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Jiang L, Yan J, Yao J, Jing X, Chen Y, Deng Y, Zhang W, Yuan Y, Yang X. Nurse-led follow-up care versus routine health education and follow-up in diabetes patients: An effectiveness analysis. Medicine (Baltimore) 2024; 103:e38094. [PMID: 39259103 DOI: 10.1097/md.0000000000038094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2024] Open
Abstract
Patients with diabetes have physical and psychological issues due to chronic illness. According to the guidelines of the Chinese Diabetes Society, after the diagnosis of patients with diabetes, they should receive routine health education, but this is the passive installation method of education. Nurses have made important contributions to the follow-up, education, and support of patients with diabetes and their families. The objective of this study was to evaluate the effectiveness of nurse-led follow-up care in routine health education and follow-up for patients with diabetes. Medical records of 721 patients with type 1 and type 2 diabetes were reviewed. Patients received nurse-led follow-up care including educational programs + Tai Chi exercises (patients received nurse-led follow-up care including educational programs for 6 months, n = 108), routine health education and follow-up + Tai Chi exercises (patients received routine health education and follow-up for 6 months, n = 205), or Tai Chi exercises only, but did not receive nurse-led follow-up care or routine health education and follow-up (patients received Tai Chi exercises only for 6 months, n = 408) for 6-months. The Zung Self-Rating Depression and Anxiety Scale and Summary of Diabetes Self-Care Activities were used to evaluate anxiety, depression, and self-care activities, respectively. Before the start of follow-up care (BFC), knowledge regarding diabetes and its threat was ≤1.75, anxiety and depression scores were ≥52 each, and self-care activities were ≤37. After 6 months of follow-up care, patients in the patients received nurse-led follow-up care including educational programs for 6 months improved their knowledge regarding diabetes and its threat, anxiety, depression, and self-care activities as compared to their before the start of follow-up care conditions and patients in the RF and patients received Tai Chi exercises only for 6 months at after 6 months of follow-up care conditions (P < .001 for all). Chinese type 1 or 2 diabetes patients had worse physical and psychological conditions and less knowledge regarding diabetes and its threat. Nurse-led aftercare, including educational programs with Tai Chi exercises for 6 months, decreased anxiety and depression and improved knowledge regarding diabetes and its threat and self-care activities in diabetic patients (Level of Evidence: IV; Technical Efficacy: Stage 5).
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Affiliation(s)
- Lan Jiang
- Outpatient Department, Chongqing Emergency Medical Center, Chongqing Fourth People's Hospital, Chongqing University Affiliated Central Hospital, Chongqing, China
| | - Jiao Yan
- Department of Nursing, Chongqing Emergency Medical Center, Chongqing Fourth People's Hospital, Chongqing University Affiliated Central Hospital, Chongqing, China
| | - Jing Yao
- Department of Traditional Chinese Medical Rehabilitation, Chongqing Emergency Medical Center, Chongqing Fourth People's Hospital, Chongqing University Affiliated Central Hospital, Chongqing, China
| | - Xi Jing
- Department of Cardiology, Chongqing Emergency Medical Center, Chongqing Fourth People's Hospital, Chongqing University Affiliated Central Hospital, Chongqing, China
| | - Yan Chen
- Department of Endocrinology and Metabolism, Chongqing Emergency Medical Center, Chongqing Fourth People's Hospital, Chongqing University Affiliated Central Hospital, Chongqing, China
| | - Yimin Deng
- Outpatient Department, Chongqing Emergency Medical Center, Chongqing Fourth People's Hospital, Chongqing University Affiliated Central Hospital, Chongqing, China
| | - Wanyi Zhang
- Department of Neurology, Chongqing Emergency Medical Center, Chongqing Fourth People's Hospital, Chongqing University Affiliated Central Hospital, Chongqing, China
| | - Yi Yuan
- Department of Endocrinology and Metabolism, Chongqing Emergency Medical Center, Chongqing Fourth People's Hospital, Chongqing University Affiliated Central Hospital, Chongqing, China
| | - Xiaoyu Yang
- Outpatient Department, Chongqing Emergency Medical Center, Chongqing Fourth People's Hospital, Chongqing University Affiliated Central Hospital, Chongqing, China
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Lomborg K, Munch L, Krøner FH, Elwyn G. "Less is more": A design thinking approach to the development of the agenda-setting conversation cards for people with type 2 diabetes. PEC INNOVATION 2022; 1:100097. [PMID: 37213776 PMCID: PMC10194191 DOI: 10.1016/j.pecinn.2022.100097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 10/14/2022] [Accepted: 11/07/2022] [Indexed: 05/23/2023]
Abstract
Objectives To report a design-thinking approach to a user-centred agenda-setting tool for use in type 2 diabetes clinics. Methods The study followed design-thinking phases: emphasizing, defining, and ideating an intervention, followed by iterative user-testing of prototypes. It was conducted at a Danish diabetes center using observations, interviews, workshops, focus groups, and questionnaires. Results Nurses wanted to put more emphasis on agenda-setting in status visits. During brainstorms the idea of using illustrated cards that listed key agenda topics was proposed and became the goal of this research. Adopting a design-thinking approach provided the basis for developing prototypes for iterative user-testing that led to a version that was acceptable to stakeholders. The resulting tool, Conversation Cards, was a set of cards that listed and illustrated seven key topics that were considered important to consider during diabetes status visits. Conclusion The goal of the Conversation Card intervention is to support collaborative agenda-setting in diabetes status visits. Further evaluation is needed to determine the utility and acceptability of the tool to nurses and to people with diabetes in routine settings. Innovation This novel tool is designed to trigger agenda-setting conversations and thereby prioritize individuals' choice of topics to talk about during diabetes status visits.
