Patients’ Expectations of the Health Advice Conversation With the Diabetes Nurse Practitioner

Abstract

Type 2-diabetes usually makes its first appearance in adult age. In order for patients to feel in control of the disease, they need support and information that can easily be understood and which is relevant for the individual. By educating and supporting them, patients can conduct self-care and take control. The aim of this study was to highlight the expectations that patients with type 2-diabetes have of the health advice conversation with the nurse practitioner. A qualitative method using interviews was conducted and the data material was analysed according to manifest and latent content analysis. Three categories emerged in the results. Firstly, providing good accessibility to the diabetes nurse practitioner is of importance. Secondly, there is a demand for group activities in which patients have the opportunity to talk with other individuals who have diabetes. Finally, knowledge about self-care means that the patients themselves are able to change the intake of medication, their eating habits, and exercise according to need, as this leads to increased independence and self-management. The latent content demonstrates that the patient is striving towards competence and self-confidence in order to achieve a balance between lifestyle and the normalisation of blood sugar levels, which means empowerment. In addition, the informants expressed a demand for group activities where they can discuss the disease with others in the same situation. A combination of knowledge about the disease, receiving individual advice, and participation in groups can be beneficial in order to motivate the informants about lifestyle changes and to gain the ability to manage the disease.

Type 2 diabetes is the most common form of the disease, and it usually makes its first appearance in adult age. The overall aim of treating diabetes is to prevent acute and long-term complications while maintaining a high quality of life. ¹

Lifestyle Changes

Tuomilehto et al describe the preventive effect of lifestyle changes to diabetes through physical activity, changes to diet, and weight reduction. ² Today, it is generally accepted that a physically active lifestyle leads to a reduced risk of developing several types of illness, for example, cardiovascular disease and type 2 diabetes. Holmström and Rosenqvist ³ demonstrate that patients with type 2 diabetes experienced that their blood sugar levels were lower on the days they were physically active. Providing health advice and motivating lifestyle changes are therefore important aspects in the care of such patients. ¹ Edwall et al describe how diabetes care, as led by diabetes nurse practitioners (NPs) within the primary care sector, has existed since the 1980s. ⁴

In Sweden, a NP focuses on the condition of patients as well as the effects of the illness on the lives of the patients and their families. NPs make prevention, wellness, and patient education their priorities but also focus on educating patients about their health and encouraging them to make healthy choices. In addition, NPs treat physical and mental conditions through a comprehensive documentation of the patient’s health history and physical examinations, as well as through ordering and interpreting diagnostic tests. It is then possible for NPs, in dialogue with the physician, to diagnose the disease and provide appropriate treatment for the patients, including prescribing medications. The main difference between US and Swedish NPs is that Swedish NPs do not prescribe medications.

Funell and Anderson ⁵ found that if the patient is not motivated to follow the NP’s recommendations and ordinations, it can create problems. For a longer period, nursing staffs have used a model that originates from the assumption that patients are expected to do as the NP prescribes. According to Collins et al, a group of diabetes patients were reluctant to follow the NP’s self-care recommendations, which they experienced as being too demanding to carry out. ⁶

New ⁷ describes diabetic patients as experts in living with their disease and knowing what is important to learn, which behaviors can be changed, how these changes can be made, and what support is needed. Yet, the doctor is an expert on diseases and can contribute with information, advice, and support but cannot create motivation or make patients change their behavior. The diabetes NP instructs patients in evaluating consequences and teaches them how emotions affect decisions, how to be responsible for their own care, and how to find strategies. The demands on patients with diabetes have increased today with regard to knowledge about the illness as well as the significance of checkups and treatment. ³

Diabetes is a self-care disease, and the self-care ability of patients is followed up ⁵ by the NP, whose task is to support patients in their efforts to do so. In this phase, patients increasingly regain their self-care ability, and NPs increasingly withdraw.

