Autonomy through identification: a qualitative study of the process of identification used by people with type 2 diabetes

Challenges faced in daily life by persons with type 2 diabetes: A meta-synthesis

Objectives

To derive improved understanding of the implicit meanings of challenges in daily life from the perspective of persons with type 2 diabetes.

Methods

A meta-synthesis was conducted with an interpretive and constructivist approach. Four databases were searched for articles published between 2007 and 2011, producing 37 articles for analysis. Van Deurzen’s life world theory was applied as an analytic grid.

Results

Challenges in daily life with type 2 diabetes could be understood as living in a tension between opposing forces, implying a struggle with inevitable paradoxes: living in the present and for the future, trusting oneself while relying on others, and being normal while feeling changed and different.

Discussion

This synthesis adds knowledge to previous understanding of living with type 2 diabetes, revealing the complexity of daily life when struggling with a lifelong illness. Person-centred care could be used to understand what challenges diabetes may cause in family and working life and the ambivalent feelings the illness can lead to. Future research is needed to implement and evaluate a person-centred care in practice. Since new qualitative research is continuously added to this topic, metasyntheses should be undertaken regularly.

More than A1C: Types of success among adults with type-2 diabetes participating in a technology-enabled nurse coaching intervention

OBJECTIVE

Success in diabetes research and self-management is often defined as a significant decrease in glycated hemoglobin (A1C). The aim of this article is to explore different types of successes experienced by adults with type-2 diabetes participating in a health technology and nurse coaching clinical trial.

METHODS

A qualitative analysis was conducted using surveys and documentation from motivational interview-based coaching sessions between study nurses and intervention participants.

RESULTS

Of the 132 cases reviewed, types of success predominantly fell into five categories: 1) change in health behaviors; 2) change in mindset or awareness; 3) change in engagement with healthcare resources; 4) change in physical or emotional health; and 5) change in health indicators.

CONCLUSION

Experiences of success in diabetes are more varied than traditional A1C-based outcome models. Our findings suggest coaching and technology can assist patients to achieve a range of successes in diabetes management through goal setting, health tracking, resolving barriers, and aligning goals with factors that impact change.

PRACTICE IMPLICATIONS

While A1C reduction is a critical factor in decreasing risk of diabetes-related complications, when healthcare professionals focus on A1C as the main indicator of diabetes management success, important changes in individuals' health and well-being may be overlooked or undervalued.

Connectivity, contest and the ties of self-management support for type 2 diabetes: a meta-synthesis of qualitative literature

This paper presents a meta-synthesis of the literature on community-based self-management to support experiences of people diagnosed with type 2 diabetes. The aim was to synthesise findings on both formal and informal self-management support with particular reference to the relevance and influence of the social context operating at different levels. The review forms part of EU-WISE, a project financed through EU's 7th Framework Programme. The review was performed by systematically searching MEDLINE, PubMed, EMBASE, CINAHL, PsycINFO and Web of Science for English language publications between 2005 and 2014 presenting research conducted in Europe on the experiences and perspectives of self-management concerns of patients diagnosed with type 2 diabetes. The search yielded 587 abstracts, which were reduced through search strategy refinement and eligibility and quality criteria to 29 papers that were included in the review. This review highlights the relevance of contextual factors operating at micro- and macro-levels. The synthesis yielded six second-order thematic constructs relating to self-management: sense of agency and identity, the significance and meaning of social networks, minimal disruption of everyday life, economic hardship, the problem of assigning patients' responsibility and structural influences of primary care. Using a line of argument synthesis, these themes were revisited, and a third-order construct, connectivity emerged which refers to how links in daily life are interwoven with peoples' social networks, local communities, economic and ideological conditions in society in a way which support self-management activities. This meta-synthesis indicates a need to heed the notion of connectivity as a means of mobilising and supporting the self-management strategies of people with type 2 diabetes in everyday life.

