Clinical Problem of Diabetes Type i and II
This capstone paper integrates the current clinical problem of diabetes type I and II in the hospitalized adult and youth patients with the associated QSEN nursing competency of patient centered care by addressing and exploring the following question: Among patients with Diabetes, how does diabetes self-management education programs (DSME) compared with no diabetes self-management education programs affect diabetic self-care/self-management? After an introduction of the problem and its significance to patient centered care, a review of current research literature that addresses both the problem of diabetes and its possible nursing interventions is presented. Next, a case example of a patient cared for by the author during her senior preceptorship on a general medicine floor in an acute care setting is presented and applied to the clinical problem. The paper then concludes with a discussion of implications for future nursing practice, patient education, and further research on the clinical problem.
Keywords: diabetes, DSME, self- care, education, nursing, knowledge, patient centered care, barriers, quality of care, self-management, self-efficacy.
DSME and Patient Centered care: Nursing Care of Diabetic Patients
Diabetes is commonly presented in younger and older adults with poor glycemic control by the endocrine system in an acute care setting, among a variety of populations. Diabetes come in two forms: Type I and Type II. Type I occurs when the body’s pancreas does not produce enough insulin to reduce the blood sugar in the body. Type II is when there is an insulin resistance and the body does not use the insulin produced. Insulin is a type of hormone produced by the pancreas to regulate blood sugar levels (Nichols, 2017, para. 2). Untreated diabetes can increase the risk of cardiovascular disease, kidney disease, peripheral neuropathy, and retinopathy (Nichols, 2017, para. 3). According to Vas et al., 2017, “Diabetes is a major noncommunicable disease, which is increasing, and approximately 415 million people are affected around the globe (p. 1).” This illustrated the focus of problem globally, as more and more individuals are diagnosed with diabetes without the understanding of how to control and prevent the disease process. Many people with diabetes lack the knowledge about their disease and the understanding of monitoring their own health throughout life. Because of the lack of skills and understanding how to care for their own diabetes, people tend to have higher risk of complications and poorer sugar control. Thus, diabetic patients need education on their diabetes and learn how to prevent complications of diabetes. Diabetes self-management education programs provided diabetic patients teachings on pharmaceutical treatments, complications, disease process, pathophysiology, blood glucose measurement, injection techniques, diet counseling, physical activity, and emotional aspects (Herre, Graue, Kolltveit, & Gjengedal, 2016). One of the biggest problem with diabetic management is being able to grasp the ability to care for self from what is taught about the disease and how much a person knows about their condition and what needs to be prevented in order to live a sustainable life. But how does that connect to patient centered care?
Patient centered care is the ability to not just help a patient adapt to their disease process physically but also, holistically. The focus of treatment and care is not just on the patient itself but also on the patient’s family and significant others who will be affecting the patient’s overall health. Diet teaching, for example, can be affected by the food that the patient may be buying out at grocery stores with his or her family and the common foods eaten and cooked by family members daily. Much teaching must focus on the understanding of the family cultural aspect of food and their financial capabilities to purchase healthier food pertaining to the patient’s individual diabetic diet. When care is more holistically focused, Herre, Graue, Kolltveit, & Gjengedal (2016) says, “Relatives became part of the diabetes community that helped them to integrate this knowledge into the family (p. 388).” When diabetic patients could involve and include their close relatives to participate in the diabetic self-management education programs (DSME) and sit-down sessions provided by the diabetic educator, they verbalized that when both person receives the same basic information, it becomes more useful and helpful. Therefore, patient centered care is one of the core QSEN competency identified. Education plays a key part and role in regulating diabetic patient conditions. Herre, Graue, Kolltveit, & Gjengedal (2016) presented, “Systematic education is recommended to be person-centered to ensure that each person’s needs are taken care of by providing necessary knowledge (p. 383).” When there is knowledge, there is better management and adherence to self-care, and better health. In lite of diabetic knowledge and skills, DSME should be explored further on its impact in patients with diabetes in the context of the question: Among patients with Diabetes, how does diabetes self-management education programs (DSME) compared with no diabetes self-management education programs affect diabetic self-care/self-management? To address this question, a review of current research literature that explores both the problem of diabetes and related nursing interventions is presented, followed by the presentation of a case example that highlights the patient problem and a concluding discussion of implications for future nursing practice, education, and research on the issue.
