Are Diabetic Patient's Quality of Life Improved by Having Access to a Diabetic Nurse Specialist - Literature review Example

ARE DIABETIC PATIENT'S QUALITY OF LIFE IMPROVED BY HAVING ACCESS TO A DIABETIC NURSE SPECIALIST EVIDENCE BASED PRACTICE INTRODUCTION Working in a care environment often brings me in close personal and professional contact with a lot of patients of all categories, diabetic being one amongst them. When reflecting on the conditions of many of them, I feel that not all are coping well with their conditions of restriction and constraint. They are unable to manage themselves, often with the result being that they end up getting worse than better. Something needs to be done to improve their conditions and standard of living. When pulling further on this thread of thought, a solution unraveled was to provide them a 24x7 specialist nurse, of course specializing in diabetes and on coping with the condition. This report aims to develop this idea into a working solution for the real time problem. Taking into consideration all the pros and cons of the situation by various analysis techniques advocated and approved of, this report will arrive at a satisfactory result that can withstand scrutiny and practice. The final recommendation made will take into account the best of all available resources. When tackling a problem, it is very important to ask the right question. This is a difficult skill to master, but it is a ground mandate for erecting an evidence-based decision-making process. An unambiguous and precise question, often called a "well-built" question should consist of four parts, referred to as PICO (Refer Appendix), that identifies the patient's problem or population (P), intervention (I), comparison (C) and outcome(s) (O). LITERATURE BASED ON REVIEWS The following are extracts from the Cochrane Review library on various conditions relating to Diabetes Mellitus and the conditions and implications surrounding the same. They explore the areas of the problems arising due to the disease and various alternatives considered for bettering the situation are offered and analyzed in depth. The final conclusions of all these studies are stated here. CASE I: INTERVENTIONS FOR IMPROVING ADHERENCE TO TREATMENT RECOMMENDATIONS IN PEOPLE WITH TYPE 2 DIABETES MELLITUS [Vermeire E, Wens J, Van Royen P, Biot Y, Hearnshaw H, Lindenmeyer A.] Background Research suggests adherence to treatment recommendations is low. In type 2 diabetes, which is a chronic condition slowly leading to serious vascular, nephrologic, neurologic and ophthalmological complications, it can be assumed that enhancing adherence to treatment recommendations may lead to a reduction of complications. Treatment regimens in type 2 diabetes are complicated, encompassing life-style adaptations and medication intake. Objectives To assess the effects of interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus. Selection criteria Randomised controlled and controlled clinical trials, before-after studies and epidemiological studies, assessing changes in adherence to treatment recommendations, as defined in the objectives section, were included. Main results Twentyone studies assessing interventions aiming at improving adherence to treatment recommendations, not to diet or exercise recommendations, in people living with type 2 diabetes in primary care, outpatient settings, community and hospital settings, were included. Outcomes evaluated in these studies were heterogeneous, there was a variety of adherence measurement instruments. Nurse led interventions, home aids, diabetes education, pharmacy led interventions, adaptation of dosing and frequency of medication taking showed a small effect on a variety of outcomes including HbA1c. Authors' conclusions Current efforts to improve or to facilitate adherence of people with type 2 diabetes to treatment recommendations do not show significant effects nor harms. The question whether any intervention enhances adherence to treatment recommendations in type 2 diabetes effectively, thus still remains unanswered. CASE II: INTERVENTIONS TO IMPROVE THE MANAGEMENT OF DIABETES MELLITUS IN PRIMARY CARE, OUTPATIENT AND COMMUNITY SETTINGS [Renders CM, Valk GD, Griffin S, Wagner EH, van Eijk JThM, Assendelft WJJ.] Background Diabetes is a common chronic disease that is increasingly managed in primary care. Different systems have been proposed to manage diabetes care. Objectives To assess the effects of different interventions, targeted at health professionals or the structure in which they deliver care, on the management of patients with diabetes in primary care, outpatient and community settings. Selection criteria Randomised trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) analyses of professional, financial and organisational strategies aimed at improving care for people with Type 1 or Type 2 diabetes. The participants were health care professionals, including physicians, nurses and pharmacists. The outcomes included objectively