Perceptions of weight, diabetes and willingness to participate in randomised controlled trials of bariatric surgery for patients with type 2 diabetes mellitus and body mass index 30-39.9 kg/m(2)

PURPOSE

Evidence from high-quality randomised controlled trials (RCTs) is needed to establish the long-term benefit of bariatric surgery in people with type 2 diabetes mellitus (T2DM) and body mass index (BMI) 30-39.9 kg/m(2). However, willingness amongst this group to be randomised and undergo surgery is uncertain. This study assessed UK patients' perceptions of their weight and diabetes, and associations with willingness to participate in RCTs involving bariatric surgery, amongst this population.

MATERIALS AND METHODS

Postal survey of 1820 patients from four regions in England. Eligible patients were as follows: BMI 30-39.9 kg/m(2), 18-74 years, diagnosis of T2DM ≥2 years. A reminder survey was sent after 4 weeks. Independent predictors influencing patients' willingness to consider RCT participation were identified using multiple logistic regression analysis.

RESULTS

Thirty-four per cent (614/1820) of patients responded. Weight was considered to be harder to control than diabetes [468/584 (80 %) vs. 107/600 (17 %)]. More people reported a negative impact on life for weight rather than diabetes [379/579 (63 %) vs. 180/574 (31 %)]. Feeling unsatisfied/very unsatisfied with weight loss ability was common 261/578 (45 %). Sixty-four per cent (379/594, CI = 60-68) were willing to consider participating in an RCT. In multivariate analysis, negative impact of weight on life (OR = 2.55, 95 % CI = 1.68-3.89, P < 0.001) and feeling unsatisfied with weight loss ability (OR = 2.47, 95 % CI = 1.55-3.95, P < 0.001) positively influenced patients' willingness to participate in an RCT.

CONCLUSION

Strong patient interest supports the feasibility of such trials for this group. Perceptions of obesity negatively impacting on life and difficulties in achieving weight loss were common and influenced attitudes to potential participation in bariatric surgery RCTs.

Concept analysis: patient autonomy in a caring context

AIM

This paper is a report of an analysis of the concept of patient autonomy

BACKGROUND

Many problems regarding patient autonomy in healthcare contexts derive from the patient's dependent condition as well as the traditional authoritarian position of healthcare professionals. Existing knowledge and experience reveal a lack of consensus among nurses regarding the meaning of this ethical concept.

DESIGN

Concept analysis.

DATA SOURCES

Medline, CINAHL, The Cochrane Library and PsycINFO were searched (2005-June 2013) using the search blocks 'autonomy', 'patient' and 'nursing/caring'. A total of 41 articles were retrieved.

REVIEW METHODS

The Evolutionary Method of Concept Analysis by Rodgers was used to identify and construct the meaning of the concept of patient autonomy in a caring context.

RESULTS

Five attributes were identified, thus creating the following descriptive definition: 'Patient autonomy is a gradual, time-changing process of (re-)constructing autonomy through the interplay of to be seen as a person, the capacity to act and the obligation to take responsibility for one's actions'. Patient vulnerability was shown to be the antecedent of patient autonomy and arises due to an impairment of a person's physical and/or mental state. The consequences of patient autonomy were discussed in relation to preserving control and freedom.

CONCLUSION

Patient autonomy in a caring context does not need to be the same before, during and after a care episode. A tentative model has been constructed, thus extending the understanding of this ethical concept in a caring context.

Understanding through experience: information, experience and understanding in clinical rehabilitation practice

PURPOSE

According to ethical theories of patient autonomy, patients need information and understanding to make their own, autonomous choices. The aim of this article is to describe strategies used by clinical rehabilitation teams to develop patients' understanding and promote their autonomy.

METHOD

Individual semi-structured interviews were conducted with the patient, the nurse, the physiotherapist and the physician of three institution based rehabilitation teams. Analytic procedures described by Strauss and Corbin were applied, identifying categories by their properties and dimensions.

