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Q & A: Individualizing care and diabetes

Friday July 18, 2014
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We discussed diabetes care with Katie Weinger, RN, EdD, FAADE, associate professor of psychiatry at Harvard Medical School in Boston, investigator in clinical behavioral and outcomes research at Joslin Diabetes Center and director of the Center for Innovation in Diabetes Education. Weinger received the American Diabetes Association Outstanding Educator in Diabetes award earlier this year.

Q. Can you share with us some of the key points in your recent lecture, ďSix Impossible Things Before Breakfast: Examining Diabetes Self-Care.Ē

A. I spoke about the individualization of care and how that can be accomplished as well as the types of barriers that people face. When we talk about the phases of living with a chronic illness, we can think about those just recently diagnosed. Then there is the maintenance phase, a time when complications can be prevented but also a time when people are distracted by other competing events ó marriages, births, divorces, new jobs and environmental job stress. The next phase is when symptoms show up of early complications with the eyes, kidneys, nervous system, neuropathy.

This can be a very difficult time. Some become motivated; others incapacitated. It can be devastating for people and their families, and they can become unable to manage their diabetes any longer. Depending on their response, patients need different approaches, different education,and may require different support for nurses to consider. The last phase is when complications dominate; complications and co-morbidities can become so severe that diabetes becomes a lower priority because other things take precedence. Sometimes patients have a whole new healthcare team and different priorities. Nurses have to remember that.

Q. Given the current healthcare system, how can nurses empower patients with diabetes in self-care and wellness?

A. Nurses must remember diabetes is a chronic illness. Some of the issues faced are long term. With every change in life, every life event, new barriers and new problems will arise that the patient has to overcome. So the patient is not looking for the nurse to fix a current problem. The patient is looking to the nurse for help with figuring out how to live with diabetes successfully. They need help in figuring out strategies and finding out information for various problems that crop up in life. They need emotional support when they have adolescent children or when children get married.

When events happen, diabetes can be pushed to the back burner and they need help in getting through that time. It is the job of nurses as diabetes educators and other members of the healthcare team to help patients learn to live with diabetes. They donít need to be problem fixers but rather they need to be supportive and help people learn how to live with the disease and to incorporate diabetes self-care into their lives.

Q. What words of advice would you give to nurses who are caring for patients with diabetes in the hospital setting and in the ambulatory care setting?

A. Be very careful about using pejorative terms or blaming or shaming. People with diabetes can often blame themselves and be very hard on themselves when not living up to standards of healthy living. It is not helpful for patients to be negative and blame themselves, and is not good for the healthcare team. Patients with diabetes tend to have more distress and elevated depressive symptoms than the general population. So itís imperative that when patients start blaming themselves and are using terms such as, ĎIíve been bad this week; Iíve been a bad patient,í nurses can say, ĎNo, no. What happened? Letís figure out what can be done next time. Weíll have strategies in place when it comes up again.í

There are different strategies that nurses can use to support patients and prevent some of these negative effects from influencing patientsí lives. Blaming is not helpful. It keeps patients from figuring out strategies to overcome barriers.

When someone starts blaming themselves, the nurseís first reaction may be to tell them they are fine and leave the topic because it is upsetting. But the patient may need some support in that area and advice. ĎLetís think about how we can solve the problem in the future.í Not every strategy will work. It takes experimentation. If it doesnít work, try something else. Try to alleviate the blaming and shaming that is prevalent throughout diabetes. Also, in both the hospital setting and the ambulatory setting, nurses should not be tempted to try to cram too much information at one time. There is only so much any human brain can learn at one time even though they may need to know everything. It canít be done all at once. Nurses need to provide information and skill training in a stepped, reasonable manner so that patients can learn to adapt those skills to their lifestyles. One canít learn all about diabetes in one hour. It canít be done.

Q. In your research on diabetes, what have you discovered are the most influential factors that affect patientsí managing their disease?

A. Diabetes is a long-term chronic illness that requires medical treatment and many lifestyle adjustments to maximize health and quality of life. So the types of barriers that people face are different. Thereís not a one size fits all in diabetes. It depends on a personís characteristics that mark them as an individual. There are immediate social situations, family issues, where they work and then other factors that are in their broader environment including whatís available in the community as resources for them and how much access they have to healthcare.

These are very broad categories. And within each category there are many facets that have to be assessed for each individual. Some work for some people but not for others. Depression and distress are associated with diabetes, and they can impact how well people can manage diabetes. The personís organizational skills are also a factor. Iím not talking about intelligence. Iím talking about organizational and planning abilities Ė how well they can integrate diabetes self-care into their lifestyles. Thereís not one or two most influential factors as each person may differ. Each nurse, each educator has to access the person as a whole and discover barriers and challenges for that particular person and family.

To see what else is trending, visit www.Nurse.com/Diabetes.


Joe Grace is special topics editor. To comment, email specialty@nurse.com.