analysis. diabetes research
and clinical practice, 131, pp.187-199.
Etikan, I., Musa, S.A. and Alkassim, R.S., 2016. Comparison of convenience sampling and
purposive sampling. American journal of theoretical and applied statistics, 5(1), pp.1-4.
Geldhof, G.J., Warner, D.A., Finders, J.K., Thogmartin, A.A., Clark, A. and Longway, K.A.,
2018. Revisiting the utility of retrospective pre-post designs: The need for mixed-method pilot
data. Evaluation and program planning, 70, pp.83-89.
Hirschman, K.B., Shaid, E., McCauley, K., Pauly, M.V. and Naylor, M.D., 2015. Continuity of
care: The transitional care model. OJIN: The Online Journal of Issues in Nursing, 20(3), p.1.
Jingi, A. M., Nansseu, J. R., and Noubiap, J. J. 2015. Primary care physicians' practice regarding
diabetes mellitus diagnosis, evaluation and management in the West region of Cameroon. BMC
endocrine disorders, 15, 18.

25Proposal
Jutterström, L., Hörnsten, Å., Sandström, H., Stenlund, H. and Isaksson, U., 2016. Nurse-led
patient-centered self-management support improves HbA1c in patients with type 2 diabetes—A
randomized study. Patient education and counseling, 99(11), pp.1821-1829.
Krug, E.G., 2016. Trends in diabetes: sounding the alarm. The Lancet, 387(10027), pp.1485-
1486.
Kuo, Y. F., Goodwin, J. S., Chen, N. W., Lwin, K. K., Baillargeon, J., and Raji, M. A. 2015.
Diabetes mellitus care provided by nurse practitioners vs primary care physicians. Journal of the
American Geriatrics Society, 63(10), 1980-1988.
Laurant, M., van der Biezen, M., Wijers, N., Watananirun, K., Kontopantelis, E., & van Vught,
A. J. (2018). Nurses as substitutes for doctors in primary care. Cochrane Database of Systematic
Reviews, (7).
Martínez-González, N. A., Rosemann, T., Tandjung, R., & Djalali, S. (2015). The effect of
physician-nurse substitution in primary care in chronic diseases: a systematic review. Swiss
medical weekly, 145(0506).
McCusker, K. and Gunaydin, S., 2015. Research using qualitative, quantitative or mixed
methods and choice based on the research. Perfusion, 30(7), pp.537-542.
McKenna, L. and Gray, R., 2018. The importance of ethics in research publications. Retrieved
from: https://www.collegianjournal.com/article/S1322-7696(18)30062-3/pdf
Murrells, T., Ball, J., Maben, J., Ashworth, M. and Griffiths, P., 2015. Nursing consultations and
control of diabetes in general practice: a retrospective observational study. Br J Gen
Pract, 65(639), pp.e642-e648.

26Proposal
Norful, A.A., Swords, K., Marichal, M., Cho, H. and Poghosyan, L., 2017. Nurse practitioner-
physician comanagement of primary care patients: The promise of a new delivery care model to
improve quality of care. Health care management review.
Richardson, G.C., Derouin, A.L., Vorderstrasse, A.A., Hipkens, J. and Thompson, J.A., 2014.
Nurse practitioner management of type 2 diabetes. The Permanente Journal, 18(2), p.e134.
Riordan, F., McHugh, S.M., Murphy, K., Barrett, J. and Kearney, P.M., 2017. The role of nurse
specialists in the delivery of integrated diabetes care: a cross-sectional survey of diabetes nurse
specialist services. BMJ open, 7(8), p.e015049.
Seidu, S., Davies, M.J., Farooqi, A. and Khunti, K., 2017. Integrated primary care: is this the
solution to the diabetes epidemic?. Diabetic Medicine, 34(6), pp.748-750.
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and Vigersky, R., 2018. Type 2 Diabetes Management in Primary Care: The Role of
Retrospective, Professional Continuous Glucose Monitoring. Diabetes Spectrum, 31(3), pp.279-
287.
Tabesh, M., Magliano, D.J., Koye, D.N. and Shaw, J.E., 2018. The effect of nurse prescribers on
glycaemic control in type 2 diabetes: a systematic review and meta-analysis. International
journal of nursing studies, 78, pp.37-43.
Voyce, J., Gouveia, M.J., Medinas, M.A., Santos, A.S. and Ferreira, R.F., 2015. A Donabedian
model of the quality of nursing care from nurses’ perspectives in a Portuguese hospital: a pilot
study. Journal of nursing measurement, 23(3), pp.474-484.

27Proposal
World Health Organization 2018. Diabetes. Retrieved from:
https://www.who.int/news-room/fact-sheets/detail/diabetes