Flexible guided self-determination intervention for younger adults with poorly controlled Type 1 diabetes, decreased HbA1c and psychosocial distress in women but not in men: a real-life RCT

Nurse-Led Individualized Follow-Up Versus Regular Physician-Led Visits After Early Breast Cancer (MyHealth): A Phase III Randomized, Controlled Trial

PURPOSE

Follow-up after breast cancer with regular visits has failed to detect recurrences, be cost-effective, and address patient needs.

METHODS

MyHealth is a phase III randomized controlled trial (ClinicalTrials.gov identifier: NCT02949167). Patients, who recently completed primary treatment for stage I-II breast cancer, were randomly assigned in variable block sizes and stratified by age and human epidermal growth factor receptor 2 status to intervention or control follow-up. The nurse-led intervention comprised three to five individual self-management sessions, regular reporting of symptoms, and navigation to health care services. The control follow-up comprised regular outpatient visits with the physician. The primary outcome was breast cancer-specific quality of life (QoL) measured by the Trial Outcome Index-Physical/Functional/Breast summary score of the Functional Assessment of Cancer Therapy-Breast 2 years after random assignment. Secondary outcomes were fear of recurrence, anxiety, depression, and health care utilization. Analyses were intention-to-treat and P values were two-sided with 95% confidence level set at 0.005 because of multiple comparisons.

RESULTS

Among 1,101 eligible patients, 875 were invited and 503 were randomly assigned to control (n = 252) or intervention (n = 251) follow-up. At 2 years, patients in the intervention group reported a significantly and clinically relevant higher QoL (mean, 75.69 [standard deviation [SD], 12.27]) than patients in the control group (71.26 [SD, 14.08]), with a mean difference of 5.05 (95% CI, 3.30 to 6.79; P < .001). The intervention group reported significantly less fear of recurrence, anxiety, and depression; they had fewer physician consultations but more nurse contacts and an unchanged diagnostic imaging pattern. The effect on all outcomes was stable through a 3-year follow-up.

CONCLUSION

The MyHealth study suggested a new strategy for follow-up after early breast cancer as it provided significant improvements in QoL.

A Systematic Literature Review of Psychological Interventions for Adults with Type 1 Diabetes

INTRODUCTION

The psychological burden of type 1 diabetes mellitus (T1DM) is considerable. The condition affects the daily lives of adults living with T1DM (ALWT1DM) in many ways. International guidelines highlight the importance of providing psychological support to ALWT1DM to improve health outcomes and well-being.

METHODS

We conducted a systematic literature review of randomised controlled trials (RCTs) to identify the evidence on the impact of psychological interventions on glycaemic control and psychological outcomes in ALWT1DM. Literature searches of Medline, Embase, Cochrane Central Register of Controlled Trials, PsycInfo, and the grey literature were performed to identify relevant RCTs, published in English, from 2001 onward. Fourteen RCTs of ten psychological interventions in ALWT1DM were eligible and included in the qualitative synthesis. The studies varied considerably in terms of duration, target population, endpoints, and efficacy.

RESULTS

Overall, psychological interventions did not perform significantly better than control treatments in improving glycaemic control, although selected patient groups did report benefits from some psychological intervention types, such as cognitive behavioural therapy. Although most of the psychological interventions produced small, nonsignificant improvements in self-reported patient functioning, some treatments were effective in reducing diabetes distress and improving mental health, even if no impact on glycaemic control was observed.

DISCUSSION

Current guidelines for the treatment of T1DM recommend access to psychological services; however, there is a paucity of high-quality evidence from clinical trials on the effectiveness or preferred structure of psychological support. There is a clear need for more rigorous, large-scale, international research to address the efficacy of psychological interventions in ALWT1DM.

'To loosen up and talk': Patients´ and facilitators´ experiences of discovery group sessions from the Tidal Model as an introduction before engaging in a person-centred group intervention

WHAT IS KNOWN ABOUT THE SUBJECT

Treatment groups in Mental Health Service is cost-effective, increases patients´ self-understanding and stimulate change Research shows that people with mental illness have different barriers to attend group sessions which often originates from a lack of trust in other people, but it is known that the possibility to build gradual trust among the participants encourages attendance.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

This study is based on the experience from outpatients and illuminates how discovery groups from the Tidal Model can be used as introductory sessions to build gradual trust among people with mental illness before engaging in a person-centred group intervention. The study fills a research gap in methods to create a safe and trusting environment in treatment groups for people with mental illness working with recovery-oriented person-centred interventions.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This study emphasizes the importance of meeting concerns about social interactions in persons with mental illness when joining treatment groups. It presents a recovery-oriented method which meets this requirement and is easy to implement in practice.

ABSTRACT

INTRODUCTION: Recovery-oriented interventions delivered individually or in groups are more and more common within mental health nursing. However, persons with mental illness may be cautious about engaging in groups. Therefore, it is important to provide a trusting basis in the group to allow for the best opportunities to promote engagement, attendance and impact of treatment.

AIM

The aim was to explore how discovery group sessions were experienced as introductory sessions from the perspectives of participants and facilitators before engaging in a person-centred group intervention.

METHOD

A qualitative interview study was conducted, involving four group facilitators and 16 participants with mental illness from five completed groups. Data were analysed with Ricoeur's theory of interpretation.

RESULTS

The findings showed that the two discovery group sessions were experienced as useful and meaningful to all and created a safe atmosphere and a trusted relationship among group participants and facilitators.

DISCUSSION

Feeling safe and sharing experiences and emotions contribute to the relational climate in a group.

IMPLICATION FOR PRACTICE

Addressing concerns about social interactions in persons with mental illness is important in group treatment. This study proved that engaging patients in designing or adapting interventions for mental health services is important to improve quality.

Teaching Adolescents With Type 1 Diabetes Self-Compassion (TADS) to Reduce Diabetes Distress: Protocol for a Randomized Controlled Trial

BACKGROUND

Adolescents living with type 1 diabetes (T1D) often experience diabetes distress (DD), a construct distinct from depression or anxiety that refers to the negative emotions that arise from living with and managing diabetes. Self-compassion, which involves being open to one's own suffering and treating oneself with the same care one would show to loved ones, is associated with better psychological and clinical outcomes among individuals with T1D. Self-compassion is a skill that can be taught and therefore represents an opportunity for intervention.

