Expanding the enablement framework and testing an evaluative instrument for diabetes patient education

Testing the Psychometric Characteristics of the Revised Mastery of Stress Instrument in Adults With Type 2 Diabetes

BACKGROUND AND PURPOSE

A promising, yet lengthy measure to identify mastery of patient-identified stress is Younger's (1991, 1993) Mastery of Stress Instrument (MSI). With a goal for a parsimonious and valid measure, this study determined the psychometric properties of a reduced item instrument with adults diagnosed with type 2 diabetes.

METHODS

First, an expert content analysis was completed. Second, item and confirmatory factor analysis were completed with a sample of 200 adults with a diagnosis of type 2 diabetes.

RESULTS

Eight items were removed through content validity and seven items were removed with Item analysis. Factor analysis supported Younger's four sub-concepts.

CONCLUSIONS

Future research with this revised MSI scale is advocated to identify those who may need strategies to increase their mastery of stress.

Factors affecting patient enablement in an Asian setting: a mixed methods study

INTRODUCTION

Patient-centred medical care has been rising in importance since the turn of the century. It entails treating patients in relation to their biopsychosocial outlook so as to support the management of their conditions. The extent to which a patient is enabled to acquire skills and knowledge can be measured with the Patient Enablement Instrument (PEI) proposed by Howie and colleagues, and it has been noted to be more reflective of a good consultation compared to patient satisfaction scores. This study aimed to determine the level of patient enablement in the Singaporean context and the factors facilitating it.

METHODS

We conducted an embedded mixed method study with primary care patients in two phases: (a) a PEI questionnaire was completed by 150 patients; and (b) a qualitative approach using focused group discussions and individual interviews was used to explore factors associated with high enablement.

RESULTS

The mean PEI score was 4.5 ± 4.4, with significantly higher scores among patients attending specialised primary care clinics. Important physician factors were doctors' advice, attitude and relationship with the patient. Critical system factors included good continuity of care, workload and financial support, while patient factors included their beliefs, preparedness, inquisitiveness and trust, with considerable impact from the influence of community.

CONCLUSION

The PEI score in the Singaporean context is similar to that of other Asian contexts, but slightly higher than that reported in Western studies. Good doctor-patient relationships, efficient systems facilitating continuity of care, and motivated and informed patients all contribute to increased enablement.

Patient Perceptions of Satisfaction Following Diabetes Education

PURPOSE

The purpose of this study was to test the conceptual congruency of scores from the Mastery of Stress Instrument (MSI) with qualitative data in an effort to identify patients for whom a specific educational intervention was sufficient.

METHODS

A convenience sample of patients with diverse age and educational backgrounds was recruited from those who registered for a 4-session diabetes educational experience as new or refresher patients. All 57 patients completed the MSI before and after diabetes educational experiences, and half participated in before and after audiotaped interviews. All patients responded to a query about their perceptions of the educational experience. MSI scores were analyzed by demographic variables as well as compared to qualitative interviews for greater insights and explanation.

RESULTS

Consistency was noted between the MSI scores and the information revealed in the interviews. Additional support for the use of the MSI to identify patients at risk and in need of additional educational interventions was realized.

CONCLUSIONS

Further research to explore the use of the MSI with persons with different educational experiences and to standardize the MSI scores for adult persons taking diabetes or other patient education classes is needed before generalization can be achieved.

A Middle-Range Theory for Diabetes Self-management Mastery

Diabetes mellitus is the seventh leading cause of death in America and affects 382 million people worldwide. Individuals with diabetes must manage the complexity of the disease, its treatment, and complications to avert deleterious consequences associated with the illness. However, not all patients with diabetes successfully gain mastery to positively impact self-management. A new middle-range theory is proposed that merges 2 extant theories, theory of mastery and organismic integration theory, to better understand this human response. The theories' philosophical, theoretical, and conceptual perspectives were examined and relational properties synthesized to provide a conceptual representation of the phenomenon of interest.

The addition of E (Empowerment and Economics) to the ABCD algorithm in diabetes care

The ABCD (Age, Body weight, Complications, Duration of disease) algorithm was proposed as a simple and practical tool to manage patients with type 2 diabetes. Diabetes treatment, as for all chronic diseases, relies on patients' ability to cope with daily problems concerning the management of their disease in accordance with medical recommendations. Thus, it is important that patients learn to manage and cope with their disease and gain greater control over actions and decisions affecting their health. Healthcare professionals should aim to encourage and increase patients' perception about their ability to take informed decisions about disease management and to improve patient self-esteem and feeling of self-efficacy to become agents of their own health. E for Empowerment is therefore an additional factor to take into account in the management of patients with type 2 diabetes. E stands also for Economics to be considered in diabetes care. Attention should be paid to public health policies as well as to the physician faced with the dilemma of delivering the best possible care within the problem of limited resources. The financial impact of the new treatment modalities for diabetes represents an issue that needs to be addressed at multiple strata both globally and nationally.

Patients' expectations of the health advice conversation with the diabetes nurse practitioner

Type 2-diabetes usually makes its first appearance in adult age. In order for patients to feel in control of the disease, they need support and information that can easily be understood and which is relevant for the individual. By educating and supporting them, patients can conduct self-care and take control. The aim of this study was to highlight the expectations that patients with type 2-diabetes have of the health advice conversation with the nurse practitioner. A qualitative method using interviews was conducted and the data material was analysed according to manifest and latent content analysis. Three categories emerged in the results. Firstly, providing good accessibility to the diabetes nurse practitioner is of importance. Secondly, there is a demand for group activities in which patients have the opportunity to talk with other individuals who have diabetes. Finally, knowledge about self-care means that the patients themselves are able to change the intake of medication, their eating habits, and exercise according to need, as this leads to increased independence and self-management. The latent content demonstrates that the patient is striving towards competence and self-confidence in order to achieve a balance between lifestyle and the normalisation of blood sugar levels, which means empowerment. In addition, the informants expressed a demand for group activities where they can discuss the disease with others in the same situation. A combination of knowledge about the disease, receiving individual advice, and participation in groups can be beneficial in order to motivate the informants about lifestyle changes and to gain the ability to manage the disease.