Review of the Research Literature
The problem of diabetes experienced by a variety of patients in an acute care setting is documented in the literature. Jaacks et al. (2014) stated, “Only half of the participants reported meeting with the dietician or nutritionist in the past 12 months (p. 38). This highlights the fact that individuals diagnosed with diabetes are lacking the knowledge about diabetes and the lack of knowledge affected their ability to control their diabetic condition. Before we continue to discuss about the impact of education on diabetes, we want to look briefly at the barriers that could prohibit diabetic management. People living in poor conditions with a low income are more likely to have poor glycemic control (Jaacks et al., 2014). People who have lower income are unable to afford healthier food and adhere to routine clinic visits pertaining to their diabetic health. Such disadvantage makes it complicated for individuals with diabetes to seek help and gain knowledge and understanding on the management of their disease. In this case, it is important that health care providers, nurses, nutritionist, and diabetic educators help individuals solve their health problems and plan goals that are achievable based on their circumstances and abilities. Integrating patient centered care “can bring about improved health care management, lower costs, and improve quality of care” (Vas et al., 2017, p. 2). Diabetes is a significant problem that needs further recognition because of its impact on patients’ management of their condition when out of the hospital setting. Patients leaving to home have difficulty adhering to diabetic diets, balancing carbohydrates and insulin, controlling emotional aspects, and adapting to the new and different lifestyle built from their diabetic condition. Thus, patient centered care becomes a connection to their ability to obtain knowledge and support to adapt to change and maintain a balanced health that is clear of diabetic complications.
To further discuss about the link between patient centered care and diabetes, let’s talk about what DSME can do to improve health of individuals and prevent readmissions into a health care facility. The diabetes self-management education programs (DSME) have shown improvements in the reduction of weight, blood pressure, lower LDL cholesterol, decreased anxiety, depression, distress, sedentary behaviors, increased quality of life, self-efficacy, self-care, and self-management skills (Vas et al., 2017, p. 4). DSME has a great impact on increasing the quality of care, management, and knowledge among individuals participating in the program after hospitalization and a follow up is proceeded. Once DSME is effective in improving self-management of diabetes, it covers the lack of knowledge that diabetic individuals lack. According to Vas et al. (2017), “Lack of understanding of the disease and its self-management often dooms therapies to failure. Patients must attain the knowledge and skills required and develop favorable attitudes essential for diabetes control. This will help lower their stress owing to illness and its treatment (p. 1-2).” DSME is an important intervention in providing patient centered care because patients with diabetes benefit from take home understanding on how to care for their own illness, balancing their health, controlling blood sugars, reducing risks, participating in their own individualized self-care, and adhering to their knowledge developed from the program. This ensures self-management and efficient self-care among diabetic individuals once they are discharged home. Further from this, three research literatures will examine the advantages and disadvantages of DSME effectiveness among diabetic patients. But first, a close look at the number of interventions that can help improve diabetic management.
There are several diabetic interventions for patients with diabetes. But there are two interventions that are commonly used. One of the intervention is diet teaching. Diet teaching is usually initiated by the nutritionist. Patients is given an example and list of foods that are low in carbohydrates and high in proteins. They are also taught on reading food labels when grocery shopping for foods. The second type of intervention includes a Diabetic nurse educator that teaches patients injection techniques, dosing time, how to check blood sugar levels, how to balance diet with insulin, understanding the affect of physical activity with blood sugar levels and insulin corrections, carbohydrate count, and checking for urine ketones. These interventions are important in helping patients regulate their diabetic condition however, is it enough to help them adhere to managing their diabetes and enhancing their quality of life? To answer this question, we will look at three researched articles written by registered nurses and medical doctors.
