With so many advances in treatments and technologies for patients with diabetes, managing the condition has become increasingly complex for both patient and provider. For the nearly 21 million Americans who have diabetes1 and the estimated 39 million who will have it by the year 2050,2 the challenge is to juggle many aspects of their lives with the many demands of therapy.
In addition, because of the serious complications that may ensue when glycemic targets aren't achieved,3, 4 nurses often have the challenging task of translating a treatment regimen into a plan of care that a patient can follow. Nurses must teach and motivate patients to adhere to plans for meals and physical activity, take medications, monitor blood glucose levels, and make frequent adjustments in their self-care. In addition, the psychosocial aspects of managing a chronic condition, which often are placed on the back burner, should be addressed. Nurses possess the necessary skills in patient teaching and coaching, but they need specific strategies for helping patients manage their diabetes more effectively.
THE SYMPOSIUM
To address these concerns, an invitational symposium, the State of the Science on Nursing Best Practices for Diabetes Self-Management, was held in Philadelphia on September 15 and 16, 2006. The planning committee included representatives from the American Association of Diabetes Educators, the American Diabetes Association, AJN, the Joslin Diabetes Center in Boston, and the University of Pennsylvania School of Nursing. Although most of the 50 participants were nurses, there were representatives from other health care disciplines, including nutrition, pharmacy, and psychology; government health, research, and regulatory agencies; the pharmaceutical industry; and people living with diabetes. The American Diabetes Association and industry sponsors (Abbott Diabetes Care, Novo Nordisk, Roche Diabetes Care, Sanofi-Aventis, Takeda Pharmaceuticals North America, BD Medical-Diabetes Care, and Amylin-Lilly) provided funding for the project.
Specific objectives of the symposium were to
* describe issues and obstacles faced by adults with diabetes that influence their management of the illness, including those related to culturally appropriate care and disparities in access to care.
* describe the state of the science on interventions for helping people with diabetes and comorbidities to manage their care.
* identify gaps in the science and barriers to implementing interventions for promoting adherence to short-term and long-term treatment plans across settings.
* achieve consensus on an agenda identifying the clinical, educational, research, and policy priorities for developing best nursing practices that assist patients with diabetes in making lifestyle changes necessary to managing their condition and preventing complications.
* engage the health care community in identifying appropriate roles in various settings that might contribute to interdisciplinary collaboration in promoting wellness and reducing complications.
* disseminate the analysis and recommendations to clinicians, educators, researchers, organizations, policymakers, industry representatives, consumer advocacy groups, and the general public.
During the symposium, authors presented papers on the current state of diabetes care, models for changing both clinician and patient behaviors, and reviews of the research literature. Topics included psychosocial factors, community and public health influences, inadequate health literacy and language barriers, aging and functional disabilities, and comorbidities and complications. Participants also heard presentations from people who have lived with diabetes for more than 20 years. A panel of nurses discussed their experiences of providing care to patients from diverse socioeconomic backgrounds, in settings ranging from small clinics to large medical centers. Participants then worked in small groups and in plenary sessions to develop working lists of research priorities and barriers to optimal self-care and strategies to address them.
After the symposium, the presenters refined their talks into the articles published in this year's supplement to AJN. All the symposium attendees had an opportunity to provide input on the final lists of barriers and strategies (see Table 1, page 74) and research priorities (see Table 2, page 77). The entire AJN supplement is available online at http://www.nursingcenter.com/ajndiabetes.
MAIN THEMES
The health care system is built on an acute care model, with the ill person as the recipient of, rather than a participant in, interventions designed to cure. For patients with chronic and progressive conditions such as diabetes, this model is not useful for preventing serious complications and comorbidities or for enhancing the quality of their lives. An acute care model is reactive, with involvement of the health care system after a complication of diabetes occurs and the quality of the patient's life is adversely affected. A chronic care model, on the other hand, is proactive, with the health care system working to prevent complications and maintain the quality of the patient's life at a reasonable level.5 Models of diabetes care must take into account the chronic nature of the condition and its public health implications, as well as the roles the patient and family play in achieving treatment goals.
