The effectiveness of motivation‐guided PDCA cycle nursing for self‐management ability and outcomes of patients with gestational diabetes mellitus

Abstract Aim To explore the effectiveness of motivation‐guided ‘plan, do, check and action’ cycle nursing for self‐management ability and outcomes of patients with gestational diabetes mellitus (GDM). Design A pre‐ and post‐ comparison quasi experimental study. Methods Totally 108 pregnant women with GDM diagnosed and delivered in our hospital from January 2020 to April 2021 were included in this study. They were divided into study group (54 cases) and control group (54 cases). Results The score of self‐management ability were significantly higher than those of control group (t‐test, all p < 0.05), as well as themselves before interventions in both groups (t‐test, all p < 0.05). Besides, scores of anxiety, depression, extraverted stimulus and intraverted stimulus all achieved significant reduction after interventions in study group compared with control one (t‐test, all p < 0.05), as well as themselves before interventions in both groups (t‐test, all p < 0.05). Patient or Public Contribution No patient or public contribution.

improve blood glucose control and pregnancy outcome (Saravanan et al., 2020).
Due to the unnecessary requirements of hospitalization for GDM, self-management for glucose control is important for the outcomes of pregnancies (Juan et al., 2020). Nowadays, conventional nursing is mainly monodirectional education by nurses, which leading to unsatisfied blood glucose and adverse events (Yan et al., 2021). Motivation-guided 'plan, do, check and action' (PDCA) cycle nursing formulates specific, scientific and personalized interventions for pregnant women based on their health conditions. In accordance with PDCA methods, nurses analyse the effectiveness and revise the inadequacy of interventions via observation and communication of patients, and improvement on interventions will be done next (Liu, 2021;Ren et al., 2019).
However, there is few study on investigation of motivationguided PDCA nursing for pregnant women with GDM. The application of motivation-guided PDCA nursing in gestational hypertension can effectively improve pregnancy outcomes, reduce blood pressure and relieve psychological pressure, but whether it can play a certain role in pregnant women with GDM and thus provide them with self-management ability remains to be discussed (Liu, 2021).
Thus, this study aimed to explore the effectiveness of motivationguided PDCA nursing for self-management ability and outcomes of pregnant women with GDM.

| Patients
Pregnant women diagnosed as GDM from January 2020 to April 2021 and finally delivered in our hospital were enrolled into this pre-and post-comparison quasi-experimental study. In total, 108 patients were allocated to study group (n = 54) and control group (n = 54). All participants were Chinese female. The flow chart is shown in Figure 1.
We chose 54 as the sample size.

| Inclusion and exclusion criteria
Patients meeting the following criteria were included in this study: (I) diagnosed as GDM by oral glucose tolerance test according to Chinese guideline for prevention and treatment of diabetes (Wang, 2021); (II) routine examination during pregnancy and final delivery in our hospital; (III) patients with natural conception; (IV) with normal mental condition and communication ability. Patients meeting the following criteria were excluded: (I) with primary diabetes F I G U R E 1 The flow chart of patients. before pregnancy; (II) with severe comorbidity conditions; (III) with high risk factors of pregnancy; (IV) with mental disease; (V) with multiple pregnancy; (VI) with coagulation disorders; (VII) allergic to drug used in this analysis; (VIII) with abnormal cardiopulmonary function.

| Interventions
Patients in control group were given conventional nursing. Pregnant women were regularly examined by obstetric out-patient nursing staff and were instructed to attend maternity school run by the hospital after diagnosis. The maternity school provided pregnancy education through the help of slide show and video show in the form of face-to-face instruction by doctors, nursing staff and midwives from relevant departments. Family members of pregnant women can accompany them to class. Health guidelines and handbook were given by obstetrics nurses. The handbook contains diabetes related knowledge, diet control, physical exercises, glucose measurement, pharmacy regimens and home health monitoring. Routine health examination were performed every week.
Compared with control group, patients in study group were given addition of motivation-guided PDCA nursing interventions as follow: (I) plan (P): all treatment strategies were proposed by a PDCA nursing team, including a chief of gynaecology and obstetrics, two obstetricians and gynaecologists, one head nurse, one psychologist, one dietician, two rehabilitation physicians and four nurses of gynaecology and obstetrics. All the members in this team received training for a month and the ones passed the test were enrolled in.
The psychologist was in charge of mental health screening, counselling, helping patients to improve cognition of GDM, and reduce uncomfortable feelings and emotions. The personalized nursing plans was made based on the psychological condition of patients.