In one of the article, “Lasting Impact of an Implemented Self-management Programme for People with Type 2 Diabetes Referred from Primary Care: A One-group, Before-after Design,” the study used data analysis, meta-analysis/systematic reviews, and randomized controlled trials to examine the short-term impact of DSME program on diabetes knowledge in patients with diabetes type 2. A sample of unselected patients are referred from a primary care and the programs effect on secondary outcomes, patient activation, and self-efficacy is also examined (Flode et al., 2017, p. 790). The study consisted of 158 people and 115 people agreed to participate in the study (Flode et al., 2017, p. 792). Data was gathered before, immediately after, and three months after group sessions (Flode et al., 2017, p. 790). Self-efficacy is an individual’s ability to deal with stressful events when dealing with difficult tasks in their day to day living. The results of the findings indicate the lasting benefits of the DSME programme within a persistent three-month period. Diabetic knowledge becomes a core pre-requisite for good self-care. Flode et al. (2017) claims, “The study findings indicate that this programme positively influences diabetes knowledge in persons in the community, as well as patient activation and self-efficacy (p. 793).” This proves that DSME positively improve knowledge of diabetes in short and long term follow up and evaluations and improve diabetes control and increase self-efficacy. However, DSME benefits more for those with the greatest needs (Flode et al., 2017, p. 794).
In the second article, “Experience of Knowledge and Skills That are Essential in Self-managing a Chronic Condition- A Focus Group Study Among People with Type 2 Diabetes,” the focus of the article’s systematic review is to highlight the experience of DSME and how it affects an individual Type 2 Diabetic self-management and health. Ideas are supported by using a theoretical framework based on five groups being conducted. The group education session included activities and practical tasks. The participated gained more awareness of the disease and took it more seriously. In defining self-management, Herre, Graue, Kolltveit, & Gjengedal (2016) says, “How people with diabetes understand the details about the disease, related to physiology, pathology, blood sugar regulation, weight, physical activity and knowledge, is particularly important for self-management (p. 382).” It is stated that knowledge deficiency and lack of learning about diabetes and how to manage will have an adverse effect on self-care. Findings showed that participants were more encouraged to learn when placed with other people with the same struggle and similar problems. Inputs from healthcare professionals and other participants gave new insights. The practical preparedness in measuring blood glucose, performing injections, and managing nutrition strengthened. It made it easier to handle the disease. Learning to cope with the problem also helped them feel much more secure. Understanding factors that influence blood glucose and different types of medications to control blood glucose was informed as useful. Participants understanding of the relationship and benefit of physical activity and blood glucose with regards to diabetes management helped them piece things together. Participants also benefited from knowledge of different types of food, how to read food labels, and routine podiatrist visits to avoid complications (Herre, Graue, Kolltveit, & Gjengedal, 2016, p. 385-386). It is concluded that DSME enables people to gain in knowledge and experience that are shared among individuals with the same diagnosis and promoted their ability to take part in their own care. Herre, Graue, Kolltveit, & Gjengedal (2016) stated, “Ockleford et al. (21) showed that group education made people increasingly accept their disease and the changes they had to make in order to manage their chronic condition (p. 388).” Group education not only help people communicate and connect on their condition but also cope with their illness and increases their confidence in living an independent life with their diabetes well maintained.
In the third article, “Comparing Perceived Self-Management Practices of Adult Type 2 Diabetic Patients After Completion of a Structured ADA Certified Diabetes Self-management Education Program with Unstructured Individualized Nurse Practitioner led Diabetes Self-management Education,” the main focus of the article is to compare the difference between Type 2 Diabetic patients attending an American Diabetes Association (ADA) certified DSME and an unstructured nurse practitioner teaching the DSME, informally. The study is supported by demographic questions, data analysis, and Self-Care Inventory-Revised (SCIR). The study measure and compare one sample of 52 individuals that graduated from a formal DSME program and the second sample of 52 individuals that never attended the DSME classes. After one session of DSME, hospital readmission was 34% lower by 30 days and 20% lower by 180 days among diabetic patients (Wooley & Kinner, 2016, p. 172). Ineffective diabetes education and early discharges tend to increase readmissions in hospitals. When looking back at one of the barrier of diabetes knowledge among poor income individuals and families, DSME is stated to reduce diabetes in financial terms (Wooley & Kinner, 2016, p. 172). The results showed no significant difference between the two forms of DSME teachings. Thus, nursing implications illustrated the importance of diabetes education to self-efficacy and its influence on patients diabetic control. After reviewing the three research based articles, it is evident that DSME is effective in improving diabetes self-management and self-care, and enhances the quality of life in different individuals.
