Patient empowerment. Results of a randomized controlled trial

OBJECTIVE

The purpose of this study was to determine if participation in a patient empowerment program would result in improved psychosocial self-efficacy and attitudes toward diabetes, as well as a reduction in blood glucose levels.

RESEARCH DESIGN AND METHODS

This study was conducted as a randomized, wait-listed control group trial. The intervention group received a six-session (one session per week) patient empowerment education program; the control group was assigned to a wait-list. At the end of 6 weeks, the control group completed the six-session empowerment program. Six weeks after the program, both groups provided follow-up data.

RESULTS

The intervention group showed gains over the control group on four of the eight self-efficacy subscales and two of the five diabetes attitude subscales. Also, the intervention group showed a significant reduction in glycated hemoglobin levels. Within groups, analysis of data from all program participants showed sustained improvements in all of the self-efficacy areas and two of the five diabetes attitude subscales and a modest improvement in blood glucose levels.

CONCLUSIONS

This study indicated that patient empowerment is an effective approach to developing educational interventions for addressing the psychosocial aspects of living with diabetes. Furthermore, patient empowerment is conducive to improving blood glucose control. In an ideal setting, patient education would address equally blood glucose management and the psychosocial challenges of living with diabetes.

Guidelines for facilitating a patient empowerment program

The traditional medical treatment model often ignores the emotional, spiritual, social, and cognitive aspects of living with a chronic disease such as diabetes. Empowerment programs address these psychosocial areas by helping individuals develop skills and self-awareness in goal setting, problem solving, stress management, coping, social support, and motivation. Although many diabetes educators have been taught to use an empowerment curriculum to facilitate self-management, there is minimal research concerning the actual process of providing such programs to patients. We evaluated an empowerment curriculum (Empowerment: A Personal Path to Self-Care) with a diverse group of individuals with diabetes to determine the key elements of planning and implementing a successful diabetes patient empowerment program.

Diabetes care policies and practices in Michigan nursing homes, 1991

OBJECTIVE

To describe local standards of care for nursing home patients with diabetes, to characterize the care that nursing home patients with diabetes receive in Michigan, and to determine if the care provided meets local and national standards.

RESEARCH DESIGN AND METHODS

In March 1991, a questionnaire was administered and chart reviews were conducted as part of the Medical Review and Nursing Evaluation conducted by the Michigan Department of Public Health. The questionnaire was completed by the head nurses at 17 skilled nursing homes to learn about local institutional standards of care. Chart reviews were conducted on a sample of five patients with diabetes from each nursing home to describe the care provided and to compare it with local and national standards.

RESULTS

Almost all nursing homes had some diabetes care orders or protocols. Standing orders were most often present to guide nutritional and nursing care (e.g., diet, blood glucose monitoring, foot care). Standing orders were less often present to guide medical care (e.g., blood glucose parameters to contact physician) and surveillance of complications (e.g., eye exams). In general, the care provided did not meet local or national standards for diabetes care. Care practices were closer to national standards when registered dietitians (RDs) participated in meal planning and written institutional policies existed.

CONCLUSIONS

In this sample of Michigan nursing homes, those with RDs and standing orders provided care more in keeping with guidelines. There is room for improvement in diabetes care practices in nursing homes. It may be time for diabetes-related organizations to re-examine standards for diabetes care in nursing homes.

The diabetes education experience of randomly selected patients under the care of community physicians

The purpose of this study was to describe the diabetes education and nutritional counseling received by patients under the active care of community physicians. The study population consisted of 440 patients with diabetes from the practices of 68 primary care physicians in eight Michigan communities. Fifty-eight percent of the sample reported having received diabetes education, and the mean number of years since the most recent education was 4.15 years. Sixty-six percent reported having seen a dietitian. Patients who had received diabetes education scored higher on a basic diabetes knowledge test (70% correct vs 60%) than patients who had not received diabetes education. From 1981 to 1991, a decline was observed in the percentage of patients who reported having received diabetes education (70% to 58%). Although patient education is an integral part of comprehensive diabetes care, too few patients are receiving it. Furthermore, diabetes education often results in less-than-optimal levels of knowledge. The situation has deteriorated over the past 10 years, and patients who are not on insulin typically are the least well served.

