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

Intensive Insulin Therapy Program (IITP) in PWH

Picture of Peer Group Education Session

Intensive Insulin Therapy Program (IITP) in PWH

Picture of Peer Group Education Session

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

Weight Management Program for Patients with Diabetes in PWH

Patient-led Exercise Session

Weight Management Program for Patients with Diabetes in PWH

Patient-led Discussion Session

Weight Management Program for Patients with Diabetes in PWH

Patient-led Discussion Session

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

Thank Youfor

Your Participation