As the author, a case example will be based on the current completion of a nursing preceptorship on a 30 bed general medicine unit at Boston Children’s Hospital. The unit cares for patients with a wide variety of medical diagnosis but often admits patients with new onset of Diabetes, for disease management and blood sugar control, with the balance of low carbohydrate diet and insulin injections. At times, the patient pressed the call bell button to ask if he or she could have certain food for their mealtime. Patient and family would verbalize lack of understanding of how carbohydrate counts work when attended at the bedside. Patient and family also demonstrated low understanding of why it is important to eat low carbohydrates and the imbalance of sugar levels that need to be corrected. As a result, the nurse must teach the patient and significant other or family member how to correct blood sugar with insulin injections based on carbohydrate counts and blood sugar levels obtained. Injection techniques were taught and diabetes nurse educator and nutritionist were scheduled to visit prior to discharge.
During a morning shift, a 12-year-old female was admitted to the unit with the diagnosis of Type 1 Diabetes and complication of an uncontrolled blood sugar level that contributed to Diabetic ketoacidosis and dehydration. She was transferred to the general medicine unit for management after admission from the emergency department. The patient was accompanied by her mother and father by the bedside. On arrival, blood sugar was to be checked but because the mother verbalized her lack of understanding of how to use the glucometer, she was taught to do a blood sugar test on her daughter. Later in the afternoon, after the patient ate her lunch, blood sugar was checked and blood sugar was corrected by insulin and based on the afternoon meal the patient and mother said that her daughter will eat in order to keep the insulin correction accurate from the predicted carbohydrate count. However, after lunch, the patient’s mother asked the nursing assistant to grab her some orange juice for her daughter because she wanted some. When the nurse comes back in to check the patients’ blood sugar, she noticed a rise in her blood sugar. The nurse then asked the patient’s mother what she ate in addition to her lunch and the patient’s mother said she gave her orange juice because she thought it was okay. The nurse had to immediately get insulin to correct the additional carbohydrate the patient consumed to decrease her blood sugar levels. This gives insight on the patient and mother’s inadequate teaching and education on diabetes have contributed to her mistake on giving her daughter orange juice just because she preferred it. The importance of education is needed to be initiated in order to prevent serious complication and improve self-management and self-care outside of the hospital setting, at home.
In addition, more understanding needs to be explored about the diabetic patients transition from a normal baseline health to a diagnosis of diabetes. An adolescence diagnosed with diabetes must adapt to the transition from pediatric health care team to an adult health care team and to home. During the developmental stage of an adolescence, the risk-taking behaviors, thought of invincibility, and influence by peers can have a drastic effect on their ability to manage diabetes (Polfuss, Babler, Bush, & Sawin, 2015, p. 749). The big change in lifestyles and behavior modifications, peer and familial relationships, and the added increase of independence can become stressful for the individual. With regards to the transition of living alone, finding a job, and balancing family issues with diabetic condition can be very frustrating and a lot for the individual to handle all at once. However, family involvement has successfully influenced transition.
To continue exploring the factors that influence diabetes management and self-care, barriers and inhibitors are examined. According to Herre, Graue, Kolltveit, & Gjengedal (2016), “Many people with type 2 diabetes feel that the disease is challenging and they have difficulties motivating themselves in self-management (p. 382).” This barrier can influence self-management because the diabetic patient is having difficulty adjusting to new diagnosis. The other barriers include, communication with healthcare professionals, and the lack of educational programmes focused on learning (Herre, Graue, Kolltveit, & Gjengedal, 2016, p. 382-383). It is evident that the lack of knowledge could lead to practical problems and uncertainty (Herre, Graue, Kolltveit, & Gjengedal, 2016, p. 383).
