article critique

The Role of the Nurse in Diabetes Management in Primary Care

Kieonna Stewart

Indiana Wesleyan University

GNUR-501: Evidence-Based Communication

Sandra Horton

January 21, 2020

Abstract

In this paper, it is explored how the nurse affects the outcomes of the patient who is managing diabetes in primary care. Research has shown the use of a transtheoretical theory model of behavior change and empowerment can improve patient engagement. When the nurse is involved in the patient’s care it has been proven to decrease diabetic measures such as blood pressure, hemoglobin A1C, and cholesterol. The use of critical thinking skills to implement a plan is vital for diabetes management.  

The Role of the Nurse in Diabetes Management in Primary Care

In 2017, the cost of diabetes annually was 327 billion dollars (American Diabetes Association, 2020, p. S8). At the beginning of my nursing career, I worked in the hospital as a floor nurse. In the hospital as health care professionals, we focus on acute issues. I noticed the patients were admitted for the same issue—complications of their diabetes. I wanted to make a difference in preventative care. I switched positions and became a nurse in primary care. I specialize in diabetes management education. In my expertise paper, I will explore the unique role of the nurse in primary care. I will also describe the theories used when helping the patient manage their disease. The team care approach as the best practice for diabetic patients. As well as discuss ethical considerations to look for when treating an individual with diabetes. My role as a diabetes nurse is unique. 

The Unique Role of the Nurse in Primary Care

In primary care, the nurse has a unique role with the diabetic patient. The purpose of the nurse’s role is to give the patient the tools required to self-manage his or her chronic disease. It is different in acute care where at discharge, there was a small education piece, and then the patient was instructed to follow up with their primary care provider. It is required to know how to think critically in an environment where the patient has more control in comparison to the hospital. Diabetes is such a complex disease; it can be challenging to manage the condition without a support system. “Patients with diabetes are increasingly monitored by nurses in . . . family practice. These nurses can play a crucial role in helping patients to engage in behaviours that affect their health in a positive way” (van Dijk-de Vries et al., 2016, p. 59). 

A typical appointment is 60 minutes in length, which is vital to the patient. In the session, the patient will answer basic questions about their general health and methods of how they prefer to learn. In the appointment, I learn about the patient’s social determinants of health and support system at home. Patient education is delivered in the way the patient prefers to learn, such as demonstration, audio, or hands-on. Goals are set with the nurse, and the patient is held accountable for the progress of the goals set in follow up visits. But to set goals, I must first assess the patient’s readiness to learn.

The Use of the Transtheoretical Model of Behavior Change and Empowerment

To assist the patient in lifestyle change, first, I have to assess the patient’s willingness to change. The trans-theoretical model of behavior change is a resource I use in my practice. According to Newell (2018)

The use of the trans-theoretical model (TTM) of behaviour change can assist the DSNIC [diabetes nurse specialists in integrated care] in providing the most appropriate support and information based on a patient’s readiness for change and his or her level of confidence to engage in the behaviour e.g. smoking cessation, increased physical activity and eating healthy foods. If the patient is not ready to change lifestyle behaviours, the DSNIC accepts his or her decision and offers friendly non-judgemental advice, leaflets and future support. If the patient intends to make changes in the near future, the DSNIC assists him or her to consider specific, measurable, achievable, realistic and timely (SMART) goals while providing support and encouragement with releveant information. (p. 2)

 The next technique used as the diabetes nurse is empowerment. It is shown when the patient is empowered; they are more likely to see the benefits of changing their behavior to improve their health. It also increases the likelihood of effective self-management skills (Newell, 2018). It is crucial to ensure the goals are collaborative to increase the chance of accomplishment. The use of motivational interviewing will help the patient realize the problems and develop a plan. Patient education is vital. Once I have gauged the patient’s willingness to change, I introduce other disciplines in the care of the patient.  