Edwall et al indicate that continuity with the diabetes NP inspired self-care, thus giving patients the freedom and independence to manage the disease using their own methods, as well as the knowledge that empowered patients to live with a chronic disease and to feel that they can always contact the diabetes NP when needed. ⁴

Patients should receive support in discovering and developing their own resources, setting their own goals for treatment, and identifying and solving their own problems. This process of transferring power to the patient can be developed if trust and empathy are part of the relationship. ¹

Holmström and Rosenqvist ³ demonstrate that several patients did not consider themselves to be sick at times when they were feeling well. They had good knowledge about their disease with regard to diet and lifestyle habits but had difficulties transforming this knowledge into practice. By following planned educational programs based on the patients’ needs, their understanding of the disease increased, and they made positive changes to their health behavior.

Seale et al found a statistically significantly greater portion of the NPs’ advice concerned various treatments when informing patients about how they should use the advice they were receiving. ⁸ NPs also recommended a larger number of different treatments than that of the general practitioner. The conclusion was that NPs offer more comprehensive care to patients, and it is likely that this and more information led to a higher level of satisfaction for the patients. General practitioners are more focused on gathering information that has direct significance for diagnosing and treating the problems.

The NP has a key role in informing and motivating the patient to make lifestyle changes and following up on these. Hence, it is important to examine patients’ expectations regarding their contact with the diabetes NP.

Aim

The aim of this study was to highlight which expectations patients with type 2 diabetes have regarding the health advice conversation with the NP.

Methods

This was a prospective and descriptive pilot study that used a qualitative method with an inductive approach inspired by Graneheim and Lundman. ⁹ Data were collected through interviews, and the text, which was based on patients’ stories about their experiences, was subjected to an unbiased analysis.

The patient interview was a structured conversation with a purpose that moved beyond the ordinary and spontaneous exchange of opinions. In this way, the qualitative method is able to incorporate and describe patients’ expectations and experiences of the health advice conversation with the diabetes NP. ⁹

Sampling

Following an ethical approval process, 8 patients with type 2 diabetes (evenly distributed between sexes) were selected. The criteria for inclusion were patients diagnosed with type 2 diabetes for at least 1 year who followed a diet and received tablet or insulin treatment. In addition, the patients were required to speak and understand Swedish and be between 55 and 75 years of age. Patients with alcohol or other addiction problems and those unable to speak and answer for themselves were excluded from the study.

Data Collection Procedure

An information letter clarifying the purpose of the study and its procedure, including a reply slip, was sent to the patients. The interviews, which lasted 10-15 minutes, were conducted by the first author (J.G.) in a room without disruption at her place of work. In addition, she recorded the interviews with an MP3 player and transcribed them word by word. The interviews were conducted in connection with a visit to the diabetes NP at the primary health care center during 2010. None of the selected patients declined participation in the study. Each interview began with asking the patients what they expected from the meeting with the diabetes NP.

Analysis

The data material gathered was analyzed using content analysis, and it followed the steps described by Graneheim and Lundman. ⁹ Accordingly, the data were transcribed, and the entire text (unit of analysis) was read through repeatedly to obtain a sense of it as a whole. Sentences or phrases that contained similar information and were relevant to the purpose were marked as meaning units.

To maintain context, the surrounding text was included. Subsequently, the meaning units were condensed with the aim of shortening the text. These condensed meaning units were then coded and grouped into categories that reflected the central message in the interviews. The categories were closely related to the text and constituted the manifest content. In the content analysis, the purpose was to identify both the manifest content (ie, what was actually said) and the latent content (ie, what was being described in the underlying meaning).