On the other hand, there are facilitators that make diabetes management and self-care possible. Participants with diabetes that participated in the DSME felt more prepared to deal with the illness on their own. Herre, Graue, Kolltveit, & Gjengedal (2016) says, “The course had enabled them to better cope with their daily challenges, since they had learned useful skills by performing certain actions (p. 387).” The participants in the DSME pointed out that more knowledge learned from DSME made it easier to balance their diet, control blood glucose levels, demonstrating injection techniques, and caring for their own feet. Herre, Graue, Kolltveit, & Gjengedal (2016) wrote out the following verbalized by the participants in his study:
I have learned how to handle the day-to-day, simple as that. That it is me who needs to manage this. Nobody else will. It is a wake-up call, to take this seriously (p. 386). The quotation above, spoken by one of the participant, highlights the significant usage of the DSME in educational knowledge and awareness of self-management that is ideal for the importance of self-care.
To promote patient centered care among patients with diabetes, several factors and research evidence-based practice is required. The focus of the research is to discover the significance of diabetic patients from a variety of population, in an acute care setting and interventions that help improve their self-management and self-care. Diabetes is defined as poor insulin production or insulin resistance that is regulated by the pancreas. A lack of diabetes management can lead to increased risk of macrovascular and microvascular complications. Therefore, there is great emphasis on the importance of diabetes education teachings on the disease process and better knowledge on how to manage the disease. Upon review of three research literatures, it provided evidence and studies that supported the use of diabetes self-management education programs. Diabetes self-management education programs provided diabetic patients teachings on pharmaceutical treatments, complications, disease process, pathophysiology, blood glucose measurement, injection techniques, diet counseling, physical activity, and emotional aspects (Herre, Graue, Kolltveit, & Gjengedal, 2016).
Transitioning from a normal health status into a new onset of diabetes is illustrated as a stressful event for adolescence into adulthood. This does not just apply to adolescence but adult as well as they transition into living independently on their own. Family involvement can successfully integrate into the diabetic patient’s learning and shared knowledge on the disease. Adaptation with peers and accepting with the awareness of the disease removes barrier once it is implicated on seriousness of diabetes. One of the biggest inhibitors is knowledge about the disease and how to effectively manage blood sugar levels with day to day living. This includes, diet, physical activity, measuring sugar levels, performing injections, routine podiatrist visits, carbohydrate counts. To facilitate the management of diabetes, DSME included all of the sufficient teachings and needs of the patient diagnosed with diabetes. It helped provided patients with self-confidence and security on their own self-care.
In addition to patient centered care, when care is focused holistically, diabetes patients benefit from involving their partners and family member within the education process. With similar teachings taught, adjusting to accommodate the diabetes was easier to transition into and family members and significant others received the opportunity to help out or remind the patient on following the management of diabetes strictly together. So, what is the best nursing practice? After close examination and thorough reviews of client problems and literatures, DSME is efficient to increase self-management and care of diabetes compared to no DSME.
In relation to quality care and improvements, healthcare professionals need to be aware of the difficulties that diabetic patients face dealing with the disease and motivate them toward self-management (Herre, Graue, Kolltveit, & Gjengedal, 2016, p. 382). According to Vas et al. (2017), “Nurse’s role is highly prominent in diabetes care as they involve in creating awareness, managing diabetes, and educating about diabetes self-management (p. 7).” It is important that nurses and healthcare professionals are aware of their influence on patients with diabetes. For improvements in diabetes management, Herre, Graue, Kolltveit, & Gjengedal (2016) emphasized, “It is important to provide self-management courses in clinics that enables participants to gain knowledge, skills and abilities they need to self-manage their disease (p. 388).” Lastly, nurses should provide awareness of diabetes to patients with the disease and provide education, teachings, demonstrations, and pertinent information that will help patients manage their disease and carry out or perform self-care efficiently outside of the hospital settings. It is also important to assess readiness to learn and current knowledge on the disease. Referrals should be made on the correct needs of the patient and other healthcare professionals should provide sufficient education that matches each individual learning needs. This will help tackle patient knowledge deficit problems and enhance patient centered care and reduce readmissions. As a result, more understandings will provide compliance to self-management and self-care and more involvement of partners and family members.