Evaluating Ideas in Diabetes Patient Management - Book Report/Review Example

A Review of Two Qualitative Research Papers on Diabetes Patient Management This paper reviews two qualitative research papersthat specifically focus on patients with type II diabetes or non-insulin-dependent diabetes mellitus (NIDDM) to assess the value and legitimacy of this type of research. The first research paper is "Complex intervention development for diabetes self-management" by Jackie Sturt, Sandra Whitlock and Hilary Hearnshaw. It aims to provide data for phase one of the proposed modification of the Self-Efficacy Goal Achievement (SEGA) complex nursing intervention for type 2 diabetes. The second research paper is "Barriers to communication about diabetes mellitus" by Joshua Freeman and Ronald Loewe which aims primarily to discover the attitudes of clinicians towards patients with NIDDM and the effects of this attitudes on patient self-management. The paper considers the aims, methodology, ethical factors, results and analysis of the two papers and discusses how they can be of benefit to NIDDM patients and the role of nurses in the self-management of this condition. I. Introduction Diabetes mellitus is one of the most common secondary chronic diseases that beset primary care patients in the US. (Lilley and Levine 1998) In the case of non-insulin-dependent diabetes mellitus (NIDDM) it has been found that medical outcomes are often affected by patient behavior and degree of self-management. The extent to which traditional diabetes care was failed to attain desired medical outcomes has made it necessary for those in the professions that directly and indirectly relate to patient care management to consider other approaches, such a self-efficacy and effective clinician-patient communications. (Coates and Rae 2006, pp. 234-235) Because patients have to work in conjunction with health care professionals to ensure proper health maintenance, the degree to which the health care professional conveys and communicates diabetes education and affects behavior has a significant impact in managing the condition to a satisfactory level. This directly pertains to the non-medical aspect of patient-clinician relations. It is undeniable that to a certain extent, patient response relates directly to the level of understanding that exists between those who give care and those who receive care. From a research point of view, however, providing evidence for the extent of this impact or determining ways in which this can be used in the clinical context can be problematic as much of the data that can be gathered is qualitative in nature. Qualitative is not considered as definitive as quantitative research methods, but in cases where analysis and interpretation of subjective data such as anecdotes, stories and experiences are involved, the only possible method is qualitative. There are some issues that complicate the use of qualitative research, not the least of which is the risk of biased subject selection, data gathering, and interpretation of information. More often than not, the information gathered can be highly personal, potentially sensitive and culturally problematic especially if not handled in context. It is therefore necessary that ethical considerations for each stage of the research be kept in mind at all times to preserve the soundness of the study itself. This paper will consider two kinds of qualitative research in an effort to review how effective they were in accomplishing the aims of the study, the appropriateness of the methods used in selecting subjects and data gathering as well as the type of analysis used to interpret the raw data. II. Background of the research papers The two research papers under review tackle some aspects of patient self-management using qualitative measures. Jackie Sturt, Sandra Whitlock and Hilary Hearnshaw of the Primary Health Care Studies, Warwick Medical School, University of Warwick, Coventry, UK are authors of the study "Complex intervention development for diabetes self-management," the goal of which is to "develop and evaluate a Self-Efficacy Goal Achievement (SEGA) complex nursing intervention for type 2 diabetes." (2006, p. 293-303) The three-fold aim of the study was to discover the effectiveness of the transfer of smoking cessation self-efficacy consultation framework to type II diabetes, to identify the experiences that enhanced efficacy among older patients with type II diabetes and to identify the needs of the nurses for the effective use of SEGA The article by Joshua Freeman and Ronald Loewe is entitled "Barriers to communication about diabetes mellitus" which considers the difference in views of health care givers and patients with regard to diabetes. In particular, the study focused on the perceptions of control from the point of view of the patient and the health care giver. (2000) III. Ethical facets in qualitative research reviewed The National Health and Medical Research Council have identified four principles of ethical conduct in research. These include research merit and integrity, justice, beneficence and respect. (2007, p. 25-28) The issue of research merit and integrity is primarily concerned with maintaining the objectivity and rationale of the study with regard to the methods employed, the selection of study subjects, the sample size, and the relationship of researchers and study subjects. In qualitative research, the emphasis is on the particular rather than the general because it employs subjective and individualized data that could be open to interpretation. It is therefore most important that there is