Quotations from the interviews were used to clarify each category. Finally, themes were formulated clarifying the latent content of the interviews, which means that the researcher interpreted the text. The inductive approach involved an unbiased analysis from both authors, based on people’s stories about their expectations. Throughout the entire analysis process, the first author regularly returned to the original text to ensure no loss of context. ¹⁰

Ethical Considerations

The first author was given permission to carry out the study by the manager of the primary health center where the interviews were conducted. Information about the study, including the invitation to participate, was subsequently distributed in the primary health center’s catchment area in the middle region of Sweden. Thereafter, participation requests and consents were collected. The free will to participate was enhanced, and when nonparticipation does not change anything in caring.

Results

The categories that emerged during the analysis are as follows: accessibility to the diabetes NP, access to group activities, knowledge about self-care, and empowerment as the latent content.

Accessibility to the Diabetes NP

By providing easy accessibility to the NP, the patients experience an increased sense of security and support. Patients want to feel that they have support and the possibility of easily being able to speak to the diabetes NP when needed; diabetes NPs should be able to answer questions that emerge; and patients do not want to have to make an appointment with the diabetes NP to receive answers to their concerns. It was also pointed out that a direct line to the diabetes NP, for a half hour every day, could be of great value so that patients do not have to use the general advice line.

A common feature that the informants mentioned in all the interviews was that continuity and accessibility were of great importance: “She is easily accessible if you need to ask about something, I feel strong support from her. If she is not reachable via telephone she will usually call back on the same day that I left the message.” In addition, the informants wanted a telephone follow-up every 6 months for an increased sense of security.

Accessibility to Group Activities

The demand for group activities is great among patients with type 2 diabetes, as they wish to meet with other diabetics in the same situation as themselves to exchange experiences, advice, and tips. Moreover, many patients find it easier to accept advice from others in the same situation as themselves rather than listening to the advice from the diabetes NP, which can be regarded as lecturing. The informants mentioned that they would like the diabetes NP to lead the group and alternate between theory and practice. Teaching could be incorporated when the group carries out an activity—for example, when visiting the supermarket to learn about food and how physical exercise can be achieved on a daily basis. In this way, teaching would be more relaxed, and patients would more easily learn what is being taught. Such a strategy, combined with the group’s experiences of what life with diabetes entails on a daily basis, would make it easier for a patient to be motivated to make lifestyle changes.

Something that I would like to have more of, however, is that there would be some group activity where the same people with diabetes could meet in different forums, to be invited an afternoon to different lectures about diets and that an exercise group could perhaps be started up.

Knowledge of Self-care

According to the patients, the self-management of blood glucose is a fundamental beginning; they receive a level to use as a starting point, which is important for their self-care. Using these levels as reference, they regulate diets and exercise. The patients feel that the support from the NP helps them deal with their everyday life and important decisions that affect their lifestyles. They gained a greater understanding of calorie and fat intake to become aware of how and why blood sugar changes during the day and night are important for a type 2 diabetic. The goal is to achieve a blood sugar level that is as even as possible throughout the day and night.

A1C is of interest to patients as they find out the average blood sugar level for the last 3 months. It is desirable that the A1C level stays under 6%—hence, their great interest in finding out about it. Diabetics need to be aware of 2 other levels that are important: premeal plasma glucose—that is, the figure that shows the prebreakfast levels of patients on waking in the morning, as well as the blood sugar level 2 hours after a meal, so-called postprandial glucose.

By monitoring the A1C, or long-term sugar level, patients will obtain a good indication of the balance among food, exercise, and levels of medication intake in the last 3 months: “What I expect, I guess it is to find out all the results of the tests that have been taken before and what level they are at and why the sugar goes up and down and the insulin dosage, I guess is the most important.” The underlying theme that runs through all the categories is that the patient strives toward self-competence to control the disease, so-called empowerment.

Reference Levels for Blood Sugar

The previous reference system concerning A1C, which has been used in this piece of work, has been expressed in a new manner in Sweden since September 1, 2010. The change is part of an international collaboration that will make A1C results directly comparable worldwide.