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Affiliation(s)
- Kirsten Lomborg
- Department of Clinical Research, Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730 Herlev, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen N, Denmark
| | - Lene Munch
- Department of Clinical Research, Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730 Herlev, Denmark
| | - Freja Holmberg Krøner
- Department of Clinical Research, Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730 Herlev, Denmark
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Williamson Translational Research Building, 1 Medical Center Drive, Lebanon, NH 03756, USA
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Hills S, Terry D, Gazula S, Browning C. Practice nurses' communication with people living with type 2 diabetes: A scoping review. PATIENT EDUCATION AND COUNSELING 2022; 105:2664-2670. [PMID: 35393227 DOI: 10.1016/j.pec.2022.03.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/05/2022] [Accepted: 03/27/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To identify the key characteristics of practice nurses' communication with people living with Type 2 Diabetes (T2D) where lifestyle activities are discussed. METHODS A scoping review of the peer-reviewed literature was conducted. Reflexive thematic analysis was used to identify key themes that emerged. The PRISMA-ScR checklist was followed. RESULTS 25 studies were retained in the final review. Nurses who were committed to engaging in lifestyle discussions created supportive environments and built rapport to enable change conversations. However, this was present in just 20% of the studies. In most studies, (60%) nurses continued to use traditional health education communication styles, had little understanding of behaviour change theories, lacked skills in behaviour change counselling and were reluctant to engage in behaviour change discussions with people with T2D . CONCLUSIONS Nurses require a deeper understanding of behavioural change theories and skills in behavioural counselling. PRACTICE IMPLICATIONS Practice nurses have a unique opportunity to facilitate T2D remission by engaging in evidence-based behaviour change communication. A behaviour change training intervention is needed that recognises the environment of practice nurse consultations. It needs to be pragmatic and fully consider the enablers and barriers to addressing behaviour change in both the nurse and the person with T2D.
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Affiliation(s)
- Sharon Hills
- Federation University Australia, Institute of Health and Wellbeing, PO Box 663, Ballarat, VIC 3353, Australia.
| | - Daniel Terry
- Federation University Australia, Institute of Health and Wellbeing, PO Box 663, Ballarat, VIC 3353, Australia.
| | - Swapnali Gazula
- Federation University Australia, Institute of Health and Wellbeing, PO Box 663, Ballarat, VIC 3353, Australia.
| | - Colette Browning
- Federation University Australia, Institute of Health and Wellbeing, PO Box 663, Ballarat, VIC 3353, Australia; Australia Research School of Population Health, Australian National University; Health Innovation and Transformation Centre, Federation University.
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Makwero M, Muula A, Anyawu FC, Igumbor J. The conceptualisation of patient-centred care: A case study of diabetes management in public facilities in southern Malawi. Afr J Prim Health Care Fam Med 2021; 13:e1-e10. [PMID: 34636606 PMCID: PMC8517774 DOI: 10.4102/phcfm.v13i1.2755] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Patient-centred care (PCC) is one of the pillars of Malawi's quality of care policy initiatives. The role of PCC in facilitating quality service delivery is well documented, and its importance may heighten in chronic disease management. Yet, PCC conceptualisation is known to be context specific. AIM The study aimed to understand the conceptualisation of PCC amongst patients, healthcare providers (HCP) and policy makers in Diabetes Mellitus (DM) management. SETTING This study was conducted in DM clinics in Southern Malawi. METHODS Our qualitative exploratory research study design used in-depth and focus group interviews. We interviewed patients with DM, HCPs and policy makers. The study used framework analysis guided by Mead and Bower's work. RESULTS Patient-centred care conceptualisations from groups of participants showed convergence. However, they differed in emphasis in some elements. The prominent themes emerging from the participants' conceptualisation of PCC included the following: meeting individual needs, goals and expectations, accessing medication, supporting relationship building, patient involvement, information sharing, holistic care, timeliness and being realistic. CONCLUSION Patient-centred care conceptualisation in Malawi goes beyond the patient-HCP relational framework to include the technical aspects of care. Contrary to the global view, accessing medication and timeliness are major elements in PCC conceptualisation in Malawi. Whilst PCC conceptualisation is contextual, meeting expectations and needs of patients is fundamental.
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Affiliation(s)
- Martha Makwero
- Department of Family Medicine, School of Public Health and Family Medicine, University of Malawi, Blantyre, Malawi; and, Department of Public Health, School of Public Health, University of the Witwatersrand, Johannesburg.