no compromise regarding the pureness of the data collected or its assessment. An offshoot of maintaining research merit is the justifiable selection of participants. Because sample size does not have the same weight in qualitative research that it has in quantitative data, researchers must have a clear criteria for including and excluding study subjects. Given the need for representative, quality data, the selection of subjects can become quite complex. Beneficence refers to protecting the identity of participants who may supply sensitive information. The need for such confidentiality is dependent on the discretion and knowledge of researchers regarding the potential distress that any particular topic may have on patients and other participants in the study. Respect for study participants usually takes the form of their informed consent prior to collection of data and carried through to completion of analysis to ensure that the data gathered are accurate and complete. The form of the consent may be in verbal or written form, depending on the circumstances of the research. Some studies may impact on the sensitivity, cultural context and vulnerability of the participants; the researchers are expected to anticipate and provide for these contingencies. In the study of Sturt, Whitlock and Hearnshaw, the study proposal was submitted to the research ethics committee of Warwick Medical School who gave approval. The health givers, two practice nurses who had completed a diabetes education course, obtained permission from their employers to participate in the study. For patient participants, a letter of invitation was sent and consent was sought, in which confidentiality of patient data was assured and provided throughout the study up to its dissemination. (2006, p. 297) In the study conducted by Freeman and Loewe, the participants were health care givers and their patients in a family practice training site in Chicago, although some patients from residency training sites were also recruited. The patients were mostly the poor, older and from minority populations. Type 2 diabetes is statistically more common in African Americans, Latinos, Asian Americans/Pacific Islanders, Native Americans, and the aged. (Type 2 diabetes) In the interest of preserving research merit and integrity, multiple qualitative methods were employed in data gathering, using interviews, participant observation and informal conversation in order to validate the statements and observed actions in the proper cultural or clinical context. Data was collected in a variety of venues as well to validate statements and beliefs taken in different interview settings. However in the interest of respect based on the paper, it was only during the taped interaction between clinicians and patients that informed solicited prior to data gathering. The healthcare givers involved were also representative, comprised of two nurses, two fellows, one physician's assistant, one medical student and three family practice residents. Interviews were conducted using a guide based on the constant comparative method of Glaser and Strauss to address issues that were raised in earlier interviews. (Freeman and Loewe 2000) IV. Benefits and limitations of the sampling methods used Typically applied to research into new therapies, randomized trials reduce bias. In the study conducted by Sturt, Whitlock and Hearnshaw, the use of a randomized controlled trial was indicated because the intervention closely involved the health care professionals and their relationship with their patients. Any preconceived ideas and reservations the participating nurses may have had about the efficacy of the intervention on certain patients would have been effectively neutralized. The measurement of self-efficacy is highly qualitative, and there had been no published scientific research on intervention combined with self-efficacy theory, considered as one of the strongest predictor of change in health behavior. On the other hand, the use of a randomized trial may have compromised the value of individual relationships for giving insights into patient self-efficacy observed by the nurses outside the consultations. Given that the patients were all over 65 years old, and with admitted issues with self-efficacy, monthly periods of intervention may not have been frequent enough. (Sturt, Whitlock and Hearnshaw 2006, p. 296-297) An ethnographic research method was employed in the family practice study with the use of multiple qualitative methods, multiple venues and Glaser and Strauss interview methods. This ensured that the information gathered was reliable and that the statements were consistent when applied in different settings. In other words, the multiplicity of methods applied to a culturally mixed patient provided robust data. (Freeman and Loewe 2000) However, because there was no formal schedule maintained by researchers for the data gathering, nor were there clear criteria for patient selection, the anecdotal data exhibits some inconsistencies and opens the analysis to debate. V. Data analysis Nurses in the SEGA study were required to maintain a diary on their consultations with each of their four patients, and interviews and questionnaires were also conducted. The data from the questionnaire was analyzed using Statistical Package for the Social Sciences (SPSS). The diaries and interviews were analyzed using NVIVO, a software system used for qualitative data for constructing complex theories with a small population. (NVIVO Overview 2006) The combined data analysis provided the basis for identifying the strengths and weaknesses of