The new way of measuring provides more reliable results. For a nondiabetic person up to 50 years of age, the new A1C levels are normal within the range of 27 and 42 mmol/mol; for a person over 50 years, the range is normally 31 to 46 mmol/mol. ¹¹

Discussion

The aim of the study was to highlight patients’ expectations of the health advice from the diabetes NP. The result shows that patients’ expectations were easy accessibility to the diabetes NP. Patients considered the following as important: receiving regular calls for diabetes checkups, having the possibility of joining group activities, and receiving self-care advice in a way that strengthens their self-management ability. In this way, patients would be able to manage their own situations.

One important fact that emerged in this study was that the diabetes NP has enough time in the meeting with the patient. It was perceived important that there is enough time to ask questions and for the diabetes NP to give individual advice. This is in accordance with Pooley et al, who believed that time and accessibility played a part in the development of appropriate self-care. ¹² Since the diabetes NP is often more accessible, it follows that patients regard this meeting as more positive than that with the doctors. ¹³ To manage their diabetes, patients should learn about the disease and make independent decisions about routines that are carried out on a daily basis. Di Lorto et al draw the conclusion from their study that self-confidence and trust in one’s own ability are 2 central factors that enable a person’s motivation to overcome that obstacle in life that stands in the way of change. ¹⁴ The results of this study agree with those of Edwall et al, who found that patients who met their diabetes NP regularly had a better understanding of their situation, felt acknowledged, gained better self-confidence, and could act independently. ⁴ The role of an NP is more of a supervisory nature that is meant to strengthen the patient into becoming independent.

The patients in this study expressed an interest in group activities where they could meet with others in the same situation and where diabetes questions could be discussed with other patients. Similarly, Cooper et al demonstrate that patients in group activities can share their own experiences and give free rein to their frustrations, as well as offer one another good advice for an easier everyday life. ¹⁵ Group activities have yielded positive results on blood glucose levels in the long term.

Educating patients in self-care has a central role in diabetes care. Self-care for patients with diabetes means that they are themselves able to change the dosage of their medicine, eating habits, and exercise according to varying needs, which leads to increased independence. This is in accordance with Whiting et al, who found that comprehensive strategies that enable patients to make daily decisions about their diabetes care can, on one hand, assist patients in discovering and developing their natural capacity (ie, be responsible for their own lives) and, on the other, make people with diabetes feel that the spontaneous life no longer exists—that is, everything else is secondary to the disease being the most important factor. ¹⁶

Self-care advice also means that patients are able to carry out their own blood glucose checkups, read the results, and take appropriate action according to the blood sugar results. Moser et al describe how patients respond positively to not having a solution forced on them but rather having an option about making a decision. ¹⁷ This kind of freedom leads to patients’ increased responsibility for their own treatment and strengthens the motivation to be responsible for their own lifestyle. It is important for patients to have a guideline for blood checkups that support their decision. ¹⁸

The latent content that has emerged in this study is the importance of self-management by being able to influence one’s own situation—that is, empowerment. Raeburn and Rootman ¹⁹ describe that the components constituting the term empowerment are (1) competence, as it entails having valuable information that enables a person to independently perform actions in a satisfactory manner; (2) control for the individual, by influencing the surroundings and not being a victim under the circumstances; and (3) self- confidence that demonstrates an inner strength and self-esteem.

Limitations

A limitation of this study was that our sample size was small. However, no new information emerged from the participants in the last interviews. Since the participants no longer provided the researcher with any new information, data saturation occurred. Thereby, credibility of research findings was achieved. However, the result may not represent any other setting. A software program used during the analysis could have strengthened the interrater reliability.

New Findings and Clinical Implications

Findings in this study have initiated an innovation by introducing a regular group activity for those with diabetes. The group meets on 6 occasions with differing themes. This study also demonstrated that patients require more time to raise questions during their health checkup appointments. Consequently, patients are now given more time to ask questions; thus, by granting the individual patient more scope, he or she will be the one setting the topics for the meeting with the diabetes NP.