OBJECTIVE

The overall aim of this study is to assess the effectiveness of a web-based mindful self-compassion for teens (MSC-T) intervention on improving DD, anxiety, depression, diabetes-related disordered eating, and suicidal ideation experienced by youth with T1D (aged between 12 and 17 years) compared with a waitlist control group (standard of care). We will also explore (1) if the effect of the MSC-T intervention changes over time, (2) if the MSC-T intervention has a positive impact on measures of glycemic control, and (3) if the effect of the MSC-T intervention differs based on self-reported gender.

METHODS

We will conduct a single-center, parallel-group randomized controlled trial of 140 adolescents with T1D followed for 12 months. Participants will be randomly allocated (using hidden allocation) in a 1:1 ratio to either the MSC-T intervention or the waitlist control group. Our primary outcome is DD, as measured by the Problem Areas in Diabetes-Teen (PAID-T) version at 3 months. Secondary outcomes, assessed at 3 and 12 months, include anxiety (Generalized Anxiety Disorder 7-item [GAD-7] scale), depression (Patient Health Questionnaire-9 [PHQ-9]), diabetes-related disordered eating (Diabetes Eating Problem Survey-Revised [DEPS-R] version), and suicidal ideation (using 1 question from the PHQ-9).

RESULTS

Study recruitment began in October 2022 and was completed in March 2023, with a total of 141 participants enrolling. Data collection will be ongoing until March 2024. The first results are expected in June 2024.

CONCLUSIONS

This study will be the first randomized trial to assess the effectiveness of the web-based MSC-T intervention on adolescents with T1D. Given that adolescence is a period where individuals are typically required to assume more responsibility for their diabetes care, providing adolescents with the tools they need to better manage the stress that often accompanies T1D management is paramount.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05463874; https://clinicaltrials.gov/study/NCT05463874.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53935.

Self-determination theory interventions versus usual care in people with diabetes: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Autonomy-supporting interventions, such as self-determination theory and guided self-determination interventions, may improve self-management and clinical and psychosocial outcomes in people with diabetes. Such interventions have never been systematically reviewed assessing both benefits and harms and concurrently controlling the risks of random errors using trial sequential analysis methodology. This systematic review investigates the benefits and harms of self-determination theory-based interventions compared to usual care in people with diabetes.

METHODS

We used the Cochrane methodology. Randomized clinical trials assessing interventions theoretically based on guided self-determination or self-determination theory in any setting were eligible. A comprehensive search (latest search April 2022) was undertaken in CENTRAL, MEDLINE, Embase, LILACS, PsycINFO, SCI-EXPANDED, CINAHL, SSCI, CPCI-S, and CPCI-SSH to identify relevant trials. Two authors independently screened, extracted data, and performed risk-of-bias assessment of included trials using the Cochrane risk-of-bias tool 1.0. Our primary outcomes were quality of life, all-cause mortality, and serious adverse events. Our secondary outcomes were diabetes distress, depressive symptoms, and nonserious adverse events not considered serious. Exploratory outcomes were glycated hemoglobin and motivation (autonomy, controlled, amotivation). Outcomes were assessed at the end of the intervention (primary time point) and at maximum follow-up. The analyses were conducted using Review Manager 5.4 and Trial Sequential Analysis 0.9.5.10. Certainty of the evidence was assessed by GRADE.

RESULTS

Our search identified 5578 potentially eligible studies of which 11 randomized trials (6059 participants) were included. All trials were assessed at overall high risk of bias. We found no effect of self-determination theory-based interventions compared with usual care on quality of life (mean difference 0.00 points, 95% CI -4.85, 4.86, I2 = 0%; 225 participants, 3 trials, TSA-adjusted CI -11.83, 11.83), all-cause mortality, serious adverse events, diabetes distress, depressive symptoms, adverse events, glycated hemoglobulin A1c, or motivation (controlled). The certainty of the evidence was low to very low for all outcomes. We found beneficial effect on motivation (autonomous and amotivation; low certainty evidence).

CONCLUSIONS

We found no effect of self-determination-based interventions on our primary or secondary outcomes. The evidence was of very low certainty.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020181144.

Impact of the person-centred intervention guided self-determination across healthcare settings-An integrated review

AIM

To review the evidence of the existing literature on the impact of guided self-determination across methodologies in different healthcare settings.

METHODS

An integrated five-stage review.

RESULTS

Forty-five eligible papers were included. Guided self-determination was applied in full- or small-scale, or combined with another intervention or approach in different healthcare settings handling, for example diabetes, stroke survivorship, schizophrenia, attention-deficit hyperactivity disorder and medical disorder, gynaecological and breast cancer, endometriosis, persons with chronic pain, persons in haemodialysis and intensive care survivors. The included studies covered 12 randomised trials, 26 qualitative and seven papers of different methodology. A statistically significant effect was found in three trials. Six main themes describe the qualitative findings across papers on patients: (1) Guided self-determination reduces disease-related loneliness, (2) Insight enables integration of life and disease, (3) Reflection sheets-appreciated but challenging tool to prompt insights and person-specific knowledge, (4) New person-specific knowledge enables person-centred support, (5) Feeling seen and believed in a new and trusted relationship and (6) Exchange of knowledge enables the development of life skills. Four themes describe the healthcare professionals' experience: (1) Change of usual practice-a decision from above, (2) A new role-unlearning previous behaviour and need for support, (3) Reflection sheets as facilitators and barriers and (4) Discovering the benefits of changing to a person-centred approach.

CONCLUSION

Overall, guided self-determination proved to have a great impact on patient important outcomes and was useful and well-accepted by the majority of patients and healthcare professionals. Albeit guided self-determination is not a 'one size fits all' method. Continuous training and supervision of professionals are a necessary mean when implementing guided self-determination to enhance adoption and sustainability in clinical practice.