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Impacto de los Centros Avanzados de Diabetes en la experiencia de los pacientes con diabetes tipo 2 con la atención sanitaria mediante la herramienta IEXPAC. ENDOCRINOL DIAB NUTR 2021. [DOI: 10.1016/j.endinu.2020.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Gómez-García A, Ferreira de Campos K, Orozco-Beltrán D, Artola-Menéndez S, Grahit-Vidosa V, Fierro-Alario MJ, Alonso-Jerez JL, Villabrille-Arias MC, Zuazagoitia-Nubla JF, Ledesma-Rodríguez R, Fernández G. Impact of Advanced Diabetes Centers on the healthcare experience of patients with type 2 diabetes using the IEXPAC tool. ENDOCRINOL DIAB NUTR 2021; 68:416-427. [PMID: 34742475 DOI: 10.1016/j.endien.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/16/2020] [Indexed: 06/13/2023]
Abstract
AIMS To determine the experience with healthcare among patients with type 2 diabetes according to the assistance model provided in their primary care centers, and to determine factors related with their experience. METHODS This was a cross-sectional study performed in patients with type 2 diabetes with cardiovascular or renal complications. The patients were divided in two groups according to whether they had been attended in Advanced Diabetes centers (ADC) or the traditional assistance centers. Patient's healthcare experience was assessed with the "Instrument for Evaluation of the Experience of Chronic Patients" (IEXPAC) questionnaire, with possible scores ranging from 0 (worst experience) to 10 (best experience). RESULTS A total of 451 patients (215 from ADC and 236 from traditional assistance centers) were included. The mean overall IEXPAC scores were 5.9 ± 1.7 (ADC) and 6.0 ± 1.9 (traditional assistance centers; p = 0.82). In the multivariant analyses, in ADC, the regular follow-up by the same physician (p = 0.01) and follow-up by a nurse (p = 0.01), were associated with a better patient experience, whereas receiving a higher number of medications with a worse patient experience (p = 0.04). In the traditional assistance centers, only the regular follow-up by the same physician was associated with a better experience (p = 0.02). Patients from ADC centers reported a higher score in the quality of life scale (69.1 ± 16.5 vs 64.6 ± 17.5; p = 0.008). CONCLUSIONS In general, the healthcare experience of type 2 diabetic patients with their sanitary assistance can be improved. Patients from ADC centers report a higher score in the quality of life scale.
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Affiliation(s)
| | | | - Domingo Orozco-Beltrán
- Departamento de Medicina Clínica, Universidad Miguel Hernández, San Juan de Alicante, Spain
| | - Sara Artola-Menéndez
- Centro de Salud José Marvá, SED (Sociedad Española de Diabetes) - Grupo de Diabetes, Madrid, Spain
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Orozco-Beltrán D, Artola-Menéndez S, Hormigo-Pozo A, Cararach-Salami D, Alonso-Jerez JL, Álvaro-Grande E, Villabrille-Arias C, de Toro-Santos FJ, Galindo-Puerto MJ, Marín-Jiménez I, Gómez-García A, Ledesma-Rodriguez R, Fernández G, Ferreira de Campos K. Healthcare experience among patients with type 2 diabetes: A cross-sectional survey using the IEXPAC tool. ENDOCRINOLOGY DIABETES & METABOLISM 2021; 4:e00220. [PMID: 33855220 PMCID: PMC8029499 DOI: 10.1002/edm2.220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/10/2020] [Accepted: 12/12/2020] [Indexed: 12/15/2022]
Abstract
Aim To assess the experience with health care among patients with type 2 diabetes (T2DM) and to evaluate patients’ demographic variables and healthcare‐related characteristics which may affect their experience. Methods A cross‐sectional survey was delivered to T2DM adults. Patient experiences were assessed with the ‘Instrument for Evaluation of the Experience of Chronic Patients’ (IEXPAC) questionnaire, a validated 12‐item survey, which describes patient experience within the last 6 months (items 1–11) and hospitalization in the last 3 years (item 12), with possible scores ranging from 0 (worst) to 10 (best experience). Results A total of 451 T2DM patients responded to the survey (response rate 72.3%; mean age 69.5 ± 10.1 years, 67.8% men). The mean overall IEXPAC score was 5.92 ± 1.80. Mean scores were higher for productive interactions (7.92 ± 2.15) and self‐management (7.08 ± 2.27) than for new relational model (1.72 ± 2.01). Only 32.8% of patients who had been hospitalized in the past 3 years reported having received a follow‐up call or visit after discharge. Multivariate analyses identified that regular follow‐up by the same physician and follow‐up by a nurse were associated with a better patient experience. Continuity of healthcare score was higher only in those patients requiring help from others. Conclusions The areas of T2DM care which may need to be addressed to ensure better patient experience are use of the Internet, new technologies and social resources for patient information and interaction with healthcare professionals, closer follow‐up after hospitalization, and a comprehensive multidisciplinary approach with regular follow‐up by the same physician and a nurse.
