Diabetes - a Contemporary Approach

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Birdsall et al (2013) agree that diabetes care is most efficient when moved out of secondary care and into the community but still feel the need of an inpatient specialist nurse. Good communication between the DSN and the inpatient specialist nurse provides a good linkage for patients to continue their diabetes management. Jane was referred to a psychologist and endocrinologist. The endocrinologist further referred Jane to an ophthalmologist who continued to follow her every six months. A podiatry referral was deemed unnecessary after foot examination and lower limb circulation assessment. She was given literature in the form of a leaflet about diabetes foot care and contact numbers should she need to ask questions to a foot specialist.

The National institute for Clinical Excellence (NICE 2008) suggests that a defined structure is to be used to deliver education to the patients and their carers. This structured education should start upon first diagnosis and continued to be reviewed annually. An approved patient education programme that suits the needs of the individual is chosen. Any of these programmes used should be evidence based, theory driven, delivered by trained professionals, aims towards specific learning objectives and promote self-management.

The Diabetes Attitudes, Wishes and Needs study (DAWN) reported results of a study on diabetes self-management in both type 1 and type 2 diabetes. Regarding type 2 diabetes the study reported that 78% of patients with diabetes adhere to medication. A greater concern perhaps is that, 64 per cent of patients with diabetes adhere to self blood glucose monitoring with only 37 and 35 per cent of patients adhering to suggested diet and exercise respectively (Nash 2013). Reviewing these figures is clearly indicative of the need for more complete patient support and on-going reviews for better self-management. Shrivastava et al (2013) highlights the need for on-going reviews and education since patients may decrease glycaemic control in as little as three months after support and education were stopped.

Heiselert et al (2002) state that up to 95 per cent of diabetes care is carried out by the patients themselves. Diabetes management is mainly self-directed and patients decide upon everyday decisions that influence their care (Tetrick and Parkin 2013). For diabetes care to be effective patients have to make informed decisions about the actions they take and how it will affect their illness. When health professionals understand that the patients are the primary decision makers they become more effective in helping through their expertise (Funnell et al 2004).

It is expected that patients with the most knowledge have the best understanding of the disease. This will have the best impact on stopping or reducing progression of complications. On the other hand patients who are not informed about the efficacy of self-management have the least chance of effective care. Poor literacy is also usually associated with poor attitudes towards the disease and prevention of complications (Shrivastava et al 2013).

Shrivastava et al (2013) mention a number of factors that affect the outcome of self-care. These are following a healthy diet, physical activity, blood glucose monitoring, medication compliance, good problem solving skills, coping skills and risk reduction behaviours. These seven factors demand that the individual makes dietary and lifestyle changes, therefore it is important that the health care team promotes self-confidence to encourage these positive changes. Clark (2002) states that figures of up to 50 per cent risk reduction of diabetes complications are possible when integrating several aspect of lifestyle modification.

Health professionals should not blame the individual if compliance is poor. Good metabolic control needs more than a number of self care measures and it is the professional’s duty to individually assess the patient. Degrees of responsibility of self-care should be assigned according to the willingness of every individual (Shrivastava et al 2013). It is important to first recognize the needs of the patient and understand the barriers to be able to offer good support (Wilson 2007).

In contrast to group-structured education which will be discussed later Clark (2002) found out that brief tailored interventions are also effective in changing patient’s behaviour to one that enables self-care. These interventions should be based upon short personalized interviews designed to increase one’s motivation. Some patients are uncomfortable in carrying out activities perceived as medical decisions. A tailored approach is usually deemed feasible by the patient and increase the likelihood of carrying it out (Shrivastava et al 2013). Clark (2002) proves the effectiveness of such an approach but following every patient individually and offering on-going support is unlikely to be possible and cost effective. This study done by Clark (2002) was done before the wide spread introduction of structured education and therefore cannot be purely compared to structured group based education. A randomised control study by Weinger et al (2011) proves a better outcome through group-structured education versus individual delivery to control glycaemic status.

Wilson (2007) talks about the importance of psychosocial support for diabetic patients. The National service framework for Diabetes (NSF) 2008 recognises the need for psychological support but the majority of patients still feel that not enough support is available (Wilson 2007). A lot of research relating diabetes to psychological problems is available, yet many of these measure the efficacy of psychosocial interventions by the range of improvement in glycaemic control. While glycaemic control is the basis to reduce most complications in diabetes, other factors important to the patients like quality of life must be kept in mind when offering help to these individuals (Delamater 2001).

The Diabetes Education and Self Management for On-going and New Diagnosed (DESMOND) was formulated to serve as a cognitive re framing tool. This structured programme was based upon a number of psychological theories of learning to increase patient empowerment. When acquiring skills for self-management patients play a key role in shifting away from a traditional passive care reception approach (Davies 2008).

The programme is delivered as a six hours course in small groups of usually ten people over two half days or a single full day. The educators try to minimise dictation but rather conclude ideas together with the attendees. Health care educators receive formal training and assessment so that a consistent level of teaching is offered. The course covers mostly lifestyle factors, food choices, physical activity and recognition