Transcript Empowerment Practice in Diabetes Patient Education

Empowerment Practice in
Diabetes Patient Education
Kan Ching Yee, Eva
DMNS, AHNH
25th March 2006
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) >
skill performance (ES = 0.51) > metabolic control (ES = 0.46) > psychological
outcomes (ES = 0.28) > weight loss (ES = 0.16)
•
Interventions with regular reinforcement are more effective than one-time or short-term
education5
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Intervention approaches using informed choices, and acquiring skills of selfmanagement, 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
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1. Padgett, D., Mumford, E.,didactic
Hynes, M., &ones
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
1. The patient is the locus of control and decision maker in
day-to-day mx of diabetes (patient is in control)
2. 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)
3. Adults are much more likely to make and maintain behavior
change if these changes are meaningful and freely chosen
(emphasize behavior change and maintenance)
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University of Michigan Diabetes Research and Training Center (MDRTC)
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Advanced
Diabetes Nursing
Practice
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Patient
Empowerment
Philosophy
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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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1. 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
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 :
=> 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
=> 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 William’s 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 William’s 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
Nurse
Explained the parameters to William, told him that the target was not achieved
Reviewed SMBG readings fasting ~ 10 mmol/L, post-supper >16 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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2. Knowledge to Enable an Informed Choice
• Knowledge (1) to enable patient to make costbenefit 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
HELPLESS
right eye vision
• Pending laser
therapy
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The Danger
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The Reflective Journey
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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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2. Knowledge to Enable an Informed Choice
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