Measures used to assess interventions for increasing patient involvement in Danish healthcare setting: a rapid review

OBJECTIVE

To identify measures used within Denmark evaluating any type of intervention designed to facilitate patient involvement in healthcare.

DESIGN

Environmental scan employing rapid review methods.

DATA SOURCES

MEDLINE, PsycInfo and CINAHL were searched from 6-9 April 2021 from database inception up to the date of the search.

ELIGIBILITY CRITERIA

Quantitative, observational and mixed methods studies with empirical data on outcomes used to assess any type of intervention aiming to increase patient involvement with their healthcare. Language limitations were Danish and English.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data from 10% of the included studies and, due to their agreement, the data from the rest were extracted by first author. Data were analysed with reference to existing categories of measuring person-centred care; findings were synthesised using narrative summaries. Adapted Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines were used to guide reporting.

RESULTS

Among 3767 records, 43 studies met the inclusion criteria, including 74 different measures used to evaluate interventions aimed at increasing patient involvement within healthcare in Danish hospital and community settings. Generic measures assessed: patient engagement (n=3); supporting self-management (n=8); supporting shared decision-making (n=9); patient satisfaction and experiences of care (n=11); health-related patient-reported outcome (n=20).

CONCLUSIONS

Across Denmark, complex interventions designed to improve patient involvement with healthcare vary in their goals and content. Some targeting healthcare professionals, some patient health literacy and some service infrastructure. A plethora of measures assess the impact of these interventions on patient, professional and service delivery outcomes. Few measures assessed patient involvement directly, and it is unclear which proxy measures capture indicators of perceived involvement. Lack of conceptual clarity between intervention goals, the components of change and measures makes it difficult to see what types of intervention can best support change in services to ensure patients are more effectively involved in their healthcare.

Multidimensional factors determine skill acquisition development in Guided Self‐Determination : A qualitative study

AIM

The aim of the study was to investigate nurses' skill acquisition in Guided Self-Determination according to the Dreyfus model of skill acquisition and Patricia Benner's studies based on the same model.

BACKGROUND

Globally, person-centred care is acknowledged as an essential aspect of quality in health care. To succeed with person-centred care methods and skills are necessary. Guided Self-Determination is a person-centred method developed in the field of nursing. The method represents a new way of skill acquisition requiring knowledge of how skills are acquired, unfolded and best supported in Guided Self-Determination.

DESIGN

Qualitative interview study.

METHOD

From January 2019 to August 2019, 16 nurses were interviewed about their experiences of learning and using Guided Self-Determination in three different gynaecological settings: cancer, endometriosis and sexual abuse. The study was registered with the Danish Data Protection Agency (file no.: VD-2018-445, I-Suite no.: 6700).

RESULTS

The spectrum in Guided Self-Determination acquisition skills ranged from following schematical procedures in a rigorous way to an extended understanding of exploring and supporting the person-centred concept. Two main themes were identified: Elements in the transition of knowledge from theory to practice and Aspects associated with Guided Self-Determination skill acquisition.

CONCLUSIONS

Nurses practised Guided Self-Determination at different levels. Quantity of practising Guided Self-Determination was not the only aspect determining rapid progression. The Dreyfus model lacked several explanatory components of skill acquisition, such as personal dispositions, preferences, motivation, personal values and context.

Dietitians' perspectives on challenges and prospects for group-based education to adults with type 1 diabetes - a qualitative study

BACKGROUND

Type 1 diabetes (T1DM) is an autoimmune disorder which can have short- and long-term adverse effects on health. Dietitians in diabetes offer specialist evidence-based advice to people with T1DM and provide education in either individual or group settings. The purpose of this study was to explore dietitians' perception of, and role in, group-based education as well as prospects for development.

METHODS

This was a qualitative descriptive study conducted in Sweden using a convenience sampling of dietitians working in adult diabetes care. Semi-structured interviews were conducted with participants and data were analysed using a content analysis approach.

RESULTS

Ten dietitians with a median experience of 14.5 years in diabetes care were interviewed. The informants were all appreciative of facilitating group-based education and perceived that it was beneficial for people with T1DM to be part of group processes, but the informants did also suggest that there were challenges for their professional role. The main challenges reported was to adjust the level of depth and complexity to the information provided and the lack of ability to individualize the education-sessions in a heterogenous group. None of the dietitians reported performing pre-assessment or follow-up audits on the group-based education.

CONCLUSION

There was a great engagement from the dietitians, but they identified a lack of framework that address challenges regarding group-based education. The dietitians experienced examples of person-centred care while facilitating group-based education, which may benefit people with T1DM. Based on the results, it would be valuable to explore the pedagogic training level of Swedish dietitians and potential barriers in their ability to facilitate group-based education. We suggest that a framework for group-based education should be explored together with patient representatives to optimize the care given to ensure cost-effectiveness, optimize clinical outcomes, quality of life and equally accessible care for people with T1DM.

Guided self-determination intervention versus attention control for people with type 2 diabetes in outpatient clinics: a protocol for a randomised clinical trial

INTRODUCTION

In the management of type 2 diabetes, autonomy-supporting interventions may be a prerequisite to achieving more long-term improvement. Preliminary evidence has shown that the guided self-determination (GSD) method might have an effect on haemoglobin A1c and diabetes distress in people with type 1 diabetes. Previous trials were at risk of uncertainty. Thus, the objective is to investigate the benefits and harms of a GSD intervention versus an attention control group intervention in adults with type 2 diabetes.

METHODS AND ANALYSIS

This trial protocol is guided by the The Standard Protocol Items: Recommendations for International Trials Statement. We describe the protocol for a pragmatic randomised, dual-centre, parallel-group, superiority clinical trial testing a GSD intervention versus an attention control for people with type 2 diabetes in outpatient clinics. The participants (n=224) will be recruited from two diverse regions of Denmark. The experimental stepped-care intervention will consist of three to five GSD sessions lasting up to 1 hour with a trained GSD facilitator. The sessions will be conducted face to face, by video conference or over the telephone. The attention controls will receive three to five sessions lasting up to an hour with a communication-trained healthcare professional provided face to-face, by video conference, or over the telephone. Participants will be included if they have type 2 diabetes,>18 years old, are not pregnant. Participants will be assessed before randomisation, at 5-month, and 12-month follow-up, the latter being the primary. The primary outcome is diabetes distress. Secondary outcomes are quality of life, depressive symptoms and non-serious adverse events. Exploratory outcomes are haemoglobin A1c, motivation and serious adverse events. Data will be collected using REDCap and analysed using Stata V.16.

