Advanced Nursing Practice in Diabetic Care Outcome of Empowerment in Diabetes Education

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Advanced Nursing Practice in Diabetic Care
Outcome of Empowerment in Diabetes Education

• Rebecca Yee Man WONG
• RN, BN, MSc
• Nurse Specialist (Diabetes Care)
• Diabetes Endocrine Centre
• Prince of Wales Hospital
• Hong Kong SAR

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Diabetes Mellitus

• Diabetes is a chronic disease
• A successful diabetes treatment program
  requires patientsactive 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

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Diabetes Mellitus

• Glycemic control is an important predictor of
  many of the chronic complications of diabetes
• ADA Position Statement 2001

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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 1993329683-689

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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 1998352837-853.

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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

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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

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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
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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

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Intensive Insulin Therapy Program (IITP) in PWH

• Contents of the Empowerment program

• Patient contract
• Intensive education
• Group sharing
• Clinic follow up
• Lunch together

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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

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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

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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

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Intensive Insulin Therapy Program (IITP) in PWH

• A summary of subjects characteristics n39

Characteristics Frequency ()
Male 19 (48.7)
Female 20 (51.3)
Age 18 25 8 (20.5)
26 35 13 (33.3) mean 34.489.33
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)
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Intensive Insulin Therapy Program (IITP) in PWH
Results
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Intensive Insulin Therapy Program (IITP) in PWH

• Conclusion
• Up to 12/2005, total no. of patients on multiple
  dose insulin injection (gt4 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

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Intensive Insulin Therapy Program (IITP) in PWH

• Picture of Peer Group Education Session

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Intensive Insulin Therapy Program (IITP) in PWH

• Picture of Peer Group Education Session

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Weight Management Program for Patients with
Diabetes in PWH

• Pilot programme12.2003-3.2004 (14 weeks)
• Target group type 2 patients with BMI over 25
• Organised by DM nurses and social worker from
  Centre of Rehabilitation Network

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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.

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Weight Management Program for Patients with
Diabetes in PWH

• A total of 7 sessions
• Each session was focused on different themes

- general concepts - individual counseling -
exercise, diet therapy - lifestyle
modification - stress management - common myths

• Diabetes self-care knowledge was incorporated

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Weight Management Program for Patients with
Diabetes in PWH
Contents of the Program
- Lecturing - Practicum - Sharing -
Therapeutic Games
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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 partners phone contact
• Learning contract
• Biweekly objectives were set with participants

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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.

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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

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Weight Management Program for Patients with
Diabetes in PWH
Results
Pre program Post program
DKN (n15) 6.7 11.7
Self efficacy (n10) 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

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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
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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 ??) 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

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Weight Management Program for Patients with
Diabetes in PWH

• Patient-led Exercise Session

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Weight Management Program for Patients with
Diabetes in PWH

• Patient-led Discussion Session

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Weight Management Program for Patients with
Diabetes in PWH

• Patient-led Discussion Session

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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

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Constraints of the Empowerment Program

• Patients
• Ability to comprehend the materials
• Lifestyle socio-cultural, health belief
• Motivation and collaboration
• Financial issue

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We are each of us angels with only one wing, and
we can only fly by embracing one
anotherLuciano de Crescenzo
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Thank Youfor Your Participation