SEGA. (Sturt, Whitlock and Hearnshaw 2006, p. 297) Freeman and Loewe chose to analyze the data from precepting sessions, interviews, medical consultations, lectures and informal conversations with input from three professional perspectives known as researcher triangulation. The resulting data was input into NVIVO and indexed accordingly. The results were derived from common content analysis. (Freeman and Loewe 2000) VI. Comparison of the findings Phase I of the SEGA intervention review involved eight patients who completed the monthly Diabetes Management Self-Efficacy Scale (DMSES) and seven of the eight who completed the Diabetes Empowerment Scale (DES). They showed a slight increase in diabetes self-efficacy, a finding supported by the clinical reduction of glycosylated haemoglobin (HbA1c) levels from pre- to post-intervention measures. However, a decline in the treatment satisfaction levels of three of the patients was shown based on the Diabetes Treatment Satisfaction Questionnaire (DTSQ). The nurses attributed this to the repetitive and restrictive aspects of using DMSES in SEGA after the second month. They also identified the importance of follow-up consultations and goal evaluation on the treatment satisfaction of patients. In consequence, it was concluded that modifications in the intervention program that allowed for these results would further increases the effectiveness of the intervention on self-efficacy levels of patients. (Sturt, Whitlock and Hearnshaw 2006, p. 297-298) Based on the qualitative data gathered, the importance of control and frustration was emphasized in terms of complexity of the disease, importance of internal processes, long-term outcomes and deep pessimism. Impediments to control on the part of patients were identified despite purported clinician attitudes on the importance of sociocultural and biological factors dictating patient behavior. Upon analysis of clinician and patient narratives, it was found that the primary concern of healthcare givers to patient control was on the their behavior that directly pertained to clinical levels maintained by the patient instead of patient belief issues regarding their condition. The clinician is the primary source of directives for the care given to patients and there is little input solicited from patients regarding how they want treatment meted out in terms of non-clinical factors. Because there is a lack of cohesion between the attitudes of clinicians and patients, there is a subsequent failure of patients to comply with clinician instructions, resulting in frustration for both parties to the treatment. It was also revealed that macrovascular complications that are historically a major cause of mortality in people with diabetes, this was not associated with the condition in the consciousness of either the clinicians of the patients. (Freeman and Loewe 2000) VII. How the research findings may be incorporated into health care practices The findings in the study on the effectiveness of SEGA intervention as it was currently constructed indicated the need for improvement in certain aspects, especially on the effect of DMSES on patient treatment satisfaction. Considering the importance of patient self-efficacy on medical outcomes for people with type II diabetes, any study that would help in improving intervention would be of benefit for both clinicians and patients. The SEGA study reviewed here is just the first phase in the improvement process, and one of the first published systematic study on self-efficacy for diabetic patients. Until the next phase of the research is completed, the recommendations on the SEGA intervention improvement should be applied by nurses in clinical practice on a trial basis. (Sturt, Whitlock and Hearnshaw 2006, p. 299-301) Too often, the health care givers are the end-all and be-all in patient management, especially when patients are elderly. However, because diabetes is a chronic condition, patients need to cultivate behavior and attitudes that will ensure the effectiveness of the treatment protocols prescribed by clinicians. The failure to address ethnographic factors such as culture and perceptions of control undermines the efforts of healthcare givers to keep patients healthy and functioning. It is not enough that clinicians know how to treat patients; they have to be able to communicate their concerns and seek to change the behavior of patients by working together rather than dictating to them. Involving the patient in the treatment decision will increase the chances of compliance with treatment as well as the fostering of a positive attitude towards management of the condition to minimize its impact. (Freeman and Loewe 2000) VIII. Discussion Diabetes is a lifelong, chronic condition, and can only be managed effectively if the patient is compliant and willing to follow through with treatment as well as lifestyle changes that address risk factors of the illness. No one can force a patient to avoid destructive behavior or to take medication; central to living a healthy life boils down to self-management. The role of nurses as primary health care givers for elderly patients whose diabetes may have become a subject of concern are well aware that the relationship between clinicians and patients have a significant impact on patient cooperation. The SEGA study in this paper focuses on the experiences of nurses, who were specifically to deal with diabetes in their encounters with patients because they are often at the beginning, then middle and end of the intervention. While they may not prescribe or dictate treatment, they are the ones who come in