ETHICS AND DISSEMINATION

The trial will be conducted in compliance with the protocol, the Helsinki Declaration in its latest form, International Harmonisation of Good Clinical Practice guidelines and the applicable regulatory requirement(s). The trial has been approved by the Danish Data Protection Agency (P-2020-864). The Ethics Committee of the Capital Region of Denmark reviewed the trial protocol, but exempted the trial protocol from full review (H-20003638). The results of the trial will be presented at the outpatient clinics treating people with type 2 diabetes, at national and international conferences as well as to associations for people with diabetes and their relatives.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT04601311.

Psychological interventions to improve self-management of type 1 and type 2 diabetes: a systematic review

BACKGROUND

For people with diabetes mellitus to achieve optimal glycaemic control, motivation to perform self-management is important. The research team wanted to determine whether or not psychological interventions are clinically effective and cost-effective in increasing self-management and improving glycaemic control.

OBJECTIVES

The first objective was to determine the clinical effectiveness of psychological interventions for people with type 1 diabetes mellitus and people with type 2 diabetes mellitus so that they have improved (1) glycated haemoglobin levels, (2) diabetes self-management and (3) quality of life, and fewer depressive symptoms. The second objective was to determine the cost-effectiveness of psychological interventions.

DATA SOURCES

The following databases were accessed (searches took place between 2003 and 2016): MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, PsycINFO, EMBASE, Cochrane Controlled Trials Register, Web of Science, and Dissertation Abstracts International. Diabetes conference abstracts, reference lists of included studies and Clinicaltrials.gov trial registry were also searched.

REVIEW METHODS

Systematic review, aggregate meta-analysis, network meta-analysis, individual patient data meta-analysis and cost-effectiveness modelling were all used. Risk of bias of randomised and non-randomised controlled trials was assessed using the Cochrane Handbook (Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928).

DESIGN

Systematic review, meta-analysis, cost-effectiveness analysis and patient and public consultation were all used.

SETTING

Settings in primary or secondary care were included.

PARTICIPANTS

Adolescents and children with type 1 diabetes mellitus and adults with types 1 and 2 diabetes mellitus were included.

INTERVENTIONS

The interventions used were psychological treatments, including and not restricted to cognitive-behavioural therapy, counselling, family therapy and psychotherapy.

MAIN OUTCOME MEASURES

Glycated haemoglobin levels, self-management behaviours, body mass index, blood pressure levels, depressive symptoms and quality of life were all used as outcome measures.

RESULTS

A total of 96 studies were included in the systematic review (n = 18,659 participants). In random-effects meta-analysis, data on glycated haemoglobin levels were available for seven studies conducted in adults with type 1 diabetes mellitus (n = 851 participants) that demonstrated a pooled mean difference of -0.13 (95% confidence interval -0.33 to 0.07), a non-significant decrease in favour of psychological treatment; 18 studies conducted in adolescents/children with type 1 diabetes mellitus (n = 2583 participants) that demonstrated a pooled mean difference of 0.00 (95% confidence interval -0.18 to 0.18), indicating no change; and 49 studies conducted in adults with type 2 diabetes mellitus (n = 12,009 participants) that demonstrated a pooled mean difference of -0.21 (95% confidence interval -0.31 to -0.10), equivalent to reduction in glycated haemoglobin levels of -0.33% or ≈3.5 mmol/mol. For type 2 diabetes mellitus, there was evidence that psychological interventions improved dietary behaviour and quality of life but not blood pressure, body mass index or depressive symptoms. The results of the network meta-analysis, which considers direct and indirect effects of multiple treatment comparisons, suggest that, for adults with type 1 diabetes mellitus (7 studies; 968 participants), attention control and cognitive-behavioural therapy are clinically effective and cognitive-behavioural therapy is cost-effective. For adults with type 2 diabetes mellitus (49 studies; 12,409 participants), cognitive-behavioural therapy and counselling are effective and cognitive-behavioural therapy is potentially cost-effective. The results of the individual patient data meta-analysis for adolescents/children with type 1 diabetes mellitus (9 studies; 1392 participants) suggest that there were main effects for age and diabetes duration. For adults with type 2 diabetes mellitus (19 studies; 3639 participants), baseline glycated haemoglobin levels moderated treatment outcome.

LIMITATIONS

Aggregate meta-analysis was limited to glycaemic control for type 1 diabetes mellitus. It was not possible to model cost-effectiveness for adolescents/children with type 1 diabetes mellitus and modelling for type 2 diabetes mellitus involved substantial uncertainty. The individual patient data meta-analysis included only 40-50% of studies.

CONCLUSIONS

This review suggests that psychological treatments offer minimal clinical benefit in improving glycated haemoglobin levels for adults with type 2 diabetes mellitus. However, there was no evidence of benefit compared with control interventions in improving glycated haemoglobin levels for people with type 1 diabetes mellitus.

FUTURE WORK

Future work should consider the competency of the interventionists delivering a therapy and psychological approaches that are matched to a person and their life course.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016033619.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 28. See the NIHR Journals Library website for further project information.

The patient's agenda: nurses' experience of learning and using guided self-determination

OBJECTIVES

Health care has seen a shift towards person-centred care to encompass the entirety of a person's needs and preferences, but research is sparse on healthcare professionals learning and using person-centred care.

AIM

To investigate nurses' experiences of learning and using the person-centred method guided self-determination (GSD) in three different gynaecological settings and to determine whether, and potentially, how new tasks introduced by the GSD method influence their professional identity.