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Affiliation(s)
| | - Sara Artola-Menéndez
- José Marvá Heath Care Center SED (Spanish Diabetes Society) Diabetes Group Madrid Spain
| | | | | | | | | | | | | | - María José Galindo-Puerto
- Internal Medicine Department Clinic University Hospital Valencia Spain.,Research Department SEISIDA (Spanish AIDS Multidisciplinary Society Madrid Spain
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Peltola M, Isotalus P. Competing Discourses of Professional-patient Relationships in Type 2 Diabetes Management. HEALTH COMMUNICATION 2020; 35:1811-1820. [PMID: 31502472 DOI: 10.1080/10410236.2019.1663586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Type 2 diabetes is a contradictory chronic illness that needs to be managed in cooperation with health care professionals. Despite the significant role of the professional-patient relationship in diabetes management, the meaning of this relationship as part of diabetes management has not yet been studied. The aim of this qualitative study is to describe the competing discourses of professional-patient relationships in type 2 diabetes management. As a background theory, the study applied the relational dialectics theory (RDT) 2.0 by analyzing discourses in patients' interpersonal communication experiences with health care professionals. Overall, 63 experiences were analyzed using contrapuntal analysis. According to the results, both the patients' positive and negative descriptions were connected to three struggling discourses: 1) having the right to care versus deserving care, 2) guidance versus control, and 3) personalization versus standardization. These discourses offered new perspectives to clarify and strengthen the role of professional-patient relationships in type 2 diabetes management.
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Affiliation(s)
- Maija Peltola
- Speech Communication, Faculty of Information Technology and Communication Sciences, Tampere University
| | - Pekka Isotalus
- Speech Communication, Faculty of Information Technology and Communication Sciences, Tampere University
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Paiva D, Abreu L, Azevedo A, Silva S. Patient-centered communication in type 2 diabetes: The facilitating and constraining factors in clinical encounters. Health Serv Res 2019; 54:623-635. [PMID: 30815858 PMCID: PMC6505418 DOI: 10.1111/1475-6773.13126] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE To explore the perceptions of the constraining and facilitating factors to patient-centered communication in clinical encounters of patients with type 2 diabetes and the providers involved in their care. DATA SOURCES/STUDY SETTING Patients (n = 12) and providers (n = 33) involved in diabetes care in northern Portugal. STUDY DESIGN Seven focus groups. DATA COLLECTION/EXTRACTION METHODS Grounded theory, using open, axial, and selective coding. PRINCIPAL FINDINGS Patients focused on the patient-provider relationship, while providers emphasized the constraining factors when exchanging information and the facilitating factors regarding disease and treatment-related behavior. Patients and providers both agreed on some constraints (power imbalance, avoidance of criticism, disease minimization, use of jargon, and insufficient competencies and consistency among providers) and facilitators (seeing patients as persons, providing tailored information in plain language, and recognizing the "wake-up call"). Patients perceived an aggressive attitude as a barrier to communication, but providers perceived it as a facilitator. Patients included issues related to trust, respect, and psychosocial support as important factors to them. Only providers mentioned the influence of macro-level interventions and patients' socioeconomic position as essential factors. CONCLUSIONS Improvements in patient-centered communication depend on fostering the patient-provider relationship, patients' participation and involvement, and training providers' communication skills.
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Affiliation(s)
- Dagmara Paiva
- EPIUnit – Instituto de Saúde PúblicaUniversidade do PortoPortoPortugal
- USF Monte MuradoACES Espinho‐GaiaARS NorteVila Nova de GaiaPortugal
| | - Liliana Abreu
- EPIUnit – Instituto de Saúde PúblicaUniversidade do PortoPortoPortugal
| | - Ana Azevedo
- EPIUnit – Instituto de Saúde PúblicaUniversidade do PortoPortoPortugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação MédicaFaculdade de Medicina da Universidade do PortoPortoPortugal
- Centro de Epidemiologia HospitalarCentro Hospitalar São JoãoPortoPortugal
| | - Susana Silva
- EPIUnit – Instituto de Saúde PúblicaUniversidade do PortoPortoPortugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação MédicaFaculdade de Medicina da Universidade do PortoPortoPortugal
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Crowe M, Jones V, Stone MA, Coe G. The clinical effectiveness of nursing models of diabetes care: A synthesis of the evidence. Int J Nurs Stud 2019; 93:119-128. [PMID: 30908959 DOI: 10.1016/j.ijnurstu.2019.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/20/2019] [Accepted: 03/06/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To determine the clinical effectiveness (glycemic control, other biological measures, cost-effectiveness and patient satisfaction) of primary care nurse-led interventions for diabetes. DESIGN A systematic review following methods described for complex interventions and using PRISMA guidelines for reporting was undertaken. Nurse-led care for diabetes can be regarded as a complex intervention requiring the measurement of more than one outcome and for this reason we chose a range of outcomes clinical (symptoms), patient-centred (experiences) and organisational (cost-effectiveness). DATA SOURCES An extensive literature search using MEDLINE (PubMed) EMBASE, and CINAHL was conducted. REVIEW METHODS Primary studies with adults in primary care with both quantitative (comparison with physician-led care and cost-effectiveness) and qualitative (patient experiences of nurse-led care) methodologies from 2003 until June 2018. All studies were appraised using the Cochrane Collaboration's tool for assessing risk of bias. The appraisal involved evaluation of the degree of risk of bias in selection, performance, detection, attrition and reporting. Because of the complexity of multiple outcomes (quantitative and qualitative) a narrative synthesis was undertaken. RESULTS The search generated 18 published studies that met our eligibility criteria. Three randomized controlled trials and one historical control trial found statistically significant differences in glycemic levels in favour of the nurse-led interventions. Two cluster randomized trials, two randomized pragmatic trials and two randomized controlled trials found no differences between groups. The three open-label studies found statistically significant improvements in HbA1c levels. The audit identified that more patients had lower HbA1c levels after the initiation of a nurse-led intervention. Three randomized controlled trials found significant improvements in biological outcomes and one did not. The four studies measuring cost-effectiveness found the nurse-led intervention was associated with less costs. Four studies examined patient satisfaction with nurse-led care and found this was very good. CONCLUSION This review which incorporated a broad range of studies to capture the complexity of nurse-led interventions has identified that there is evolving evidence that nurse-led interventions for community treatment of diabetes may be more clinically effective than usual physician-led care.