| Study index
The glucose level, self-management ability, psychology status, compliance with health habits and outcomes of patients before and after interventions in both groups were compared.
The glucose level was measured before and after the interventions, including fasting plasma glucose (FPG), postprandial blood glucose (PBG) and glycated haemoglobin (HbAlc). Automatic biochemistry analyser 7180 (Hitachi, Co. Ltd.) was used to analyse the indexes. Glucose oxidase method and enzymic method were used for the test of blood glucose and HbAlc, respectively.
A self-management questionnaire scale was used for the evaluation of these patients (Li & Li, 2013), including four dimensions, care for foetus, daily life, self-protection and compliance with medical advice. Each dimension was graded as 0-100. A higher score of this questionnaire indicates greater ability of self-management. The reliability of the scale is 0.957, Cronbach's alpha is 0.926. The content validity index (CVI) is 0.907.
Irritation, depression and anxiety (IDA) (Yuan et al., 2004) questionnaire scale was used for evaluation of psychology status in both groups, including four dimensions, extraverted stimulus score, intraverted stimulus score, anxiety score and depression score. There are 18 items in total. Each item is graded on a scale of 0-3, among which 6 items (Item 1, Item 2, Item 5, Item 12, Item 13, Item 17) are forward scoring, and the remaining 12 items are reverse scoring. A higher score of this questionnaire indicates more serious irritation, depression and anxiety. The reliability of the scale is 0.957, Cronbach's alpha is 0.769, and the CVI is 0.810.
Compliance with medical advice of patients  before and after interventions were recorded in both groups, including four dimensions, self-management, weight monitoring, exercises and dietary. Each dimension is graded as 0-10. A higher score in this scale indicates a better compliance with medical advice.
Blood loss in 2 h after surgery, gestational hypertension, caesarean delivery, premature delivery, foetal macrosomia, polyhydramnios, neonatal hypoglycemia, foetal distress and Apgar score of foetus were recorded.
All data were collected and analysed by two independent nursing staff. Data would be reviewed by the head nurse in case of discrepancies.

| Indications for caesarean delivery
The majority of pregnant women who received C-section were strictly follow the indications, including foetal distress, previous caesarean section, non-progress of labour, oligohydramnios, malpresentation, cephalo pelvic disorders, hypertensive disorder in pregnancy (Maskey et al., 2019).

| Statistical analysis
All the data collected in this study were analysed using SPSS 21.0 software (IBM Co., Ltd.). Continuous data conforming to normal distribution were expressed as mean (SD), and the comparisons were examined by Student-t test. The categorical data were expressed as n (%), and the differences between the two groups were examined by chi-square analysis or Fisher's exact test. p < 0.05 was considered statistically significant.

| Study index
There was no difference of FPG, PBG and HbAlc between these 2 groups before interventions (t-test, all p > 0.05) but both with a significantly decrease after interventions (t-test, all p < 0.05). Besides, the indexes in study group were significantly lower than those of control group after interventions (t-test, all p < 0.05). There was no difference of self-management scores between the study and the control group before interventions (t-test, all p > 0.05).
After interventions, the scores were both significantly increased compared with before in both groups (t-test, all p < 0.05). In addition, the scores after interventions in study group were significantly higher than those of control group (t-test, all p < 0.05).
There was no difference of IDA scores between these 2 groups before interventions (t-test, all p > 0.05). However, significant reduction of scores were obtained in both groups after interventions (t-test, all p < 0.05). Furthermore, the scores after interventions in study group were significantly lower than those of control group (ttest, all p < 0.05).
There was no difference of compliance scores between these 2 groups before interventions (t-test, all p > 0.05). Nevertheless, scores were significantly increased in both groups after interventions (t-test, all p < 0.05). Furthermore, the scores after interventions in study group were significantly higher than those of control group (t-test, all p < 0.05).
All results mention above could be seen in Table 1.
The blood loss in 2 h after surgery were significantly reduced in study group than that of control one (t-test, all p < 0.05). Besides, the incidence of caesarean delivery, premature delivery, foetal macrosomia, polyhydramnios and neonatal hypoglycemia were significantly lower than those of control group (χ 2 test, all p < 0.05). The incidence of gestational hypertension and foetal distress were with no difference between 2 groups (χ 2 test, both p > 0.05). Moreover, there was also no difference of neonatal Apgar score between these 2 groups (t-test, p > 0.05; Table 2).