DESIGN

A qualitative interview study conducted between January 2019 and January 2020.

METHOD

We conducted 16 semi-structured interviews with nurses educated in using GSD. Applying inductive and deductive reasoning, we analysed the interviews using thematic analysis. The study was registered with the Danish Data Protection Agency (file no.: VD-2018-445, I-Suite no.: 6700).

RESULTS

The analysis generated three main themes with two subthemes each: (a) prerequisites and barriers to learning and using GSD in terms of personal factors and organisational and method-related factors; (b) new knowledge and understanding of illness with the subthemes expanded understanding of illness and a different relationship; and (c) nursing undergoing change with the subthemes, a new role and a professional self shaped through interaction with other professions.

CONCLUSIONS

Although other professionals may have either supported or challenged the use of GSD, most nurses indicated that it supplemented their professional role and identity as they gained new knowledge about person-centred challenges and felt more confident. When introducing GSD in nursing, the organisation must not only consider individual characteristics, multidisciplinary collaboration and communication but also plan individual education and supervision. This is necessary because all these factors affect how a new professional role is constructed and adopted, not to mention how it influences the nurses' perception of their professional identity and use of GSD. Establishing a helpful person-centred environment must also be considered.

Self-determination theory interventions versus usual care in people with diabetes: a protocol for a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Existing self-management and behavioural interventions for diabetes vary widely in their content, and their sustained long-term effectiveness is uncertain. Autonomy supporting interventions may be a prerequisite to achieve 'real life' patient engagement and more long-term improvement through shared decision-making and collaborative goal setting. Autonomy supportive interventions aim to promote that the person with diabetes' motivation is autonomous meaning that the person strives for goals they themselves truly believe in and value. This is the goal of self-determination theory and guided self-determination interventions. Self-determination theory has been reviewed but without assessing both benefits and harms and accounting for the risk of random errors using trial sequential analysis. The guided self-determination has not yet been systematically reviewed. The aim of this protocol is to investigate the benefits and harms of self-determination theory-based interventions versus usual care in adults with diabetes.

METHODS/DESIGN

We will conduct the systematic review following The Cochrane Collaboration guidelines. This protocol is reported according to the PRISMA checklist. A comprehensive search will be undertaken in the CENTRAL, MEDLINE, EMBASE, LILACS, PsycINFO, SCI-EXPANDED, CINAHL, SSCI, CPCI-S and CPCI-SSH to identify relevant trials. We will include randomised clinical trials assessing interventions theoretically based on guided self-determination or self-determination theory provided face-to-face or digitally by any healthcare professional in any setting. The primary outcomes will be quality of life, mortality, and serious adverse events. The secondary will be diabetes distress, depressive symptoms and adverse events not considered serious. Exploratory outcomes will be glycated haemoglobin and motivation. Outcomes will be assessed at the end of the intervention and at maximum follow-up. The analyses will be performed using Stata version 16 and trial sequential analysis. Two authors will independently screen, extract data from and perform risk of bias assessment of included studies using the Cochrane risk of bias tool. Certainty of the evidence will be assessed by GRADE.

DISCUSSION

Self-determination theory interventions aim to promote a more autonomous patient engagement and are commonly used. It is therefore needed to evaluate the benefit and harms according to existing trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020181144.

About me as a person not only the disease - piloting Guided Self-Determination in an outpatient endometriosis setting

INTRODUCTION

Endometriosis is a chronic disease affecting 5-10% of women in the reproductive age. Despite surgical and medical treatment, many women struggle with pain, infertility, sexual dysfunction, depression, distress and reduced workability, affecting their overall quality of life. The usual follow-up procedures may not support the women's self-management of this condition. Therefore, person-centred empowerment-based approaches are needed.

AIM

To assess if the implementation of the Guided Self-Determination method targeted women with complex endometriosis appeared feasible and supported self-management.

METHODS

Guided Self-Determination was offered to 10 out-patients with complex endometriosis. Each of the women had five conversations based on prefilled disease-specific reflection sheets. A qualitative evaluation was conducted in 2016-2017 covering semi-structured, telephone interviews and focus group interviews, which were analysed using thematic analysis. Additionally, we assessed if the women changed the self-reported questionnaires, Endometriosis Health Profile 30 and the Patient Activation Measure from before and after the conversations.

RESULTS

We identified four themes: feeling alone with the disease; establishing a meaningful relationship with healthcare professionals in a traditional hospital setting; person-specific knowledge facilitated new behaviours and; accepting a chronic condition - the beginning of a process. All dimensions of the Endometriosis Health Profile 30 and the Patient Activation Measure appeared to improve at two weeks and so did almost all the dimensions of Endometriosis Health Profile 30 after 1 year.

CONCLUSIONS

The implementation of the Guided Self-Determination method appeared feasible and the women developed self-management skills in relation to endometriosis and its symptoms. This was achieved by increasing insight into their needs and behaviours and gaining new knowledge about the disease itself. The before-and-after assessment suggested benefit of the intervention, but this should be further tested in a randomised trial.

How Do the Challenges of Emerging Adulthood Inform our Understanding of Diabetes Distress? An Integrative Review

PURPOSE OF REVIEW

Emerging adulthood (ages 18-29) presents many emotional, social, and developmental challenges that can contribute to an increased sense of burden when managing type 1 diabetes (T1D). Diabetes distress (DD) is the concept that captures the emotional burden, frustrations, and worries resulting from living with T1D. This integrative review sets out to examine the impact of developmental context by answering this question: How do the challenges of emerging adulthood inform our understanding of DD?

RECENT FINDINGS

DD is highly prevalent in emerging adults and occurs at higher rates than in other age groups. Qualitative studies reveal that DD is embedded within the developmental challenges specific to living with T1D during this stage. Quantitative studies reveal the prevalence and correlates of DD in this age group, and qualitative studies augment these findings by capturing the scope and complexity of the emotional burden of living with T1D as an emerging adult.