measured health professional performance or patient outcomes, and self-report measures with known validity and reliability. Main results Forty-one studies were included involving more than 200 practices and 48,000 patients. Twenty-seven studies were RCTs, 12 were CBAs, and two were ITS. The studies were heterogeneous in terms of interventions, participants, settings and outcomes. The methodological quality of the studies was often poor. In all studies the intervention strategy was multifaceted. In 12 studies the interventions were targeted at health professionals, in nine they were targeted at the organisation of care, and 20 studies targeted both. In 15 studies patient education was added to the professional and organisational interventions. A combination of professional interventions improved process outcomes. The effect on patient outcomes remained less clear as these were rarely assessed. Arrangements for follow-up (organisational intervention) also showed a favourable effect on process outcomes. Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients' health outcomes. Authors' conclusions Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes. Organisational interventions that improve regular prompted recall and review of patients (central computerised tracking systems or nurses who regularly contact the patient) can also improve diabetes management. The addition of patient-oriented interventions can lead to improved patient health outcomes. Nurses can play an important role in patient-oriented interventions, through patient education or facilitating adherence to treatment. CASE III: SYSTEMS FOR ROUTINE SURVEILLANCE FOR PEOPLE WITH DIABETES MELLITUS [Griffin S, Kinmonth AL.] Background There is wide variation in the extent of general practice involvement in diabetes care. Objectives To assess the effects of involving primary care professionals in the routine review and surveillance for complications of people with established diabetes mellitus compared with secondary care specialist follow up. Selection criteria Randomized trials in which people with diabetes were allocated to a system of review and surveillance for complications by primary care professionals. Outcomes included mortality, metabolic control, cardiovascular risk factors, quality of life, functional status, satisfaction, hospital admissions, costs, completeness of screening, and development of complications. Main results Five trials involving 1058 people were included. Results were heterogeneous between trials. In those schemes featuring more intensive support through a prompting system for general practitioners and patients, there was no difference in mortality between hospital and general practice care (odds ratio 1.06, 95% confidence interval 0.53 to 2.11), HbA1 tended to be lower (a weighted difference in means of -0.27%, 95% confidence interval -0.59 to 0.03) and losses to follow up were significantly lower (odds ratio 0.37, 95% confidence interval 0.22 to 0.61) in primary care. However, schemes with less well-developed support for family doctors were associated with adverse outcomes for patients. Quality of life, cardiovascular risk factors, functional status and the development of complications were infrequently assessed. Authors' conclusions Unstructured care in the community is associated with poorer follow up, greater mortality and worse glycaemic control than hospital care. Computerised central recall, with prompting for patients and their family doctors, can achieve standards of care as good or better than hospital outpatient care, at least in the short term. The evidence supports provision of regular prompted recall and review of people with diabetes by willing general practitioners and demonstrates that this can be achieved, if suitable organisation is in place. CASE IV: SPECIALIST NURSES IN DIABETES MELLITUS [Loveman E, Royle P, Waugh N.] Background The patient with diabetes has many different learning needs relating to diet, monitoring, and treatments. In many health care systems specialist nurses provide much of these needs, usually aiming to empower patients to self-manage their diabetes. The present review aims to assess the effects of the involvement of specialist nurse care on outcomes for people with diabetes, compared to usual care in hospital clinics or primary care with no input from specialist nurses. Objectives To assess the effects of diabetes specialist nurses / nurse case manager in diabetes on the metabolic control of patients with type 1 and type 2 diabetes mellitus. Selection criteria Randomised controlled trials and controlled clinical trials of the effects of a specialist nurse practitioner on short and long term diabetic outcomes were included in the review. Main results Six trials including 1382 participants followed for six to 12 months were included. Two trials were in adolescents. Due to substantial heterogeneity between trials a meta-analysis was not performed. Glycated haemoglobin (HbA1c) in the intervention groups was not