Empowerment Practice in Diabetes Patient Education

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Empowerment Practice in Diabetes Patient Education

• Kan Ching Yee, Eva
• DMNS, AHNH
• 25th March 2006

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Overall Effects of Patient Education

• Diabetes educational programs are effective for
  patients across a different outcomes1-5
• Effect sizes (from largest to smallest) for the
  outcomes of knowledge (ES 0.88) gt skill
  performance (ES 0.51) gt metabolic control (ES
  0.46) gt psychological outcomes (ES 0.28) gt
  weight loss (ES 0.16)
• Interventions with regular reinforcement are more
  effective than one-time or short-term education5
• Intervention approaches using informed choices,
  and acquiring skills of self-management,
  including group work, audiovisual aids, and
  behavioral and social learning approaches, were
  more effective than didactic approaches1-5.
• Interventions that involve patient participation
  and collaboration seem to produce more favorable
  effects on glycemic control, weight reduction,
  and lipid profiles than didactic ones6.

1. Padgett, D., Mumford, E., Hynes, M., Carter,
R. (1988). "Meta-analysis of the effects of
educational and psychosocial interventions on
management of diabetes mellitus." Journal
Clinical Epidemiology 14(10) 1007-1030. 2.
Brown, S. A. (1990). "Studies of Educational
Interventions and Outcomes in Diabetic Adults A
Meta-Analysis Revisited." Patient Education and
Counseling 16 189-215. 3. Brown, S. A. (1990).
"Quality of Reporting in Diabetes Patient
Education Research 1954-1986." Research in
Nursing Health 13 53-62. 4. Brown, S. A.
(1992). "Meta-Analysis of Diabetes Patient
Education Research Variations in Intervention
Effects across Studies." Research in Nursing
Health 15 409-419. 5. Ellis, S. E., Speroff, T.,
Dittus, R. S., Brown, A., Pichert, J. W.,
Elasy, T. A. (2004). "Diabetes patient education
a meta-analysis and meta-regression." Patient
Education and Counseling 52 97-105. 6. Norris,
S. L., Engelgau, M. M. Narayan, K. M. (2001).
"Effectiveness of self-management training in
type 2 diabetes a systematic review of
randomized controlled trials." Diabetes Care
24(3) 561-87.
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Empowerment Approach in Diabetes Patient Education

• A promising approach based on key principles
  related to the reality of diabetes, its
  management, and psychology of behavior change
• The patient is the locus of control and decision
  maker in day-to-day mx of diabetes (patient is in
  control)
• HCPs role is to provide ongoing diabetes
  expertise, education, and psychological support
  to enable patients informed decision making
  regarding day to day mx of diabetes (partnership
  relationship informed choice)
• Adults are much more likely to make and maintain
  behavior change if these changes are meaningful
  and freely chosen (emphasize behavior change and
  maintenance)

University of Michigan Diabetes Research and
Training Center (MDRTC)
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Patient Empowerment Philosophy
Advanced Diabetes Nursing Practice
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Empowerment Education in Nurse Clinic Practice

1. A real partnership relationship
2. Knowledge to enable an informed choice

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A Real Partnership Relationship
See how the process takes place ?
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The Patient Needs Insulin Therapy

• Mr. William Wong was referred to the Nurse clinic
  
• M/58, cleansing worker, NSND
• DM for 15 years, deteriorated glycemic control
  (Hba1c 10 ? overall glucose level 14 mmol/L)
  since 6 years ago
• Renal impairment (plasma creatinine 170 mmol/L)
• C/O thirst, polyuria, malaise and weight loss
• Current treatment Daonil 10 mg BD, Metformin 1
  gm BD (a maximum dose)

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The Patient Needs Insulin Therapy

• Short-term Goals of DM management
• Improved glycemic control Hba1c to 7
• Patient understood and accepted insulin
  replacement therapy (to replace the oral drug
  treatment)
• Mastered insulin injection and self-monitoring,
  etc