A person-centered education for adolescents with type 1 diabetes-A randomized controlled trial

INTRODUCTION

Young people with type 1 diabetes and their parents need to receive person-centered education to be able to manage their diabetes. Guided Self-Determination-Young (GSD-Y) is a person-centered communication and reflection education model that can be used in educational program for young people with type 1 diabetes.

OBJECTIVE

To evaluate whether GSD-Y leads to improved glycaemic control, increased self-perceived health and health-related quality of life, fewer diabetes-related family conflicts, and improved self-efficacy in a group-based intervention for adolescents starting continuous subcutaneous insulin infusion (CSII) and their parents.

METHODS

This randomized controlled trial included 71 adolescents starting CSII. Participants were followed for 12 months. The intervention group (n = 37) attended seven group training sessions over a period of 5 months, using the GSD-Y model, the control group received standard care. Variables evaluated were HbA1c, self-perceived health, health-related quality of life, family conflicts, self-efficacy, and usage of continuous glucose monitoring.

RESULTS

When adjusted for sex and family conflicts, there was a difference in glycaemic control between the groups at 12 months, favoring the intervention group (62 vs 70 mmol/mol, P = .009). When analyses were performed on boys and girls separately and adjusted for family conflicts, the only difference detected was for boys after 12 months (P = .019). The intervention showed no effect on self-perceived health, health-related related quality of life, family conflicts, or self-efficacy.

CONCLUSIONS

An intervention with GSD-Y may have an effect on glycaemic control. The content of the GSD-Y groups may serve as a model for person-centered care in adolescents with type 1 diabetes.

Psychosocial Interventions for Emergent Adults With Type 1 Diabetes: Near-Empty Systematic Review and Exploratory Meta-Analysis

Risk for developing mental health concerns is increased for people with diabetes. Coupled with stressors related to the transition from adolescence to adulthood, emergent adults may be in greater need of psychosocial interventions to help them cope. This review summarizes the literature on interventions used with people with diabetes aged 15-30 years on psychosocial and biological (A1C) outcomes. Core databases were searched for both published and grey research. Studies completed between January 1985 and October 2018 using any psychosocial intervention and meeting age and diabetes type requirements were selected if they included a control or comparison group and findings reported in such a way that effect size was calculable. Two authors independently extracted relevant data using standard data extraction templates. Six studies with 450 participants met the broad inclusion criteria. Sample-weighted pooling of 12 outcomes, six each on glycemic control and psychosocial status, suggested the preventive potential (d = 0.31, 95% CI 0.17-0.45) and homogeneity (χ² [11] = 11.15, P = 0.43) of studied interventions. This preliminary meta-analysis provides some suggestion that psychosocial interventions, including telephone-based case management, individualized treatment modules, and small-group counseling interventions, may diminish burden, depression, and anxiety and enhance glycemic control among emerging adults with type 1 diabetes as they transition from adolescence to adulthood.

Development and Psychometric Properties of the Inflammatory Bowel Disease Distress Scale (IBD-DS): A New Tool to Measure Disease-Specific Distress

BACKGROUND

Inflammatory bowel disease (IBD) imposes a heavy psychosocial burden, with many patients reporting anxiety, depression, and distress. In diseases such as diabetes, disease-specific distress is associated with concordance with treatments and disease control. IBD distress, distinct from anxiety and depression, is evident in people with IBD. We aimed to develop a questionnaire for assessing IBD-specific distress, validate this against a gold standard distress measure for diabetes, and demonstrate the difference between anxiety, depression, and distress.

METHODS

The 94-item IBD Distress Scale (IBD-DS) was developed through secondary analysis of 3 qualitative data sets from previous IBD studies. Items were then refined through cognitive interviews in 2 stages (n = 15, n = 3). Three supplementary unscored questions were added to enable patients to identify their overall level of distress, their perceived level of disease activity, and their 3 most distressing issues. Subsequently, the 55-item IBD Distress Scale was subjected to test-retest. Two hundred seventy-five people received the test draft IBD-DS, and 168 responded (60.4%). Of these, 136 (82%) returned the retest draft of IBD-DS 3 weeks later. After analysis, further item reduction was informed by response rates, kappa values, and correlation coefficients, and test-retest was repeated. One hundred fifty-four people received the test final 28-item IBD-DS, and 123 people responded (58.8%). Of these, 95 (77%) returned the retest final IBD-DS.

RESULTS

The 94 items were reduced to 28 items. Good intraclass correlation (ICC) was found between test-retest scores on 72 complete data sets with unchanged disease status (ICC, 0.92; 95% confidence interval, 0.88-0.95). Cronbach's alpha was 0.95, indicating excellent internal consistency. Factor analysis indicated scoring the items as a single domain (score range, 0-168).

CONCLUSION

The final IBD-DS performs well and offers a tool for assessing IBD-specific distress.

New Possibilities in Life with Type 2 Diabetes: Experiences from Participating in a Guided Self-Determination Programme in General Practice

Research suggests that guided self-determination programmes can support self-management of diabetes by empowering self-determined goal setting and competence building. As most research in this area has focused on people with type 1 diabetes, knowledge is lacking on how adults with type 2 diabetes mellitus experience participation in such programmes. This study reports the modelling phase of a complex intervention design that explored the experiences of adults with type 2 diabetes who participated in a nurse-led guided self-determination programme in general practice and examines how the programme affected patients' motivation to self-manage diabetes. The qualitative design with semistructured interviews included 9 adults with type 2 diabetes who participated in the programme. Qualitative content analysis was used to analyse the data. The findings indicate that the participants experienced new life possibilities after participating in the programme, which seemed to have a positive influence on their motivation for self-management. Through reflections about how to live with diabetes, the participants reinterpreted their life with diabetes by gradually developing a closer relationship with the disease, moving towards acceptance. The fact that dialogue with the nurses was seen to be on an equal footing helped support the participants to become more self-determined.

Written reflection in an eHealth intervention for adults with type 2 diabetes mellitus: a qualitative study

BACKGROUND

Individuals with type 2 diabetes mellitus (T2DM) are responsible for the daily decisions and actions necessary to manage their disease, which makes self-management the cornerstone of diabetes care. Many patients do not reach recommended treatment goals, and thus it is important to develop and evaluate innovative interventions that facilitate optimal motivation for adequate self-management of T2DM.

