advanced nursing practice in diabetic care outcome of empowerment in diabetes education rebecca yee...
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Advanced Nursing Practice in
Diabetic Care
Outcome of Empowerment in
Diabetes Education
Rebecca Yee Man WONGRN, BN, MSc
Nurse Specialist (Diabetes Care)Diabetes & Endocrine Centre
Prince of Wales HospitalHong Kong SAR
Diabetes Mellitus
• Diabetes is a chronic disease
A successful diabetes treatment program requires patients’active involvement in the management of diet, exercise and medication
• Making changes in their lifestyle is one of the greatest challenges patients face in controlling their diabetes
Diabetes Mellitus
• Glycemic control is an important predictor of many of the chronic complications of diabetes
ADA Position Statement 2001
Diabetes Control and Complications Trial (DCCT)
• Significant risk reduction with tight glucose control
• Reductions in microvascular complications with HbA1c = 7.2% :
- 76% retinopathy
- 60% for neuropathy
- 56% for nephropathy
N Eng J Med 1993;329:683-689
United Kingdom Prospective Diabetes Study (UKPDS)
• For every 1% reduction in the HbA1c, there is a 35% reduction in microvascular complications:
- Control group 7.9%
- Intervention group 7%
Lancet 1998;352:837-853.
Results of Diabetes Self-Management Education (DSME)
on Glycemic Control• Systematic review reports of 31 published,
randomized controlled trials to ascertain the efficacy of diabetes self-management education (DSME) in adults with type 2 diabetes
• Examine the effect of baseline HbAlc, follow-up interval and intervention characteristics on HbAlc
• HbA1c improved with DSME, with an average change of 0.76%
Norris et al., 2002
Results of Diabetes Self-Management Education (DSME) on
Glycemic Control• HbA1c was lowered in patients who received education
from dieticians or diabetes nurses than those who had not (7.9% vs 8.7% )
Chan et al., 2000
• Patients discharged early and received a follow up programme by diabetes nurse specialist had a decrease in HbA1c at 24 weeks when compared with those who remained in hospital until the glycemic control is stable (7.6% vs 8.1%)
Wong et al., 2004
Intensive Insulin Therapy Program (IITP) in PWH
• Pilot program started since 1998• Saturday morning session in Diabetes
Centre• Target groups :
- Type 1 and Type 2 patients with multiple dose injection per day (MDI),
- BD injection pending to MDI - Patients with insulin pump
Intensive Insulin Therapy Program (IITP) in PWH
Our Objectives
• To offer Diabetes self care knowledge and skills
• To enhance participants’ self-efficacy in disease management
• To facilitate peer group support and sharing
Intensive Insulin Therapy Program (IITP) in PWH
Contents of the Empowerment program :
• Patient contract
• Intensive education
• Group sharing
• Clinic follow up
• Lunch together
Intensive Insulin Therapy Program (IITP) in PWH
• Patients with insulin pump are designated as group leaders to lead the experience sharing
• DM nurses as partners to provide information on diabetes self care knowledge and skills
• Other health care professionals such as dietitians, doctors to give education on specific topics
Intensive Insulin Therapy Program (IITP) in PWH
Topics of the IITP Education Program:
• Diet : food exchange, food labels, glycemic index, dining out• Exercise and weight reduction• Insulin dose adjustment• Self Monitoring of Blood Glucose (SMBG)• Acute complications : Diabetic ketoacidosis, Hypoglycaemia• Special issue : traveling, sick day management• Stress management
Intensive Insulin Therapy Program (IITP) in PWH
Mode of education delivery
- Group- Role play- Games- Competition
Program duration
- 22.9 ±11 months- 6.74 ± 2.9 visits
Intensive Insulin Therapy Program (IITP) in PWH
A summary of subjects’ characteristics n=39
Characteristics Frequency (%)
Male 19 (48.7%)
Female 20 (51.3%)
Age : 18 – 25 8 (20.5%)
26 – 35 13 (33.3%) mean 34.48±9.33
36 - 45 14 (35.9%)
46 – 53 4 (10.3%)
Type 1 32 (82.1%)
Type 2 7 (17.9%)
MDI 24 (61.5%)
BD injection 15 (38.5%)
Intensive Insulin Therapy Program (IITP) in PWH
p<0.00123.6 4.222.8 4.2BMI
p<0.00162.6 10.660.7 10.6 BW(kg)
p<0.00017.8 1.48.7 1.7HBAlc(%)
P valueUpon completion of the programme
Before joining the programme
Results
Intensive Insulin Therapy Program (IITP) in PWH
Conclusion
• Up to 12/2005, total no. of patients on multiple dose insulin injection (>4 times injection per day) : 258,
increase in 10 folds at 5 years
• Friday afternoon session in diabetes specialist clinic– Group education session and experience sharing– Clinic follow up visit
Weight Management Program for Patients with Diabetes in PWH
• Pilot programme:12.2003-3.2004 (14 weeks)
• Target group : type 2 patients with BMI over 25
• Organised by DM nurses and social worker from Centre of Rehabilitation Network
Weight Management Program for Patients with Diabetes in PWH
Our Objectives
• To facilitate participants in learning various weight management skills and knowledge.