found to be significantly different from the control groups over a 12 month follow up period. One study demonstrated a significant reduction in HbA1c in the presence of the diabetes specialist nurse/nurse case manager at 6 months. Significant differences in episodes of hypoglycaemia and hyperglycaemia between intervention and control groups were found in one trial. Authors' conclusions The presence of a diabetes specialist nurse / nurse case manager may improve patients' diabetic control over short time periods, but from currently available trials the effects over longer periods of time are not evident. There were no significant differences overall in hypoglycaemic episodes, hyperglycaemic incidents, or hospital admissions. Quality of life was not shown to be affected by input from a diabetes specialist nurse/nurse case manager. On careful evaluation of all these cases, it is seen that the literature works are at loggerheads on the issue of constant monitoring and specialist nurse appointment. We can only conclusively state our final recommendation based on personal experience, and by weighing all these options on an even scale. This has been endeavored in the further parts of this report. LEWIN'S MODEL OF CHANGE AND IMPLEMENTATION LEWIN'S FREEZE PHASES: [Changing Minds Org.2007] In the early 20th century, psychologist Kurt Lewin identified three stages of change that are still the basis of many approaches today. Unfreeze A basic tendency of people is to seek a context in which they have relative safety and feel a sense of control. In establishing themselves, they attach their sense of identity to their environment. Talking about the future thus is seldom enough to move them from this 'frozen' state and significant effort may be required to 'unfreeze' them and get them moving. This usually requires Push methods to get them moving, after which Pull methods can be used to keep them going. The term 'change ready' is often used to describe people who are unfrozen and ready to take the next step. Some people come ready for change whilst others take a long time to let go of their comfortable current realities. Transition A key part of Lewin's model is the notion that change, even at the psychological level, is a journey rather than a simple step. This journey may not be that simple and the person may need to go through several stages of misunderstanding before they get to the other side. Transitioning requires time. Some form of coaching, counseling or other psychological support will often be very helpful also. Although transition may be hard for the individual, often the hardest part is to start. Even when a person is unfrozen and ready for change, that first step can be very scary. Transition can also be a pleasant trap and, as Robert Louis Stephenson said, 'It is better to travel hopefully than arrive.' People become comfortable in temporary situations where they are not accountable for the hazards of normal work and where talking about change may be substituted for real action. Refreeze At the other end of the journey, the final goal is to 'refreeze', putting down roots again and establishing the new place of stability. In practice, refreezing may be a slow process as transitions seldom stop cleanly, but go more in fits and starts with a long tail of bits and pieces. There are good and bad things about this. In modern organizations, this stage is often rather tentative as the next change may well be around the next corner. What is often encouraged, then, is more of a state of 'slushiness' where freezing is never really achieved (theoretically making the next unfreezing easier). The danger with this that many organizations have found is that people fall into a state of change shock, where they work at a low level of efficiency and effectiveness as they await the next change. IMPLEMENTATION OF A SPECIALIST NURSE Stage I: Unfreeze In this stage, first the patient has to be prepared to take up a specialist nurse for his case in order to help him out. Many patients may feel apprehensive about having a nurse around them 24 hours a day as this might play a negative role on their recuperation. They might complain about always having a feeling of being sick and being unable to concentrate on improving their health due to nostalgia about the hospital. Getting them out of this rut and instilling the sense that it is being done for their benefit and making them open to the idea is the first step in the implementation project. Stage II: Transition The second stage involves a psychological journey as Lewin puts it. This is a very important part of the entire operation. This is an indicator of the level of acceptance of the patient and his willingness to move forward. Transition typically requires time and commitment on all levels. Stage III: Refreeze The third stage is the destination of the journey. Herein the patient has accepted his new state of being under periodic surveillance. He understands that this is for his benefit and better quality of