OBJECTIVE

The aim of the current study was to explore how adults with T2DM experience using reflection sheets to stimulate written reflection in the context of the Guided Self-Determination (GSD) eHealth intervention and how written reflection might affect their motivation for self-management of T2DM.

METHODS

We used a qualitative design in which data were collected through individual interviews. The sample consisted of 10 patients who completed the GSD eHealth intervention, and data were analyzed using qualitative content analysis.

RESULTS

The qualitative content analysis yielded 2 main themes. We labeled the first theme as "Written reflection affects awareness and commitment in diabetes self-management", which reflects 2 subthemes, namely, "Writing creates space and time for autonomous reflection" and "Writing influences individuals' focus in diabetes self-management". We labeled the second theme as "Written reflection is perceived as inapplicable in diabetes self-management", which reflects 2 subthemes, namely, "Responding in writing is difficult" and "The timing of the writing is inappropriate".

CONCLUSION

Our findings indicate that written reflection in the context of the GSD eHealth intervention may be conducive to motivation for diabetes self-management for some patients. However, it seems that in-person consultation with the diabetes nurse may be necessary to achieve the full potential benefit of the GSD as an eHealth intervention. We advocate further development and examination of the GSD as a "blended" approach, especially for those who consider written reflection to be difficult or unfamiliar.

Guided self-determination-young versus standard care in the treatment of young females with type 1 diabetes: study protocol for a multicentre randomized controlled trial

Background

Female adolescents with type 1 diabetes mellitus (T1DM) have the most unsatisfactory glycaemic control of all age groups and report higher disease burden, poorer perceived health, and lower quality of life than their male counterparts. Females with T1DM face an excess risk of all-cause mortality compared with men with T1DM. New methods are needed to help and support young females with T1DM to manage their disease.

A prerequisite for successful diabetes management is to offer individualized, person-centred care and support the patient’s own motivation. Guided self-determination (GSD) is a person-centred reflection and problem-solving method intended to support the patient’s own motivation in the daily care of her diabetes and help develop skills to manage difficulties in diabetes self-management. GSD has been shown to improve glycaemic control and decrease psychosocial stress in young women with T1DM. The method has been adapted for adolescents and their parents, termed GSD-young (GSD-Y). The aim of this study was to evaluate whether an intervention with GSD-Y in female adolescents with T1DM leads to improved glycaemic control, self-management, treatment satisfaction, perceived health and quality of life, fewer diabetes-related family conflicts, and improved psychosocial self-efficacy.

Methods/design

This is a parallel-group randomized controlled superiority trial with an allocation ratio of 1:1. One hundred female adolescents with T1DM, 15–20 years of age, and their parents (if < 18 years of age), will be included. The intervention group will receive seven individual GSD-Y education visits over 3 to 6 months. The control group will receive standard care including regular visits to the diabetes clinic. The primary outcome is level of glycaemic control, measured as glycosylated haemoglobin (HbA1c). Secondary outcomes include diabetes self-management, treatment satisfaction, perceived health and quality of life, diabetes-related family conflicts, and psychosocial self-efficacy. Data will be collected before randomization and at 6 and 12 months.

Discussion

Poor glycaemic control is common in female adolescents and young adults with T1DM. Long-standing hyperglycaemia increases the risks for severe complications and may also have an adverse impact on the outcome of future pregnancies. In this study, we want to evaluate if the GSD-Y method can be a useful tool in the treatment of female adolescents with T1DM.

Trial registration

Current controlled trials, ISRCTN57528404. Registered on 18 February 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2296-6) contains supplementary material, which is available to authorized users.

The effect of guided self-determination on self-management in persons with type 1 diabetes mellitus and HbA1c ≥64 mmol/mol: a group-based randomised controlled trial

OBJECTIVES

To determine whether the impact of guided self-determination (GSD) applied in group training (GSD-GT) in people with chronically elevated HbA_1c and type 1 diabetes mellitus (DM) was superior to 'care as usual' in improving HbA_1c and psychological functioning.

SETTING

An outpatient clinic at a university hospital in Western Norway.

PARTICIPANTS

A total of 178 adults (all Caucasian) aged 18-55 (mean age 36.7±10.7, 62% women) with type 1 DM for at least 1 year and HbA_1c ≥64 mmol/mol (8.0%) were randomly assigned to participate in either GSD-GT or a control group (CG). Exclusion criteria were severe comorbidity, major psychiatric disorder, cognitive deficiency/language barriers and pregnancy.

INTERVENTION

Intervention group met seven times for 2 hours over 14 weeks to promote patient autonomy and intrinsic motivation using reflection sheets and advanced professional communication in accordance with the GSD methodology.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was HbA_1c and secondary outcomes (all outcomes 9 months post intervention) were self-monitored blood glucose frequency, self-reported diabetes competence, autonomy support by healthcare providers (Health Care Climate Questionnaire), autonomous versus controlled diabetes motivation (Treatment Self-Regulation Questionnaire), diabetes distress (Problem Areas In Diabetes Scale (PAID) and Diabetes Distress Scale (DDS)), self-esteem (Rosenberg Self-Esteem Scale) and psychological well-being (World Health Organization five-item Well-Being Index scale).

RESULTS

Among participants allocated to the GSD-GT (=90) 48 completed the study, whereas 83 completed in the CG (n=88). With 95% CIs GSD-GT did not have effect on HbA_1c (B -0.18, CI (-0.48, 0.12), p=0.234). GSD-GT improved autonomy-motivated behaviour (B 0.51, CI (0.25, 0.77), p<0.001), diabetes distress (PAID, B -6.96, CI (-11.40, -2.52), p=0.002), total DDS (B -5.15, CI (-9.34, -0.96), p=0.016), DDS emotional burden (B -7.19, CI (-13.20, -1.19), p=0.019) and self-esteem (B 1.43, CI (0.34, 2.52), p=0.011).