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Affiliation(s)
- Marie Crowe
- Centre for Postgraduate Nursing Studies, University of Otago, Christchurch, New Zealand.
| | - Virginia Jones
- Centre for Postgraduate Nursing Studies, University of Otago, Christchurch, New Zealand
| | | | - Gillian Coe
- Nurse Maude, 24 McDougall Ave, Christchurch, New Zealand
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Faminu F. Diabetes: Setting and achieving glycemic goals. Nursing 2019; 49:49-54. [PMID: 30801408 DOI: 10.1097/01.nurse.0000549727.37810.3d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Implementing lifestyle changes can be a substantial challenge for patients with diabetes. This article offers nursing strategies to help patients set and meet glycemic goals and manage their own therapy.
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Affiliation(s)
- Femi Faminu
- Femi Faminu is a clinical nurse with the US Department of Veterans Affairs Greater Los Angeles Healthcare System
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Fazio S, Edwards J, Miyamoto S, Henderson S, Dharmar M, Young HM. More than A1C: Types of success among adults with type-2 diabetes participating in a technology-enabled nurse coaching intervention. PATIENT EDUCATION AND COUNSELING 2019; 102:106-112. [PMID: 30172572 PMCID: PMC6289853 DOI: 10.1016/j.pec.2018.08.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 08/17/2018] [Accepted: 08/22/2018] [Indexed: 05/07/2023]
Abstract
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.
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Affiliation(s)
- Sarina Fazio
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, USA; UC Davis Medical Center, UC Davis Health.
| | - Jennifer Edwards
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, USA.
| | - Sheridan Miyamoto
- College of Nursing, The Pennsylvania State University, University Park, USA.
| | - Stuart Henderson
- Schools of Health Evaluation, Clinical and Translational Science Center, University of California Davis, Sacramento, USA.
| | - Madan Dharmar
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, USA; Department of Pediatrics, School of Medicine, Betty Irene Moore School of Nursing University of California, Davis, Sacramento, USA.
| | - Heather M Young
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, USA.
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Daly BM, Arroll B, Scragg RKR. Diabetes knowledge of primary health care and specialist nurses in a major urban area. J Clin Nurs 2018; 28:125-137. [PMID: 30302838 DOI: 10.1111/jocn.14684] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 09/26/2018] [Accepted: 09/30/2018] [Indexed: 11/29/2022]
Abstract
AIM AND OBJECTIVES To examine trends since a previous 2006-2008 survey in diabetes knowledge held by primary health care nurses and their use of national diabetes guidelines, perceived ability to advise diabetes patients and preferences for further diabetes education. BACKGROUND The obesity epidemic has led to a rapid increase in the prevalence of prediabetes and type 2 diabetes and to greater expectations for an expanded role for primary health care nurses in the prevention and community management of diabetes. DESIGN Cross-sectional survey using a self-administered questionnaire and telephone interview and adheres to the STROBE guidelines. METHODS All nurses who provide community-based care in a major urban area were identified, and stratified by group, prior to random selection to participate in the study. A total of 1,416 practice, district (home care) and specialist nurses were identified who provide community-based care. Of the 459 who were randomly selected, 336 (73%) participated in 2016 and were compared with a representative sample of 287 nurses surveyed in 2006-2008. RESULTS Compared with nurses in 2006-2008, significantly more nurses in 2016 used diabetes guidelines, knew that stroke was a diabetes-related complication, had a greater understanding of the pathology of diabetes and reported having sufficient knowledge to advise patients on laboratory results and improving outcomes through lifestyle changes. Despite these improvements, in 2016, only 24% of nurses could state that stroke was a complication of type 2 diabetes, only 37% felt sufficiently knowledgeable to advise patients on medications, and <20% could state that hypertension, smoking and the dyslipidaemia profile were important modifiable risk factors. CONCLUSION There have been improvements in nurse's knowledge but gaps remain for cardiovascular outcomes and associated modifiable risk factors and medication management. RELEVANCE TO CLINICAL PRACTICE Education programmes should focus on improving cardiovascular risk management in patients with type 2 diabetes.