Adapting a diabetes patient education program for use as a university course

A study was conducted to determine if a patient education program, "Life With Diabetes," could be converted to an undergraduate course. The course consisted of seven 2-hour sessions with presentations by a physician, dietitian, psychologist, and clinical nurse specialists. Topics included definition, treatment, nutrition, monitoring, children, older adults, and patient empowerment. A total of 52 students (45 without diabetes, 7 with diabetes) have completed this one-credit course. A patient diabetes knowledge test and a 50-item Diabetes Attitude Survey were administered before and after the course. For the students without diabetes, mean knowledge posttest scores improved significantly, and significant changes were seen on the attitude subscales, with posttest scores moving closer to those of a national panel of diabetes experts. Students with diabetes scored closer to the national panel on the pretest and improved significantly only on the patient autonomy subscale. This course measurably improved knowledge and attitudes among undergraduates, suggesting that a patient education program can be adapted successfully to provide additional training opportunities for diabetes education programs.

Evaluation of an activated patient diabetes education newsletter

This study evaluated a monthly, activated patient newsletter sent to over 7000 patients in Michigan with diabetes. The newsletter provided concise and action-oriented information about diabetes care. Patients who had signed up to receive the newsletter during the first 4 months of the project (1863) were surveyed to determine how many patients found the newsletter helpful; 80% (1498) of the patients replied. Patients who found the newsletter most helpful were older; had lower incomes, and reported more complications, less understanding of diabetes, and being in poorer overall health. They also were more likely to have non-insulin-dependent diabetes mellitus (NIDDM) than insulin-dependent diabetes mellitus (IDDM). We concluded that the activated patient newsletter is a useful public health/patient education intervention for persons with diabetes. Such a newsletter should be part of a coordinated system of ongoing patient care, education, screening, and social and psychological support.

A prospective study identifying risk factors for discontinuance of insulin pump therapy

OBJECTIVE

To identify characteristics of adult patients at baseline associated with duration of subsequent, continuous, subcutaneous infusion of insulin treatment (pump therapy) of type I diabetes.

RESEARCH DESIGN AND METHODS

For 6 wk, patients followed a standardized conventional therapy and kept a record of insulin dosages, capillary blood glucose concentrations, and symptomatic hypoglycemia. They were then hospitalized. Additional baseline data were obtained and pump therapy was started. Survival analysis was used to determine the relationship between baseline independent variables or risk factors and duration of pump therapy, which is the dependent variable.

RESULTS

Of the 68 participants, 33 (49%) terminated pump therapy after an average of 9.9 mo of treatment. Two models (each P < 0.00005) were developed that exhibited a high degree of consistency. Of the 6 variables, 5 were common to both models (HbA1, autonomic neuropathy, mean amplitude of glycemic excursions, frequency of symptoms of hypoglycemia when blood glucose was < 70 mg/dl, and erythema at injection sites). The sixth variable in model 1 (insulin dosage) was replaced in model 2 by a variable, Adult Self-Efficacy for Diabetes, which was obtained on the 33 more recently enrolled patients; this variable related to patient perceptions of self-care behaviors.

CONCLUSIONS

We found that, at baseline, the presence of a high concentration of HbA1 and a low estimation by the patient of their ability to treat the disease portend failure of insulin pump therapy as evidenced by its discontinuation. This effect is accentuated when clinical evidence of autonomic neuropathy is observed. These findings offer guidance in selecting patients with type I diabetes for insulin pump therapy.

The challenges of diabetes and older adults

Diabetes is a chronic illness that affects a disproportionate number of older adults and members of ethnic minorities. It is an illness that requires long-term active patient participation to maintain metabolic control and challenges both the patient and health care provider. The need for the patient to carry out daily self-care behaviors is no less important simply because the person is older. Older adults, however, experience unique challenges because of the physical and functional changes that may be imposed by the aging process and the prevalence of multiple chronic illnesses and complications. Because diabetes self-care is carried out within the context of all aspects of a person's life, it is important, then, for the health professional to recognize these social, functional, and psychological challenges. All aspects of physical, functional, and psychosocial status need to be taken into account, and diabetes education needs to be provided based on jointly identified goals, interests, abilities, and needs.