CONCLUSIONS

Results from this behavioural intervention must be interpreted cautiously because of recruitment and attrition problems. Medical outcomes did not improve. Psychological outcomes improved, especially reduced diabetes distress.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov NCT 01317459.

Learning to practise the Guided Self-Determination approach in type 2 diabetes in primary care: A qualitative pilot study

Aim

To describe how diabetes nurses in primary care experience the process of learning to practise the person‐centred counselling approach Guided Self‐Determination among adults with type 2 diabetes.

Design

A descriptive qualitative design.

Method

Data were collected in 2014–2015 by means of individual interviews with four diabetes nurses at two points in time. The data were analysed using qualitative content analysis.

Results

Three themes that reflect nurses’ processes in learning to use the Guided Self‐Determination approach were identified: (1) from an unfamiliar interaction to “cracking the code”; (2) from an unspecific approach to a structured, reflective, but demanding approach; and (3) from a nurse‐centred to a patient‐centred approach. The overall findings indicate that the process of learning to practise Guided Self‐Determination increased the nurses’ counselling competence. Moreover, the nurses perceived the approach to be generally helpful, as it stimulated reflections about diabetes management and about their own counselling practices.

Translating person-centered care into practice: A comparative analysis of motivational interviewing, illness-integration support, and guided self-determination

OBJECTIVE

Person-centred care [PCC] can engage people in living well with a chronic condition. However, translating PCC into practice is challenging. We aimed to compare the translational potentials of three approaches: motivational interviewing [MI], illness integration support [IIS] and guided self-determination [GSD].

METHODS

Comparative analysis included eight components: (1) philosophical origin; (2) development in original clinical setting; (3) theoretical underpinnings; (4) overarching goal and supportive processes; (5) general principles, strategies or tools for engaging peoples; (6) health care professionals' background and training; (7) fidelity assessment; (8) reported effects.

RESULTS

Although all approaches promoted autonomous motivation, they differed in other ways. Their original settings explain why IIS and GSD strive for life-illness integration, whereas MI focuses on managing ambivalence. IIS and GSD were based on grounded theories, and MI was intuitively developed. All apply processes and strategies to advance professionals' communication skills and engagement; GSD includes context-specific reflection sheets. All offer training programs; MI and GSD include fidelity tools.

CONCLUSION

Each approach has a primary application: MI, when ambivalence threatens positive change; IIS, when integrating newly diagnosed chronic conditions; and GSD, when problem solving is difficult, or deadlocked.

PRACTICE IMPLICATIONS

Professionals must critically consider the context in their choice of approach.

A person-centered intervention targeting the psychosocial needs of gynecological cancer survivors: a randomized clinical trial

PURPOSE

We investigated the effect of a person-centered intervention consisting of two to four nurse-led conversations using guided self-determination tailored to gynecologic cancer (GSD-GYN-C) on gynecological cancer survivors' quality of life (QOL), impact of cancer, distress, anxiety, depression, self-esteem, and self-reported ability to monitor and respond to symptoms of recurrence.

METHODS

We randomly assigned 165 gynecological cancer survivors to usual care (UC) plus GSD-GYN-C or UC alone. Self-reported QOL-cancer survivor (QOL-CS) total score and subscale scores on physical, psychological, social, and spiritual well-being were assessed before randomization and at 3 and 9 months after randomization using t tests. Bonferroni and Pipper corrections were applied for multiple testing adjustments.

RESULTS

At 9 months, the GSD-GYN-C plus UC group scored significantly higher on the QOL-CS total scale (P = 0.02) and on the QOL-CS physical well-being subscale (P = 0.01), compared to women receiving UC alone. After adjusting for baseline scores, only the difference in the physical well-being subscale was statistically significant. No other measured outcomes differed between the intervention and control groups after baseline adjustment.

CONCLUSION

We observed higher physical well-being 9 months after randomization in the GSD-GYN-C group, as compared to women receiving usual care.

IMPLICATIONS FOR CANCER SURVIVORS

The results suggest that the person-centered intervention GSD-GYN-C may improve physical well-being in gynecological cancer survivors. However, further testing is needed.

The detection and management of diabetes distress in people with type 1 diabetes

Diabetes distress (DD) represents a significant clinical burden in which levels of DD are related to both glycated haemoglobin (HbA1c) and some self-management behaviours. DD is related to, but different from, depression. Differences in DD experienced in people with type 1 and type 2 diabetes have been observed. Commonly measured using the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS), rates of elevated DD in research study participants range from 20 to 30 %. Risk factors for elevated DD in type 1 diabetes are longer duration of diabetes, severe hypoglycaemia, younger age and being female. A systematic review of intervention studies assessing DD identified eight randomised controlled trials (RCTs) and nine pre-post design studies. Only three studies targeted DD with the intervention. Intervention types were diabetes self-management education (DSME), psychologically informed self-management and devices. DSME pre-post studies, namely the Dose Adjustment For Normal Eating (DAFNE) programme, produced more consistent improvements in DD and HbA1c at follow-up. Psychologically informed self-management was more heterogeneous, but several RCTs were effective in reducing DD. Group interventions offered the greatest benefits across intervention designs.

Dramatic change in a young woman's perception of her diabetes and remarkable reduction in HbA1c after an individual course of Guided Self-Determination

A 24-year-old woman with type 1 diabetes participated in a randomised controlled trial proving effectiveness of a flexible Guided Self-Determination (GSD) intervention. She had for 10 years been living with a complex situation of eating disorder, poor glycaemic control, non-attendance and psychosocial distress. She managed to change her perception of diabetes dramatically and improved her glycaemic control. Considering the complexity of her case, we explored how she achieved these changes. A GSD-trained nurse delivered the intervention, which involves reflection sheets and advanced professional communication. Glycated hemoglobin was reported in the patient's record and an interview conducted by external interviewers was analysed thematically, indicating that a four-stage process of empowerment had taken place: 'focusing on life prior to numbers', 'unpacking a heavy burden', 'breaking out of isolation through communication' and 'finding strength within oneself'. The article emphasises that GSD works by breaking isolation through communication as an appropriate way to achieve good diabetes control.