Nuts and Bolts of Diabetes Education for Nurses Susan Porter MS, CRNP, CDE Susan Renda DNP, CRNP, CDE Johns Hopkins Comprehensive Diabetes Center
Objectives The participant will: Identify opportunities in their practice to provide diabetes education. Explain strategies to improve the cultural competency of diabetes education initiatives. Be able to quickly convey a teaching point to a patient and receive feedback to evaluate comprehension.
Current State of Diabetes 29.1 million people or 9.3% of the US population have diabetes and the number is steadily growing Retrieved from: http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html
Impact of Nurses in Diabetes Education 34 randomized controlled trials (5993 patients) of nurse-led diabetes selfmanagement education (DSME) were reviewed. Mean change in A1C was a reduction by -0.70% for nurse-led DSME versus -0.21% with usual care. Nurse-led DSME was also associated with improvements in cardiovascular risk factors. Tshiananga, JK, Kocher, S, Weber, C, Erny-Albrecht, K, Berndt, K, & Neeser, K (2012). The effect of nurse-led diabetes self-management education on glycosylated hemoglobin and cardiovascular risk factors: A metaanalysis. Diabetes Educator, 38(1), 108-123.
Settings Where do you encounter people with diabetes? Inpatient Global Nurse Local Outpatient
Seize the Opportunity!! All encounters with patients can be teaching encounters Assess baseline knowledge and health literacy level Find out what the patient needs and wants to know Keep it short Evaluate understanding
Adapt! Culturally appropriate education Ask preferences Learn about common practices, foods, and beliefs in your patient population Examples. Health literacy/literacy Don t assume patient understands Written material will be understood by 90% of the population if at a third grade level. Use of tools such as Flesch-Kincaid readability
Strategies Effective communication--reflective listening Ask an open ended question. Tell me about Listen. Repeat back to patient what they said What is most difficult about caring for your diabetes? It sounds like it s hard for you to take your pills every day because it is a constant reminder that you have diabetes versus If you don t take you pills every day you may end up losing your eyesight
Strategies Avoiding traps Giving false reassurance Giving unwanted advice Using authority Avoidance language Leading questions Talking too much Interrupting Why Overuse of professional terminology
Motivational Interviewing Ask permission to talk about diabetes. Elicit change talk What would you like to see different about your diabetes? Look at extremes; look forward. On a scale of 1-10, how likely are you to change? Normalize difficulties about change. Written goals. Affirmation/praise. Advice and feedback.
Setting Goals Mutually set goals with the patient: Identify the problem Explore feelings Set a goal Evaluate results Goals healthy eating, physical activity, monitoring, risk reduction, taking medications, problem-solving, stress management/healthy coping
Successful Behavior Change Does your patient have self efficacy? How do you help increase self efficacy? Explore feelings, concerns, and barriers. Involve family, friends, community. Manage follow-up and work with the health care team.
Evaluating and Maintaining a Goal What did you learn? What worked? What didn t work? What support did you have? Look for successes even if small.
Dealing with Relapse Return to previous behavior. The patient may feel embarrassed, like a failure, and may avoid coming for appointments. Intervention: avoid judgments about the relapse create a comfortable/supportive relationship with the patient explore the causes of the relapse and begin to set goals again
Noncompliant Patient Patients who have the most difficulty following a diabetes regimen have issues with one or all of the following areas: EDUCATIONAL EMOTIONAL LOGISTICAL
Clinical Pearls for Delivering Content Nutrition Physical Activity Monitoring Taking medications (especially that move to insulin)
Meal Planning: Healthy Nutrition
Nutrition 5 minute consult There isn t a single thing someone with diabetes can t eat all about portion and how often it is healthy. 24 hour meal plan history Carbs, fats, proteins What about special DIETS? Utilize your dietitian colleagues.
Nutrition Pick a few manageable goals to start. For example, three goals: 1) Eat a larger portion of vegetables and smaller portion of starch. 2) Eat breakfast every day. 3) Drink more water and less juice or soda.
Physical Activity Benefits Lose weight and/or maintain weight loss Lower blood glucose level Lower blood pressure Lower cholesterol Increase energy level Improve sleep and mood Keep bones strong
Recommendations Thirty minutes of increased activity at least 5 days/week. Light weights for toning and strength 3 times a week. Start slow and consult with provider.
More Recommendations Check glucose before and after activity. Do not exercise if glucose is over 250. Carry a sugar source in case of a low glucose. Wear proper footwear.
Monitoring Glucose
Monitoring Benefits of self monitoring of blood glucose. Check impact of: Meals Medications Activity Illness
Monitoring Fasting before meals 70-130mg/dl Two hours after a meal <180 mg/dl How to make the most use of the finger sticks. Proper technique Record keeping
Medications Progressive nature of type 2 diabetes medications will be necessary and for the majority, insulin will eventually be needed. Other medications for comorbidities will also be needed. Explore fears about medications. Patients have choices. Consider cost. Dispel myths. Explain, explain, explain and have the patient repeat back.
Time for Role Play
Conclusion and Questions
References American Association of Diabetes Educators (2003). A Core Curriculum for Diabetes Education 5th ed. Chicago: AADE. American Diabetes Association (2015). Standards of medical care in diabetes. Diabetes Care, 38:S1-S2 Centers for Disease Control, National Diabetes Statistics Report, 2014. Retrieved from: http://www.ced.gov/diabetes/pubs/statsreport14/national-diabetes-report-web.pdf Coyne N. & Correnti D. (2014). Effectiveness of motivational interviewing to improve chronic condition self-management: what does the research show us? Home Healthcare Nurse. 32(1):56-63. Hall, K., Gibbie, T. & Lubman, D. (2012). Motivational interviewing techniques - facilitating behaviour change in the general practice setting. Australian Family Physician. 41(9):660-7. McGowan, P. (2013). The challenge of integrating self-management support into clinical settings. Canadian Journal of Diabetes. 37(1): 45 50. Purnell, L.D. (2005). Culturally Competent Health Care. 2nd ed. Philadelphia: E.A. Davis. Spector, R. (2009). Cultural diversity in health and illness 7th ed. New Jersey: Prentice Hall. Tshiananga, J. K., Kocher, S., Weber, C., Erny-Albrecht, K., Berndt, K., & Neeser, K. (2012). The effect of nurse-led diabetes self-management education on glycosylated hemoglobin and cardiovascular risk factors: A meta-analysis. Diabetes Educator, 38(1), 108-123