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Affiliation(s)
- Barbara M Daly
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Bruce Arroll
- General Practice & Primary Health Care, School of Population Health, University of Auckland, Auckland, New Zealand
| | - Robert Keith R Scragg
- Epidemiology and Biostatistics, School of Population Health, University of Auckland, Auckland, New Zealand
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Nurse-led psychological intervention for type 2 diabetes: a cluster randomised controlled trial (Diabetes-6 study) in primary care. Br J Gen Pract 2018; 68:e531-e540. [PMID: 30012812 DOI: 10.3399/bjgp18x696185] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/12/2018] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Suboptimal glycaemic control in type 2 diabetes (T2D) is common and associated with psychological barriers. AIM To investigate whether it was possible to train practice nurses in six psychological skills (Diabetes-6 [D6]) based on motivational interviewing (MI) and basic cognitive behaviour therapy (CBT), and whether integrating these with diabetes care was associated with improved glycaemic control over 18 months compared with standard care. DESIGN AND SETTING Two-arm, single-blind, parallel cluster randomised controlled trial in primary care. METHOD Adult participants (n = 334) with T2D and persistent HbA1c ≥69.4 mmol/mol were randomised to receive 12 sessions of either the D6 intervention or standard care over 12 months. Practice nurses were trained in the six psychological skills and their competencies were measured by standardised rating scales. Primary outcome was a change in HbA1c level at 18 months from randomisation. Secondary outcomes were changes in systolic and diastolic blood pressure, body mass index, waist circumference, depressive symptoms, harmful alcohol intake, diabetes-specific distress, and cost-effectiveness. RESULTS Using intention-to-treat analysis, there was no significant difference between D6 intervention and standard care in HbA1c (mean difference -0.79 mmol/mol, 95% confidence interval [CI] = -5.75 to 4.18) or for any of the secondary outcomes. The competency level of D6 nurses was below the beginner proficiency level and similar to the standard-care nurses. CONCLUSION Training nurses in MI and basic CBT to support self-management did not lead to improvements in glycaemic control or other secondary outcomes in people with T2D at 18 months. It was also unlikely to be cost-effective. Furthermore, the increased contact with standard-care nurses did not improve glycaemic control.
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Peltola M, Isotalus P, Åstedt-Kurki P. Patients' Interpersonal Communication Experiences in the Context of Type 2 Diabetes Care. QUALITATIVE HEALTH RESEARCH 2018; 28:1267-1282. [PMID: 29542395 DOI: 10.1177/1049732318759934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The aim of our study is to determine the relational communication characteristics of professional-patient communication situations that have either facilitated or impeded patients' self-management. Conducted from the perspective of Finnish patients in the context of type 2 diabetes care, we used as our research methods an open e-survey and semistructured interviews. Data were analyzed using inductive qualitative content analysis. The critical incident technique was utilized throughout in all these methods. The results show that both positive and negative experiences described by patients were connected to four multidimensional relational communication characteristics: (a) building trust in the other party in the professional-patient relationship, (b) willingness to communicate, (c) emotional presence, and (d) appropriateness. Although the findings support the recommendations of earlier studies concerning individually tailored patient-centered care, acknowledging the characteristics in question can be used as a communication frame for constructing significant care relationships from the perspective of patients' self-management.
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Affiliation(s)
- Maija Peltola
- 1 University of Tampere, Tampere, Pirkanmaa, Finland
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Kotsani K, Antonopoulou V, Kountouri A, Grammatiki M, Rapti E, Karras S, Trakatelli C, Tsaklis P, Kazakos K, Kotsa K. The role of telenursing in the management of Diabetes Type 1: A randomized controlled trial. Int J Nurs Stud 2018; 80:29-35. [PMID: 29353709 DOI: 10.1016/j.ijnurstu.2018.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 12/27/2017] [Accepted: 01/05/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Diabetes Mellitus type 1 (T1DM) is a chronic disease that requires patients' self-monitoring and self-management to achieve glucose targets and prevent complications. Telenursing implicates technology in the interaction of a specialized nurse with patients with chronic diseases in order to provide personalized care and support. OBJECTIVE To evaluate the effect of telenursing on T1DM patients' compliance with glucose self-monitoring and glycemic control. DESIGN Randomized controlled study. SETTINGS Outpatient Department of Diabetes, Endocrinology and Metabolism of a University Hospital in Northern Greece. METHODS Ninety-four T1DM patients were recruited and randomized in two groups by a random number generator. The intervention group (N = 48) was provided with telenursing services. A specialized nurse made a weekly contact via telephone motivating patients to frequently measure blood glucose and adopt a healthy lifestyle. The control group (N = 46) received standard diabetes advice and care in the clinic. The primary outcome was the effect of the intervention in glucose control and glucose variability. The secondary outcome was the effect on frequency of self-monitoring. SPSS 20.0 was used for data analysis. RESULTS The two groups did not differ in age, sex, physical activity or initial HbA1c. In the intervention group, blood glucose significantly decreased at the end of the study in all predefined measurements, compared to control group: morning (93.18 ± 13.30 mg/dl vs. 105.17 ± 13.74 mg/dl, p < 0.005), pre-prandial (114.76 ± 9.54 mg/dl vs. 120.84 ± 4.05 mg/dl, p < 0.005), post-prandial (193.35 ± 25.36 mg/dl vs. 207.84 ± 18.80 mg/dl, p < 0.005), and HbA1c decreased significantly over time in the intervention group (8.3 ± 0.6% at the beginning of the study vs. 7.8 ± 1% at the end of the study, p = 0.03). In the intervention group there were also fewer omitted glucose measurements than in the control group. CONCLUSIONS Patients in the intervention group achieved better glucose control and more frequent self-monitoring than patients in routine care in the clinic. The findings of our study indicate that telenursing can motivate T1DM patients to better control their disease.