regular contact with patients and often administer the treatment. Their role in strategic management is often underestimated. (Crossan 2003, p. 333) They are the ones to whom patients often confide in and are in the best position to provide information regarding their frame of mind at the same time assessing the clinical effectiveness of the treatment. This last factor eliminates the variables regarding treatment, enhancing the value of the findings of the SEGA intervention. The role of perceptions becomes apparent in the second study considered in this paper. The consideration of attitude was extended to include the side of the health care giver rather than just the patient, because after all medical care is two-sided. If it is accepted that patient attitudes are directly affected by the attitude of the caregiver, then it follows that a study of the clinician's behavior should be taken into account as well as that of the patient in ensuring the effectiveness of treatment and management, which was the aim of the second study. Other studies have reviewed how proper training of nurses in actual nursing skills have increased their effectiveness in patient management, rather than keeping them occupied with non-nursing activities i.e. making beds. (Crossan and Ferguson 2005, p. 358) The findings of the study reveal the responsibility of clinicians in general to cultivate an effective method of communication as well as a more collaborative and holistic attitude towards patient treatment to minimize frustration. The ethnographic approach to the study also indicated the need for more sensitivity towards cultural and social issues regarding patient management, a facet of medical care that is often ignored or overlooked by primary caregivers. These two studies emphasize the need for systematic and robust studies on the quality of treatment and management of patients with type II diabetes. Because such studies are necessarily qualitative, it would require particular attention paid to the way information is gathered and interpreted to ensure that the findings are not open to dispute and render the study without merit or value. In the analysis, both studies used the NVIVO instrument to interpret the findings, a software system designed specifically for studies in behavior and sociocultural inquiries. The instrument has limited scope, and is highly dependent on the way the entries are encoded into the system. This is another aspect in which lies the strength and weakness of qualitative study; if executed properly, the results would be valuable indeed. Executed poorly, the results would be of no value whatsoever. IX. Conclusion It is expected that qualitative research would be met with skepticism and scrutiny because the value of the data cannot be reduced to a numerical value, nor can it be compared with any degree of confidence with other measures of quality. It is undeniable that the qualitative type of research is primarily assigning meaning to experiences withing certain contexts, precluding a purely objective viewpoint. This does not detract from the legitimacy or value of the methodology in empirircal investigations, especially in nursing education and practice. (Myers 2000) In fact, therein lies the value of such research. Because the emphasis is on the quality rather than the quantity of the information, it is not necessary to have a large sampling to ensure the applicability of the findings. Provided ethical principles of research are conscientiously applied at each stage of the study, the data gathered should stand up to scrutiny and cross-examination. The character and conscientiousness of the researcher of qualitative studies is therefore central to the value and significance of the research. At any point that the researcher fails to maintain the integrity and the objectivity of the work is the point in which the study loses its importance and credibility. References Coates, V & Rae, G 2006, 'Commentary on Whittemore R, Melkus GD & Grey M (2005) Metabolic control, self-management and psychosocial adjustment in women with type 2 diabetes. Journal of Clinical Nursing 14, 195-203', Journal of Clinical Nursing, vol.15, pp. 234-236. Crossan F & Ferguson D 2005, 'Exploring nursing skill mix: a review', Journal of Nursing Management, vol. 13, pp. 356-362. Crossan F 2003, 'Strategic management and nurses: building foundations', Journal of Nursing Management, vol. 11, pp. 331-335. Freeman, J & Loewe, R 2000, 'Barriers to communication about diabetes mellitus', The Journal of Family Practice, vol. 49, no. 6. Retrieved September 14, 2007 from http://www.jfponline.com/Pages.aspAID=2535&UID= Lilley, S & Levine, G 1998, Management of hospitalized patients with type 2 diabetes mellitus. Retrieved September 16, 2007 from http://www.aafp.org/afp/980301ap/lilley.html Myers, M 2000, 'Qualitative research and the generalizability question: standing firm with proteus', The Qualitative Report, vol. 4, no. 3/4. Retrieved September 16, 2007 from http://www.nova.edu/ssss/QR/QR4-3/myers.html National Health and Medical Research Council 2007, National Statement on Ethical Conduct in Human Research. Australian Research Council, Australia. Retrieved September 14, 2007 from http://www.nhmrc.gov.au NVIVO Overview 2006. Retrieved September 14, 2007 from http://www.indiana.edu/statmath/other/nudist/overview.html Sturt J, Whitlock S & Hearnshaw H 2006, 'Complex intervention development for diabetes self-management', Journal Of Advanced Nursing, vol. 54, no. 3, pp. 293-303. Type 2 diabetes. Retrieved September 16, 2007 from http://www.diabetes.org/type-2-diabetes.jsp Read More