Multidisciplinary Intervention Approach

In my role, I  work with a multidisciplinary team. The team consists of a behavioral health specialist, dietitian, and pharmacist. Every month it is my duty to conduct a care team meeting. The group discusses the high-risk population and possible interventions needed to help the patient manage their diabetes. It is shown the method is beneficial. 

The results of our study show that intervention by a multidisciplinary team managed proactively by a nurse significantly improves diabetes control in almost all measures examined [hemaglobin A1C, systolic blood pressure, cholesterol levels]. These improvements are observed in the post-intervention follow up period. As expected, these changes included an immediate improvement of diabetes control markers, but also in the patients’ ability to manage their illness, as exhibited in the continued visits to the multidisciplinary staff. ( Ginzburg, Hoffman, & Azuri, 2017, p. 29)

In my experience, a patient is more likely to see other specialties if it is introduced in one of the sessions with the diabetes nurse. The patient is informed of the services the disciplines would provide. Most patients do not want to attend appointments if they do not know what is expected. The team provides insight from their point of view on the patient’s health, which is useful when taking into consideration the patient’s social dynamic. 

Ethical Considerations When Treating Patients With Diabetes

From my own experience with the assigned patient load, there is an issue with compliance. Part of the problem is a knowledge deficit, but once I assess the situation closer, I find there is a more significant issue. The cost of medications. Krall et al. (2017) stated, “some barriers . . . the DE [diabetes educator] working with a practice in an underserved area found that lack of insurance and the costs of insulin and associated devices were issues” (p. 103).  I noticed a patient would not tell the provider he or she has not taken the medication since it was last prescribed. In response, the provider will add another drug or increase the dosage. The patient will not tell the provider the truth due to fear. I have the chance to build rapport with the patient, where they feel comfortable enough to confide in me. 

The patient population is very diverse. The practice also provides services to an underserved population. The population can have issues with homelessness, have a language barrier, and cultural considerations when treating the patient. These are only some of the barriers encountered. As a diabetes nurse, when implementing a plan, I tailor each intervention to the needs of the patient. For example, if an issue is food insecurity, it would not be beneficial to recommend the patient to eat a healthy meal. I would provide the patient with resources to a food pantry. 

Conclusion

The nurse has a unique role in managing the patient with diabetes. Through the use of behavioral change models and empowerment, the nurse can engage the patient and improve their health outcomes. It is accomplished by using a team-based care approach which uses the disciplines’ expertise. The nurse has the responsibility to use critical thinking skills to eliminate barriers in the process. The goal is for the patient to have self-management skills.  

References

American Diabetes Association. (2020). Improving care and promoting health in populations: Standards of medical care in diabetes-2020. Diabetes Care, 43(suppl. 1), S7–S13. https://doi.org/10.2337/dc20-S001

Ginzburg, T., Hoffman, R., & Azuri, J. (2017). Improving diabetes control in the community: A nurse managed intervention model in a multidisciplinary clinic. Australian Journal of Advanced Nursing, 35, 23–30. Retrieved from http://www.anmf.org.au/

Krall, J., Durdock, K., Johnson, P., Kanter, J., Koshinsky, J., Thearle, M., & Siminerio, L. (2017). Exploring approaches to facilitate diabetes therapy intensification in primary care. Clinical Diabetes, 35, 100–105. https://doi.org/10.2337/cd16-0013

Newell, E. (2018). Integrated care: Evaluation of patient satisfaction with education provided by the diabetes specialist nurse. Journal of Diabetes Nursing, 22(2), 1–5. Retrieved from http://www.diabetesonthenet.com/journal/journal-of-diabetes-nursing

van Dijk-de Vries, A., van Bokhoven, M. A., de Jong, S., Metsemakers, J. F. M., Verhaak, P. F. M., van der Weijden, T., & van Eijk, J. T. M. (2016). Patients’ readiness to receive psychosocial care during nurse-led routine diabetes consultations in primary care: A mixed methods study. International Journal of Nursing Studies, 63, 58–64. https://doi.org/10.1016/j.ijnurstu.2016.08.018

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