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Affiliation(s)
- Konstantia Kotsani
- Diabetes Center, Department of Endocrinology and Metabolism, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Vasiliki Antonopoulou
- Diabetes Center, Department of Endocrinology and Metabolism, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Aikaterini Kountouri
- Diabetes Center, Department of Endocrinology and Metabolism, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Maria Grammatiki
- Diabetes Center, Department of Endocrinology and Metabolism, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Eleni Rapti
- Diabetes Center, Department of Endocrinology and Metabolism, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Spyridon Karras
- Diabetes Center, Department of Endocrinology and Metabolism, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Christina Trakatelli
- Diabetes Center, Department of Endocrinology and Metabolism, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Panagiotis Tsaklis
- Department of Nursing, Alexander Technological Educational Institute of Thessaloniki, Thessaloniki, Greece
| | - Kiriakos Kazakos
- Department of Nursing, Alexander Technological Educational Institute of Thessaloniki, Thessaloniki, Greece
| | - Kalliopi Kotsa
- Diabetes Center, Department of Endocrinology and Metabolism, 1st Department of Internal Medicine, AHEPA University Hospital, Thessaloniki, Greece.
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17
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Oftedal B, Kolltveit BCH, Zoffmann V, Hörnsten Å, Graue M. Learning to practise the Guided Self-Determination approach in type 2 diabetes in primary care: A qualitative pilot study. Nurs Open 2017; 4:134-142. [PMID: 28694977 PMCID: PMC5500461 DOI: 10.1002/nop2.76] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 12/14/2016] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Bjørg Oftedal
- Department of Health Studies University of Stavanger Stavanger Norway
| | | | - Vibeke Zoffmann
- The Research Unit Women's and Children's Health The Juliane Marie Centre Copenhagen University Hospital Copenhagen Denmark
| | - Åsa Hörnsten
- Department of Nursing Umeå University Umeå Sweden
| | - Marit Graue
- Centre for Evidence-Based Practice Bergen University College Bergen Norway
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Odnoletkova I, Goderis G, Nobels F, Fieuws S, Aertgeerts B, Annemans L, Ramaekers D. Optimizing diabetes control in people with Type 2 diabetes through nurse-led telecoaching. Diabet Med 2016; 33:777-85. [PMID: 26872105 DOI: 10.1111/dme.13092] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2016] [Indexed: 12/28/2022]
Abstract
AIMS To study the effect of a target-driven telecoaching intervention on HbA1c and other modifiable risk factors in people with Type 2 diabetes. METHODS We conducted a randomized controlled trial in patients receiving hypoglycaemic agents. The primary outcome was HbA1c level at 6 months in the entire sample and in a subgroup with HbA1c levels ≥ 53 mmol/mol (7%) at baseline. Secondary outcomes were HbA1c at 18 months; total cholesterol, LDL, HDL, triglycerides, blood pressure, BMI and proportion of people who had achieved guideline-recommended targets at 6 and 18 months. RESULTS A total of 287 participants were randomized to telecoaching and 287 to usual care. The mean (sd) baseline HbA1c level was 53 (11) mmol/mol [7.0 (1.0)%] overall and 63 (10) mmol/mol [7.9 (0.9)%] in the elevated HbA1c subgroup. At 6 months, the between-group differences in favour of telecoaching were: HbA1c -2 (95% CI -4; -1) mmol/mol [-0.2 (95% CI -0.3;-0.1)%; P=0.003] overall and -4 (95% CI -7; -2) mmol/mol [-0.4 (95% CI -0.7; -0.2)%; P=0.001] in the elevated HbA1c subgroup; BMI -0.4 kg/m(2) (95% CI -0.6; -0.1; P=0.003); total cholesterol -6 mg/dl (95% CI -11; -1, P=0.012). The proportion of participants on target for the composite of HbA1c , LDL and blood pressure increased by 8.9% in the intervention group and decreased by 1.3% in the control group (P=0.011). At 18 months, the difference in HbA1c was: -2 (95% CI -3;-0) mmol/mol [-0.2 (95% CI -0.3; -0.0)%; P=0.046] overall and -4 (-7; -1) mmol/mol [-0.4 (95% CI -0.7; -0.1)%; P=0.023] in the elevated HbA1c subgroup. CONCLUSION Nurse-led telecoaching improved glycaemic control, total cholesterol levels and BMI in people with Type 2 diabetes. Twelve months after the intervention completion, there were sustained improvements in glycaemic control.