living. This might typically be a "slush" state, thus making further changes easy on the patient. BARRIERS The barriers to the implementation of a specialist nurse may be the following: The hesitancy on the patient's behalf Unavailability of specialist nurses in required numbers Insufficient funds for the poor patients Societal barriers CONCLUSION Thus the implementation of a specialist nurse will typically take a long time to take effect and to be proved a profitable and positive venture. The barriers stated above will be met in aplenty and have to be removed methodically and systematically. While most of the issues are psychological, a few are economic, and every attempt has to be taken to negate this in favor of the patient. This involves various schemes like student volunteer nurses, free nursing by the huge facilities which can afford it and so on. This implementation has to go through a long process involving commitment from both the patient and the nurse, and willingness to participate on both their behalves. Like all changes, it faces hurdles in its path. Given the time and the dedication, the effort will definitely prove beneficiary in improving the quality of the patient's life as a diabetic with certain constraints. EVALUATION Thus it is conclusively seen from this report that evidence based nursing practice for provision of a specialist nurse to care for diabetic patients will not prove to be beneficial in the long run in making the lives of diabetics easier, and in improving the quality and standard of their living. The cost and commitment involved, and the time factor combined with the uncertainty of the entire change process does not make it a worthwhile project to contemplate and follow. Thus, it is not recommended for practice. APPENDIX PICO COMPONENTS ASKING A GOOD QUESTION (PICO): [University of South California.2007] Asking the right question is a difficult skill to learn, yet it is fundamental to the evidence-based decision-making process. The first step in developing the question is to identify the patient problem or population. This requires describing either the patient's chief complaint or generalizing the patient's condition to a larger population. The "P" phrase could be more detailed if the added information is going to influence the results you expect to find. Identifying the Intervention is the second step in the PICO process. It is important to identify what you plan to do for that patient. This includes usage of a specific diagnostic test, treatment, adjunctive therapy, medication or the recommendation to the patient to use a product or procedure. The intervention is the main consideration for the patient. The Comparison is the third phase of the well-built question, which is the main alternative you are considering. It should be specific and limited to one alternative choice in order to facilitate an effective computerized search. The Comparison is the only optional component in the PICO question. The Outcome is the final aspect of the PICO question. It specifies the result(s) of what you plan to accomplish, improve or affect and should be measurable. Specific outcomes will yield better search results and allow you to find the studies that focus on the outcomes you are searching for. Outcomes may consist of: Relieving or eliminating specific symptoms Improving or maintaining function Enhancing esthetics. When defining the outcome, more effective is not acceptable unless it describes how the intervention is more effective. WORK CITED Changing Minds Org.2007.Lewin's freeze phases. Changing Minds Org. [online].Available at: http://www.changingminds.org/disciplines/change_management/lewin_change/lewin_change.htm [Accessed on 29 April 2008] Griffin S, Kinmonth AL.20000. Systems for routine surveillance for people with diabetes mellitus. Abstract from The Cochrane Database of Systematic Reviews 2008 Issue 2. Available at: http://www.cochrane.org/reviews/en/ab000541.html [Accessed on 29 April 2008] Loveman E, Royle P, Waugh N. 2003. Specialist nurses in diabetes mellitus. Abstract from The Cochrane Database of Systematic Reviews 2008 Issue 2 Available at: http://www.cochrane.org/reviews/en/ab003286.html [Accessed on 29 April 2008] University of South California.2007.Asking a Good Question (PICO). Department of Health Sciences.[online].Available at: http://www.usc.edu/hsc/ebnet/ebframe/PICO.htm#PRef [Accessed on 29 April 2008] Vermeire E, Wens J, Van Royen P, Biot Y, Hearnshaw H, Lindenmeyer A. 2005.Interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus. Abstract from The Cochrane Database of Systematic Reviews 2008 Issue 2,[online] Available at: http://www.cochrane.org/reviews/en/ab003638.html [Accessed on 29 April 2008] Renders CM, Valk GD, Griffin S, Wagner EH, van Eijk JThM, Assendelft WJJ.2001nterventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. Abstract from The Cochrane Database of Systematic Reviews 2008 Issue 2. [online] Available at http://www.cochrane.org/reviews/en/ab001481.html Read More