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The Patient Needs Insulin Therapy
Visit 1 Visit 1
Nurse Informed William about his diabetic control status poor control renal impairment, and the treatment plan glycemic goal, self-care tasks injection and self monitoring of blood glucose (SMBG)
Patient Understood but not ready to accept the twice daily insulin Only agreed to nocte insulin Refused to self monitoring
Nurse Started William on nocte insulin 10u Continued the oral medications Taught him about insulin injection Accepted patient not monitoring, listened to understand his financial concern
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The Patient Needs Insulin Therapy
Visit 2 William returned after 4 weeks gt symptoms improved, had done OK with injection, increased confidence in treatment Visit 2 William returned after 4 weeks gt symptoms improved, had done OK with injection, increased confidence in treatment
Nurse Presented the difficulty in proceeding on the treatment plan without SMBG readings to guide insulin dose adjustment
Patient Showed understanding but said financially not ready Agreed to consider SMBG
Nurse Increased the nocte insulin to 14u basing on fasting CBG 12 mmol/L Ordered blood investigation FBS for the patient upon next clinic visit in 6 weeks time
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The Patient Needs Insulin Therapy
Visit 3 William returned after another 6 weeks gt FBS 10 mmol/L, no more nocturia Visit 3 William returned after another 6 weeks gt FBS 10 mmol/L, no more nocturia
Nurse Explained the progress to William, told him that the target was not achieved Checked injection, etc OK Discussed the need of SMBG and BD insulin
Patient Agreed to start monitoring, but only 1-2 x per week (after serious consideration) Declined BD insulin (too inconvenient, )
Nurse Accepted Williams proposal, advised him to monitor 1 fasting and 1 pre-dinner per week Taught him on self-monitoring technique Decreased his oral drugs to half doses Increased Williams nocte insulin to 18u to 22u to 26u Taught him on insulin use and adjustment principle Ordered blood investigation FBS and Hba1c and RFT upon next visit in 8 weeks time
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The Patient Needs Insulin Therapy
Visit 4 William returned in another 8 weeks time FBS 10.8 mmol/L, Hba1c 8.6, symptoms improved, feeling more energetic Visit 4 William returned in another 8 weeks time FBS 10.8 mmol/L, Hba1c 8.6, symptoms improved, feeling more energetic
Nurse Explained the parameters to William, told him that the target was not achieved Reviewed SMBG readings fasting 10 mmol/L, post-supper gt16 mmol/L Re-iterated to William the need for BD insulin again
Patient Accepted BD insulin Agreed to SMBG 1 day profile per 10 days
Nurse Started William on insulin 20u om and 10u Stopped oral drugs Reinforced on interpretation of SMBG readings and insulin adjustment principle.
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The Patient Needs Insulin Therapy
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Knowledge to Enable an Informed Choice

• Knowledge (1) to enable patient to make
  cost-benefit judgments
• Self awareness knowledge (2) to clarify
  emotional, social, intellectual and spiritual
  components of their lives so that the patient
  can discover her own resources for change and
  control internal discovery

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Background

• Mr. Bang
• 27 years old
• Estate agent
• BW 78 kg (BMI 27.6 kg/m2 )

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• Type 1 Diabetes since 14 years old
• Now mixtard insulin 60 units om, 42 units pm

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Diabetic Control Status

• Poor control for past 6 years
• Hba1c 10 - 12
• Rare self-monitoring his glucose at home
• Drowned in business entertainment and little
  dietary control

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The Danger

• Sudden deterioration in right eye vision
• Pending laser therapy

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The Danger
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The Reflective Journey
What Am I Doing ?
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The Reflective Journey
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Information on Diabetes and Treatment

• What is the diabetes and treatment goal
• Knowledge of diet insulin use
• Treatment options
• BD insulin
• Multiple injections
• Insulin pump therapy

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Knowledge to Enable an Informed Choice
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Thank You !