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Affiliation(s)
- I Odnoletkova
- Leuven Institute for Healthcare Policy, Leuven, Belgium
| | - G Goderis
- Academic Centre for General Practice, KU Leuven, Leuven, Belgium
| | - F Nobels
- Department of Endocrinology, OLV Hospital Aalst, Moorselbaan, Aalst, Belgium
| | - S Fieuws
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics, University of Leuven and University of Hasselt, Leuven, Belgium
| | - B Aertgeerts
- Academic Centre for General Practice, KU Leuven, Leuven, Belgium
| | - L Annemans
- Department of Public Health, Ghent University, Ghent, Belgium
| | - D Ramaekers
- Leuven Institute for Healthcare Policy, Leuven, Belgium
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Hesselink AE, Rutten GEH, Slootmaker SM, de Weerdt I, Raaijmakers LGM, Jonkers R, Martens MK, Bilo HJG. Effects of a lifestyle program in subjects with Impaired Fasting Glucose, a pragmatic cluster-randomized controlled trial. BMC FAMILY PRACTICE 2015; 16:183. [PMID: 26695176 PMCID: PMC4688978 DOI: 10.1186/s12875-015-0394-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 12/08/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND The worldwide epidemic of type 2 diabetes (T2DM) underlines the need for diabetes prevention strategies. In this study the feasibility and effectiveness of a nurse led lifestyle program for subjects with impaired fasting glucose (IFG) is assessed. METHODS A cluster randomized clinical trial in 26 primary care practices in the Netherlands included 366 participants older than 45 years with newly diagnosed IFG and motivated to change their lifestyle (intervention group, n = 197; usual care group, n = 169). The one-year intervention, consisting of four to five individual nurse-led consultations, was directed at improving physical activity and dietary habits. The primary outcome measure was body mass index (BMI). Linear and logistic multilevel analyses and a process evaluation were performed. RESULTS Both groups showed small reductions in BMI at 1 and 2 years, but differences between groups were not significant. At both 1 and 2-year follow-up the number of participants physically active for at least 30 minutes at least five days a week was significantly improved in the intervention group compared to the usual care group (intervention group vs. usual care group: OR1year = 3.53; 95 % CI = 1.69-7.37 and OR2years = 1.97; 95 % CI = 1.22-3.20, respectively). The total drop-out rate was 24 %. Process evaluation revealed that participants in the intervention group received fewer consultations than advised, while some practice nurses and participants considered the RM protocol too intensive. CONCLUSIONS This relatively simple lifestyle program in subjects with IFG resulted in a significant improvement in reported physical activity, but not in BMI. Despite its simplicity, some participants still considered the intervention too intensive. This viewpoint could be related to poor motivation and an absence of disease burden due to IFG, such that participants do not feel a need for behavioural change. Although the intervention provided some benefit, its wider use cannot be advised. TRIAL REGISTRATION Current Controlled Trials ISRCTN41209683 , date of registration 16/10/2013h .
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Affiliation(s)
- Arlette E Hesselink
- ResCon, Research & Consultancy, Kennemerplein 7, 2011 MH, Haarlem, The Netherlands.
| | - Guy E H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Inge de Weerdt
- Netherlands Diabetes Federation, Amersfoort, The Netherlands
| | - Lieke G M Raaijmakers
- Department of Health Promotion, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ruud Jonkers
- ResCon, Research & Consultancy, Kennemerplein 7, 2011 MH, Haarlem, The Netherlands
| | - Marloes K Martens
- ResCon, Research & Consultancy, Kennemerplein 7, 2011 MH, Haarlem, The Netherlands
| | - Henk J G Bilo
- Diabetes Centre and Department of Internal Medicine, Isala Clinics, Zwolle; and, University Medical Centre Groningen, Groningen, The Netherlands
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20
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Learning transitions-a descriptive study of nurses' experiences during advanced level nursing education. BMC Nurs 2015; 14:30. [PMID: 25977642 PMCID: PMC4431375 DOI: 10.1186/s12912-015-0080-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 04/30/2015] [Indexed: 01/10/2023] Open
Abstract
Background Building capacity in a changing health care system is a challenge for advanced nursing education programs. Master-level nursing education is increasingly becoming the required education level for specialist nurses, and additional studies are needed to learn more about students’ experiences and learning transitions while undertaking such education. This study aimed to explore nursing students’ experience of their learning transitions while undertaking advanced nursing education and to describe how they translated the new knowledge and competence they gained into clinical practice. Methods We used a qualitative research design with narrative self-reported reflections. 34 nurses (95 % women) from both urban and rural areas working with children, with adults in outpatient and inpatient endocrinology clinics in hospitals or with adults, including older people, attending primary health care services participated in the study. We collected data at two time points 15 months apart. Time one was the first week of the advanced nursing education, and time two was the completion of the education program. We used Malterud’s modification of Giorgi’s phenomenological analysis, otherwise known as systematic text condensation, to analyze the data. Results Two core themes captured the participants’ experiences. The first theme was “assessing the situation of people with diabetes from a different perspective”, with the subthemes “an expanded perspective of practice and higher level of reflection”, “applying critical thinking in practice” and “changing patient-nurse relationships in diabetes care”. The second core theme was “a change in participants’ perception of their professional position”, with the subthemes “a greater knowledge base enhancing professional confidence” and “a more equal position within the professional team”. Conclusions The study provides in-depth information about transition into advanced nursing education and can inform curriculum developers, nurse educators, policy-makers and nursing managers about how nursing education broadened participants’ perspectives of nursing and enhanced their confidence and professional position.
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