• To enhance participants’ self-efficacy in disease management.
• To promote lifestyle modification through psychosocial interferences by group dynamic and peer support.
Weight Management Program for Patients with Diabetes in PWH
• A total of 7 sessions
• Each session was focused on different themes
• Diabetes self-care knowledge was incorporated
- general concepts- individual counseling - exercise, diet therapy - lifestyle modification- stress management - common myths
Weight Management Program for Patients with Diabetes in PWH
Contents of the Program :
- Lecturing- Practicum- Sharing - Therapeutic Games
Weight Management Program for Patients with Diabetes in PWH
Mode of delivery:
• Telephone follow-up by social worker in between of visits
• Weekly peer-group partner’s phone contact
• Learning contract
• Biweekly objectives were set with participants
Weight Management Program for Patients with Diabetes in PWH
Pre & Post Assessment tools :
- Diabetes knowledge score (DKN)
- Self-efficacy rating on disease management
- Health parameters e.g. BW, HbA1c and lipids profile.
Weight Management Program for Patients with Diabetes in PWH
Overview of the patient group:
• Total no. of patients : 6
• Female : 6
• Occupation : housewife
• Age: 45-53
• Initial BW: 68.9kg - 93.9kg
• Initial BMI: 30.8 - 35.7kg/m/m
Weight Management Program for Patients with Diabetes in PWH
Pre program Post program
DKN (n=15) 6.7 11.7
Self efficacy (n=10) 6 7.1
BW (kg) 77 76.4
Fat Mass (kg) 36.1 35.5
HbAlc (%) 7.3 6.7
Cholesterol (mmol/l) 4.9 4.7
Triglyceride (mmol/l) 2.12 2
Results
Weight Management Program for Patients with Diabetes
Type 2 diabetes
Twelve aerobic training studies and two resistance training studies were included (total 504 subjects). Post intervention HbA1c was significantly lower in exercise than control groups (7.65 vs. 8.31%). But post intervention body weight did not differ between exercise and control groups.
Boule et al 2001
Weight Management Program for Patients with Diabetes in PWH
Conclusion
• A significant improvement in health parameters should be
proven in the future programme.
• Mutual-aid support group (fit 形糖 ) was set up in 5/2004
• Frequency of group meeting : once a month
• No. of attendance per visit : 25 – 35 patients
• Patient as group leader to lead other patients to do exercise and
experience sharing
• DM nurses and social workers as partners to provide update
information regarding diabetes related knowledge and psycho-
social support
Constraints of the Empowerment Program
Healthcare Administrators• Acute, symptom-driven patient-care
• Limited resources
Practitioners• DSME program is complex
• Limited resources
• High volume patients load
• No time
Constraints of the Empowerment Program
Patients
• Ability to comprehend the materials
• Lifestyle; socio-cultural, health belief
• Motivation and collaboration
• Financial issue
We are each of us angels with only one wing, and we can only fly
by embracing one another
Luciano de Crescenzo