Influencing the attitudes of medical students toward diabetes. Results of a controlled study

OBJECTIVE

To determine the effect of two educational interventions on the diabetes-related attitudes of medical students.

RESEARCH DESIGN AND METHODS

We studied 67 junior and senior medical students who were participating in the University of Michigan Medical School's Family Practice elective clerkship. Students were assigned to one of two interventions. The first was a 1-wk living-with-diabetes behavioral simulation that involved injections, blood glucose monitoring, diet, exercise, and record keeping. The second intervention involved reading an autobiography about living with diabetes and viewing a videotape about the psychosocial impact of diabetes.

RESULTS

No differential impact was found between the two interventions. However, both interventions were followed by a modest positive change in the attitudes of the medical students (which were very positive to begin with) toward the importance of patient autonomy and the value of the team approach to diabetes care. The attitude gains persisted at follow-up for patient autonomy but returned to baseline for team care.

CONCLUSIONS

This study suggests that these two educational interventions resulted in modest increases in the already positive attitudes of medical students toward the importance of patient autonomy and team care in diabetes. However, because the study did not include a group that received no treatment, we cannot be certain on this point. The attitude gain related to team care did not persist at follow-up. These findings are consistent with classical attitude research, which suggests that attitudes are sensitive to influences such as these interventions, but that attitude changes may not persist when those influences are changed or withdrawn. We were not able to find a differential impact between the two interventions and suspect that the general nature of the DAS used as the dependent measure may not have been sensitive enough to capture such a differential impact.

Perceived effectiveness, cost, and availability of patient education methods and materials

To determine the efficacy of and need for patient education methods and media, a needs assessment was sent to 816 members of the American Association of Diabetes Educators. Respondents (n = 325, 40%) included 62% RNs, 36% RDs, 1% other; 62% CDEs. Their mean number of years experience in diabetes education was 8.5, and 99% routinely provided patient education. Respondents indicated that videotapes and slide tapes were the most educationally effective media and books and audiotapes were the least effective. Booklets and videotapes were the most cost-effective and computer-assisted instruction the least effective. While respondents perceived one-to-one counseling, skills training, and diabetes content sessions to be the three most educationally effective methods, support groups and large and small discussion groups were seen as the three most cost-effective educational methods. Among nine potential barriers to quality patient education listed, educators rated lack of third-party reimbursement as a major barrier most frequently and national availability of quality education materials as a barrier least frequently.

Learning to empower patients. Results of professional education program for diabetes educators

The patient empowerment approach to diabetes education is intended to enable patients to make informed decisions about their own diabetes care and to be fully responsible members of the health-care team. Facilitating patient empowerment requires a specific set of skills and attitudes on the part of diabetes educators. A professional education program designed to facilitate the acquisition and enhancement of the requisite skills and attitudes was designed, implemented, and evaluated. The program involved adhering to a simulated diabetes care regimen for 3 days followed by a 3-day intensive skills-based workshop. The 23 educators who participated in the first two offerings of this program made significant gains in their counseling skills and demonstrated a positive change in attitude.

Brief: The Continuing Education Needs of Diabetes Nurse Educators

The major caveat regarding this study is the low return rate. We suspect that this is due to the extensive nature of this lengthy questionnaire. A shorter questionnaire sent at the same time to another sample drawn from the same population produced a return rate higher than 50%. However, some benefits were derived from the study. The first is the extensive set of data obtained about both the continuing education needs and the practice patterns of this sample of diabetes nurse educators. (A longer report that includes information about how the nurses spend their time, the types of diabetes education they provide, and the size and scope of the diabetes patient education programs at their institution is available from the first author.) Second, it is reasonable to assume that the nurse educators who took the time to complete this lengthy questionnaire about their continuing education needs and practices are thoughtful consumers of continuing education. Their needs and preferences should be of concern to the individuals and organizations that provide continuing education to diabetes nurse educators. In summary, the nurses in this sample are highly educated and experienced diabetes educators. They indicated a strong desire for obtaining continuing education primarily in behavioral and psychosocial issues, but perceive that they are limited by a lack of financial support and time.