| DISCUSS ION
Previous studies have shown that the incidence rate was 1%-14% in China (Han et al., 2019). With the change of life style and the comprehensive opening of two children policy in China, there are more and more elderly pregnant women with high risk of pregnancy, including GDM. GDM is not only harmful to pregnant women, foetuses and newborns but also increases the risk of developing into diabetes post-delivery. About 50% of pregnant women with GDM may develop into diabetes even after delivery, which will bring burdens to society. Therefore, early interventions and improvement of self-management ability is important for effective prevention and outcomes of these patients (Alejandro et al., 2020).
PDCA cycle quality management method has been widely used in clinical practice to promote empirical nursing transforming to scientific nursing and raise nursing quality (Liu et al., 2022). In this study, motivation was implemented as guidelines and combined with PDCA TA B L E 1 Comparison of glucose, self-management ability, psychological score and compliance with medical advice of patients included.
Self-management ability is a new health management model, which has been widely used. It can play an important role in the management of pregnant women with GDM . Good self-management behaviour can promote patients to accept new concept of health, enable them to develop healthy behaviour, enhance the awareness of active participation and effectively improve blood glucose and outcomes . Liang and Jin (2021)  All pregnant women with GDM have great negative psychology.
Most patients are worried about the health conditions of foetus and themselves. The feelings of depression and anxiety could be resolved after effective interventions (Liu, 2020). Duan et al. (2021) proposed that effective nursing interventions could control the blood glucose level, improve their psychology status and deliv- Previous study has shown that conventional nursing interventions were easy to result in high incidence of adverse event during pregnancy (Wei, 2021), because of the lack of specific nursing interventions . Lin et al. (2021) found that the incidence of adverse events in pregnant women with GDM was high and should be paid more attention to prevent. Gong and Lin (2020) found that effective nursing interventions for pregnant women with GDM could improve delivery outcomes and ensure patients health conditions. This study showed that the blood loss 2 h after surgery, caesarean delivery, premature delivery, foetal macrosomia, polyhydramnios and neonatal hypoglycemia in study group were significantly lower than those of control group. It reminded us that motivation-guided PDCA cycle nursing could improve delivery outcomes of pregnant women with GDM. It might be due to repeated revision and promotion of PDCA cycle nursing for patients.
Furthermore, nursing stuff continuously improved the nursing plan, carried out the whole process management, effectively control the weight and blood sugar level. The above measures reduced the occurrence of pregnancy complications, thus to improve the pregnancy outcome.
There were also several limitations in this study. First, there were unavoidable biases due to its non-prospective nature of this study.
Second, this was a single centre study with small sample size. Thus, all results and conclusions should be interpreted cautiously. More prospective studies with large sample size should be made in the future.

| CON CLUS ION
In conclusion, motivation-guided PDCA cycle nursing could effectively control blood glucose, strengthen self-management ability, relief psychology status, raise compliance with medical advice and improve delivery outcomes of pregnant women with GDM.

ACK N O WLE D G E M ENTS
None. Provincial Health Commission (No. 20221438).

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors declare that they have no competing interests.

DATA AVA I L A B I L I T Y S TAT E M E N T
The datasets generated and analysed during the current study are available from the corresponding author on reasonable request.

E TH I C S S TATEM ENT
This study was approved by the Ethics Committee of The First Hospital of Hebei Medical University (No. 20200624). Informed consent was obtained from all the study subjects before enrollment.

CO N S E NT FO R PU B LI C ATI O N
Not applicable.