Use of the Mastery of Stress Instrument in caregivers of children newly diagnosed with type 1 diabetes: identifying a need for further intervention

PURPOSE

The purpose of this study was to determine if the Mastery of Stress Instrument (MSI) can assess further education needs of primary caregivers of children newly diagnosed with type 1 diabetes. The MSI has been utilized to measure mastery in response to both illness and interventions, including education. The primary objective was to correlate MSI subscales and stress scores with caregiver age, ethnicity, gender, and education. Secondary objectives were to correlate MSI scores with child age at diagnosis, payer source, hemoglobin A1C (A1C), emergency room (ER) visits, or hospitalization for diabetic ketoacidosis (DKA).

METHODS

Caregivers from a pediatric endocrinology practice completed the MSI after basic diabetes education. Demographic data from caregivers and patients were obtained. A1C, ER, and DKA were evaluated 2 years following completion of the MSI. Descriptive univariate statistics and proportions on nominal or discrete data were used to describe the data. Bivariable analyses included t tests and ANOVAs.

RESULTS

Eighty-five of 88 participants completed the instrument. Caregivers between 40 and 49 years of age scored worse on change, acceptance, and growth subscales compared to those 18 to 29 years of age. Those 40 to 49 years of age reported having more stress compared to caregivers 18 to 29 years of age. Males reported having less stress and were more willing to implement change compared to females. No statistically significant relationships between secondary outcomes measurements and MSI scores were detected.

CONCLUSIONS

The mastery of stress instrument identified groups of caregivers in need of further education or team interventions.

The contribution of work environment to nurses' assessments of the quality of patient care

The quality of patient care was found to be significantly correlated with work environment measures in a quasi-experimental study in the Saskatoon Health Region. Since first line supervisors face multiple pressures in organizing the work of their units, they need to be supported by senior leadership for continuity in instilling a common purpose and shared values to the patient care staff. The role of supervision and leadership is crucial in strategically managing the human, financial and technical resources in our healthcare system, especially when such resources are likely to remain limited.

Painful diabetic neuropathy--providing the best patient service

Painful diabetic neuropathy is just one of a myriad of secondary conditions that may result from poor glycaemic control. Educating the patient to suspect diabetic complications, understanding why they may occur, what their progression is likely to be and what measures can be taken to avoid them can significantly improve outcomes. Education within the diabetes management framework needs to be consistent, prioritised, tailored to the needs of each patient and ongoing in order to be maximally effective, with tight glycaemic control playing the anchoring central role. The specialist diabetes nurse is in the ideal situation to coordinate this education and to ensure that the patient with diabetes receives the care and support needed to take dual responsibility for their condition.

Impoverished diabetic patients whose doctors facilitate their participation in medical decision making are more satisfied with their care

OBJECTIVE

Greater participation in medical decision making is generally advocated for patients, and often advocated for those with diabetes. Although some studies suggest that diabetic patients prefer to participate less in decision making than do healthy patients, the empirical relationship between such participation and diabetic patients' satisfaction with their care is currently unknown. We sought to characterize the relationship between aspects of diabetic patients' participation in medical decision making and their satisfaction with care.

DESIGN

Cross-sectional observational study.

SETTING

A general medical county hospital-affiliated clinic.

PARTICIPANTS

One hundred ninety-eight patients with type 2 diabetes.

MAIN MEASURES

Interviews conducted prior to the doctor visit assessed patients' desire to participate in medical decision making, baseline satisfaction (using a standardized measure), and sociodemographic and clinical characteristics. Postvisit interviews of those patients assessed their visit satisfaction and perception of their doctor's facilitation of patient involvement in care. A discrepancy score was computed for each subject to reflect the difference between the previsit stated desire regarding participation and the postvisit report of their experience of participation.

RESULTS

Overall, patients reported low postvisit satisfaction relative to national standards (mean of 70 on a 98-point scale). Patients perceived a high level of facilitation of participation (mean 88 on a 100-point scale). Facilitation of participation and the discrepancy score both independently predicted greater visit satisfaction. In particular, a 13-point (1 SD) increase in the perceived facilitation score resulted in a 12-point (0.87 SD) increase in patient satisfaction, and a 1.22 point increase (1 SD) in the discrepancy score (the extent to which the patient was allowed more participation than, at previsit, he or she desired) resulted in a 6-point (0.5 SD) increase in the satisfaction score, even after controlling for initial desire to participate. For women, but not for men, physician facilitation of participation was a positive predictor of satisfaction; for men, but not women, desire to participate was a significant positive predictor of visit satisfaction.

CONCLUSION

Clinicians may feel reassured that encouraging even initially reluctant patients with diabetes to participate in medical decision making may be associated with increased patient satisfaction. Greater patient participation has the potential to improve diabetic self-care because of the likely positive effect of patient satisfaction on adherence to treatment. Further research to assess the prospective effects of enhancing physician facilitation of patient participation is likely to yield important information for the effective treatment of chronically ill patients.