Empowerment: an idea whose time has come in diabetes education

We have learned much in the past 10 years about how to help patients to acquire diabetes-related knowledge and skills and how to use strategies to help patients change behaviors. However, the application of knowledge and techniques should be guided by a relevant, coherent, educational philosophy. Empowerment offers a practical conceptual framework for diabetes patient education. Empowering patients provides them with the knowledge, skills, and responsibility to effect change and has the potential to promote overall health and maximize the use of available resources. It is an idea whose time has come for diabetes education.

Effectiveness of a Foot Care Education Program on Attitudes and Behaviors of Staff Nurses

The purpose of this study was to determine differences in nurse attitude and clinical practice following a foot care education program. In a survey completed after the program, 23 nurses reported that they had less difficulty touching a smelly foot (p less than .02), that they would be less bothered by a foot with an odor (p less than .03), that they would have less difficulty touching an unsightly foot depicted in a slide (p less than .03), and that they felt less anger at patients who don't follow recommendations (p less than .03). The nurses also expressed more belief that patients quickly forget important information (p less than .03) and that if patients knew the effects of their poor health habits they would change (p less than .02). Ninety-one percent of the RN sample reported that their foot assessment and care practices had changed as a result of the program.

Feasibility of adjustment of insulin dose by insulin-requiring type II diabetic patients

Type II (non-insulin-dependent) diabetes accounts for most of the diabetes morbidity and expense, yet no systematic study of the effects of intensification of treatment by such patients who require insulin treatment has been conducted. Therefore, patients were recruited from our diabetes clinics, and by random assignment, experimental and control groups were created (n = 26 and 27, respectively) that were not different at 0 mo regarding 20 demographic, physiological, and treatment variables. Experimental patients practiced an algorithm for adjustment of insulin dosage based on daily prebreakfast capillary blood glucose (CBG) measurements and any symptomatic hypoglycemia. At 2-, 4-, and 6-mo visits, records of CBG measurements were available to the physicians (n = 7), who changed insulin dosages of both groups ad libitum. Feasibility of the experimental treatment is evidenced by study completion by 87% of enrollers, monitoring on 88% of days, accuracy of CBG recording (recorded as percentage of memory meter value, 100.8), weight gain not exceeding that of control subjects, practice of treatment algorithm to effect changes in insulin dosage, modest increase in frequency of mild insulin reactions, and a decrease of glycosylated hemoglobin into the normal range.

Development and evaluation of diabetes continuing education courses for health professionals: a synthesis of eight years of experience

Fifteen continuing education courses in diabetes care attended by 943 health professionals were evaluated and synthesized using meta-analytic techniques. Objective and subjective evalu ation results were used to monitor and improve the quality of the programs. Participants' knowl edge of diabetes care issues improved an average of 36 percentile points (P<.001), providing objective evidence of the positive impact of the courses. Favorable ratings by participants of the usefulness of the course content in meeting their own learning needs provided subjec tive evidence of the value of the courses. A follow-up survey of participants six months later indicated that more than 80 % were successful in changing the educational and psychosocial aspects of their health care practices as a result of course attendance. Many reported increased understanding of the psychosocial aspects of diabetes and compliance problems, greater confidence in their dietary recom mendations and patient education skills, and increased personal satisfaction from their diabetes patient care.

Evaluation of "Life with Diabetes" patient education booklets

Evaluation of written patient education materials is a necessary part of pro viding education to pa tients with diabetes. Evaluation, however, is useful only if the needs of both those who use the materials (patients) and those who recommend and distribute the materials (health care professionals) are considered. Eight booklets in the "Life with Diabetes" patient educa tion series (developed by the Michigan Diabetes Research and Training Center) were evaluated by both health professionals and patients. Twenty-eight to 37 health professionals including nurses, dieti tians, and physicians evaluated each booklet. Their comments were used to revise and im prove the booklets before publication (formative or process evaluation).