RESULTS

The analysis revealed how practitioners recognized that patients needed experience with practical challenges in order to understand their clinical conditions properly. Practitioners disclosed information related to the individual patient's experience with his or her clinical condition. In order to make information relevant to the individual patient's experience of possibilities and limitations, information was disclosed in discussions of these experiences, rather than in abstract verbal explanations. Patients needed to understand their situation to make autonomous choices for their future lives.

CONCLUSIONS

In clinical rehabilitation, patients and practitioners agree that adequate understanding cannot be achieved by verbal information alone, and that patients need to experience essential aspects of their physical possibilities and limitations.

IMPLICATIONS FOR REHABILITATION

Patients need an adequate understanding of their injuries or diseases to be able to make autonomous choices. In clinical rehabilitation teams, practical and bodily experiences are recognized as crucial for patients to develop such understanding. Rehabilitation practitioners may effectively enhance a patient's understanding and autonomy by disclosing information as part of discussions of the patient's own experiences.

Realizing autonomy in responsive relationships

The goal of this article is to augment the ethical discussion among nurses with the findings from empirical research on autonomy of older adults with type 2 diabetes mellitus. There are many factors influencing autonomy. These include: health conditions, treatment, knowledge, experience and skills, personal approach as well as familial patterns, type of relationship, life history and social context. Fifteen older adults with type 2 diabetes mellitus were interviewed in a nurse-led diabetes clinic. These participants perceive three processes which support autonomy in responsive relationships: preserving patterns of concern and interaction, nurturing collaborative responsibilities and being closely engaged in trustful and helpful family relations. People with diabetes realize autonomy in various responsive relationships in their unique life context. Next, we performed a literature review of care ethics and caring in nursing with regard to relational autonomy. We classified the literature in five strands of care: attitude-oriented, dialogue-oriented, activity-oriented, relationship-oriented and life-oriented. According to our respondents, autonomy in responsive relationships is fostered when patient, nurses, professionals of the health team and family members carry out care activities supported by a relational attitude of care. They can best realize autonomy in relationships with others when several essential aspects of care and caring are present in their lives. Therefore, we advocate a comprehensive approach to care and caring.

Autonomous decision making and moral capacities

This article examines how people with type 2 diabetes perceive autonomous decision making and which moral capacities they consider important in diabetes nurses' support of autonomous decision making. Fifteen older adults with type 2 diabetes were interviewed in a nurse-led unit. First, the data were analysed using the grounded theory method. The participants described a variety of decision-making processes in the nurse and family care-giver context. Later, descriptions of the decision-making processes were analysed using hermeneutic text interpretation. We suggest first- and second-order moral capacities that nurses specializing in diabetes need to promote the autonomous decision making of their patients. We recommend nurses to engage in ongoing, interactive reflective practice to further develop these moral capacities.

Self-management of type 2 diabetes mellitus: a qualitative investigation from the perspective of participants in a nurse-led, shared-care programme in the Netherlands

BACKGROUND

Diabetes mellitus is a major public health problem. Little is known about how people with type 2 diabetes experience self-management in a nurse-led, shared-care programme. The purpose of this article is to report an empirically grounded conceptualization of self-management in the context of autonomy of people with type 2 diabetes.

METHODS

This study has a qualitative descriptive, and exploratory design with an inductive approach. Data were collected by means of in-depth interviews. The sample consisted of older adults with type 2 diabetes in a nurse-led, shared-care setting. The data analysis was completed by applying the constant comparative analysis as recommended in grounded theory.

RESULTS

People with type 2 diabetes use three kinds of self-management processes: daily, off-course, and preventive. The steps for daily self-management are adhering, adapting, and acting routinely. The steps for off-course self-management are becoming aware, reasoning, deciding, acting, and evaluating. The steps for preventive self-management are experiencing, learning, being cautious, and putting into practice. These processes are interwoven and recurring.

CONCLUSION

Self-management consists of a complex and dynamic set of processes and it is deeply embedded in one's unique life situation. Support from diabetes specialist nurses and family caregivers is a necessity of self-managing diabetes.