Supporting people with diabetes in their efforts to manage the illness requires an understanding of behavioral change and appropriate interventions. Several metaanalyses have demonstrated that diabetes education, particularly those programs with a behavioral or psychological component, can motivate people with diabetes to improve their self-care and glycemic control, particularly in the short term.6-10 How to sustain these improvements in the long term is an important area for nurses' consideration; nurses must consider, for example, how necessary the patient thinks the required change is and how involved that person wants to be in self-care. By using a patient-centered empowerment model that fosters collaboration and builds relationships with patients when providing clinical care, nurses can help ensure that the person with diabetes makes informed decisions about self-care and assumes responsibility for healthful choices in everyday life.
Health literacy, the ability to understand and follow health care prescriptions and recommendations, is necessary for diabetes self-management. It contributes to problem-solving and decision-making skills that are necessary to interpret and use health care information. Thus, health literacy goes beyond reading; it also includes listening, speaking, writing, interpreting numbers, and questioning.11 Nurses in all settings need simple tools to assess health literacy and overcome barriers associated with low literacy levels.
Most studies of psychological factors and the influence of family and other social support on diabetes self-care behaviors were cross-sectional and correlational in design. Many of these studies examined social support within a specific cultural context. In general, these studies found that people with more social support perform self-care more frequently.12-14 However, the areas in which support is needed may differ according to the person's age, the quality of a marital relationship, or the patient's race or ethnic background.
People with diabetes are at risk for severe complications that can affect their ability to care for themselves. For example, vision loss associated with retinopathy, macular degeneration, glaucoma, and cataracts is more common in people with diabetes. Loss of vision makes it difficult and sometimes unsafe for them to inject insulin, take oral medications, monitor glucose levels, check their feet, and perform other self-care activities. Further, the development of complications makes the treatment regimen more complex. With aging, people with diabetes are more susceptible to common yet serious comorbidities, including hypertension, dyslipidemia, and cardiac disease. Cognitive disruptions may include memory loss and subtle impairment of executive function.15, 16
People with diabetes are at higher risk for depression than the general population.17, 18 And depression is associated with poorer glycemic control and less frequent performance of self-care behaviors.19-21 Treating depression alone does not improve self-care.22 Patients with depression need additional support to achieve glycemic targets.
Diabetes is a major public health problem requiring community monitoring, system changes to improve access to health care, and formulation of public policies at the national, state, and local levels. One major issue in need of policy change is reimbursement for nursing services related to patient self-management. Research demonstrating the effectiveness and cost-effectiveness of nursing interventions for patients with diabetes is needed to support such a change. The health care system needs to ensure coordination of care across multiple providers and use of appropriate resources. Nurses can spearhead the creation of a system to ensure communication among providers, especially when a patient sees multiple specialists.
Hospitalization may be an opportunity for diabetes self-management education. One challenge is to train and engage hospital staff in the important advances that have been achieved in diabetes care, education, and technology. Another challenge is to ensure a smooth transition from inpatient to outpatient care and support. Changes in health care systems, such as use of electronic medical records and automatic enrollment of newly diagnosed patients into diabetes education programs, can help ensure that no patient with diabetes is lost in the complex health care system. Diabetes case management can smooth the transition from hospital to home and prevent readmission. Having a system of communication between the hospital and home care or visiting nurse service is essential, as is a follow-up plan for continuing self-care training in the primary care setting.
Nurses, who are present in virtually every health care setting, can seize the opportunity to help people with diabetes follow their treatment regimens and achieve better outcomes. Patients with diabetes often are overwhelmed with information and don't know how to integrate the various and sometimes conflicting treatment recommendations into their lifestyle. By building relationships with patients through listening, coaching, and modeling survival skills, nurses can help patients be more confident in their ability to manage the disease. Nurses should be proactive in reviewing the treatment regimen with the patient, identifying barriers to self-care, and brainstorming solutions with the patient to address these barriers. Nursing should take a leadership role in designing systems to communicate among providers so that patients receive consistent, ongoing education and support. Inpatient and outpatient visits are opportunities to assess patient knowledge and the need for treatment modifications, especially as new therapies emerge.
Given the chronic and progressive nature of diabetes, an interdisciplinary team is necessary. Nurses can assume the role of coordinator in such a team.
REFERENCES