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The effectiveness of a diabetes nurse clinic in treating older patients with type 2 diabetes for their glycaemic control

Journal of Clinical Nursing
The effectiveness of a diabetes nurse clinic in treating older patients with type 2 diabetes for their glycaemic control
ISSN: 0962-1067
Accession: 00019038-200606000-00014
Full Text (PDF) 142 K
Author(s):

Chan, Moon Fai BSc, PhD; Yee, Amy Shun Wah MSc, RN; Leung, Elaine Lai Yee MSc, DNS; Day, Mary Christine BSc
Issue:
Volume 15(6), June 2006, p 770–781
Publication Type:
[ARTICLE: DIABETES]
Publisher:
Copyright © 2006 Blackwell Publishing Ltd.
Institution(s):
School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China(Chan)
Diabetes Center, Queen Mary Hospital, Hong Kong SAR, China(Yee)
Diabetes Center, Queen Mary Hospital, Hong Kong SAR, China(Leung)
School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR, China(Day)
Correspondence: Moon Fai Chan Lecturer School of Nursing The Hong Kong Polytechnic University Hung Hom, Kowloon Hong Kong SAR China Telephone: (852) 2766 4090 E-mail: hsmfchan@inet.polyu.edu.hk
Submitted for publication: 1 July 2005 Accepted for publication: 7 July 2005
Keywords: diabetes nurse, nurse education, nurse intervention, type 2 diabetes, nurse, older people
Abstract

Aims: The aim of this study is to determine the effectiveness of a diabetes nurse clinic intervention in controlling the poor glycaemia of older patients with type 2 diabetes.

Research method: This is a quasi-experimental design with pre- and follow-up tests. The study was conducted in a regional acute hospital in Hong Kong. A total of 150 (75 controls, 75 cases) poor glycaemic control older patients with diabetes were recruited in the study.

Outcome measures: Biomedical and psychological data were collected at pre- and follow-up period and compared between groups.

Results: The study results show an effective intervention of diabetes nurse clinic in giving consultation and education to the type 2 diabetic patients. Subjects in the nurse follow-up group showed an improvement in the HbA1c, and systolic blood pressure and reduction on healthcare utilization.

Conclusion: The study provided evidence to support the diabetes nurse clinic in treating the older patients with diabetes. This study has provided confidence to the diabetes nurse to treat the unstable older patients with diabetes.

Relevance to clinical practice: Diabetes mellitus is a serious health concern that most commonly affects older people. As indicated by the results of this study, this educational programme can act as an effective nursing intervention to the type 2 diabetic patients.

Introduction

Diabetes mellitus (DM) is defined as a group of metabolic diseases characterized by hyperglycaemia that results from defects in insulin secretion, insulin action or both. Chronic hyperglycaemia is associated with long-term damage, dysfunction and failure of various organs, especially the eyes, kidney, nerves, heart and blood vessels (American Diabetes Association 2003). Patients with diabetes have an increased incidence of long-term complications like retinopathy, neuropathy and nephropathy and atherosclerotic cardiovascular, peripheral vascular and cerebrovascular diseases (American Diabetes Association 2003). King et al. (1998) predicted that by the year 2025 the number of patients with diabetes would increase to 300 million worldwide, and it was estimated that there are 38 million people in China with DM, and 50% will remain undiagnosed. According to the World Health Organization, rapid changes in lifestyle and socio-economic developments in Asia will cause major increases in the prevalence of DM in Mainland China and India (King et al. 1998). Hong Kong is facing an epidemic of DM. Over 30% of patients are admitted to hospitals because of the complications of diabetic such as stroke, acute myocardial infarction and heart failure (Chan et al. 1996). Over 90% of them have type 2 diabetes and half of them with a 10-year history requiring insulin treatment for optimal glycaemic control to curb and delay the onset of diabetic complications (Chan 2000, Shiu & Wong 2002). Their glycaemic control will be worsened and thus an optimal control of glycaemia can slow down the progression of complications.
Background

Several reports have demonstrated that a nurse follow-up group had a significant improvement in the HbA1c (Aubert et al. 1998, Thompson et al. 1999, Yong et al. 2002), reduction in cost (Brooten & Naylor 1995) and length of stay during hospitalization (Sadur et al. 1999). Yong et al. (2002) conducted a study that investigated the role of the specialist nurse in glycaemic control of insulin-treated patients with diabetes (HbA1c levels >7·5%). The intervention involved re-education, dietary advice and insulin dosage adjustment and regular follow-up by telephone. At the end, almost 63% of patients achieved improvement with a final HbA1c <7·0%>1·0% at six months post-intervention, with no increase in hypoglycaemic episodes. Thompson et al. (1999) conducted a randomized trial involving 46 IDDM with poor glucose control (HbA1c >8·5%). The study lasted for six months and, as a result, the mean HbA1c level in the intervention group was significantly lower than the level for the standard care group (P < 0·01). Aubert et al. (1998) and his colleagues conducted a randomized trial on diabetic patients and results showed that patients in the nurse care management group had mean decreases of 1·7% points in HbA1c values and 2·4 mmol/l (43 mg/dl) in fasting glucose level than patients in the usual care group (P < 0·01). In Hong Kong, the Hospital Authority suggested that the prognosis of the poor control patients with diabetes had a significant improvement and treatment adherence after the patients attended a Diabetes Review Clinic run by a senior nurse specialist (Hospital Authority 1999). Wong (2003) conducted a study that investigated the metabolic control of patients under the management of a diabetes nurse specialist and results showed a significant decrease in HbA1c level and fasting blood glucose in the experimental groups at 24-week interval. Mok (2002) conducted a study that investigated the control of glycaemia in a diabetes clinic and results showed that subjects in the experimental group had a lower HbA1c level (P = 0·06) and a higher blood monitoring adherence score (P < 0·001) than the control group at 24 weeks. All these studies demonstrated that an effective patient education, periodic assessment and a treatment protocol have been shown to improve the outcome of diabetes (So et al. 1998).
Diabetes in older people

Diabetes mellitus affects around 10–25% of older people worldwide and the majority of diabetes occurred in the group age above 60 years old (Pickup & Williams 2003). It is estimated that people aged 60 years and older have, on average, 2·2 chronic conditions, and that chronic disease is responsible for almost 70% of healthcare expenditures (Lorig et al. 1999). A survey from the Hospital Authority, reported that in the year 2001 there were 55·7% of older patients with diabetes admitted to hospitals and the length of stay for each older patient ranged from 4·3 to 7·8 days in different cluster (Hospital Authority 2003). The deteriorating condition of older patients is the principal reason for their hospitalization (Chin et al. 2000). Self-care management is defined as the integral part of patient education run by diabetes educators. As diabetes management is relied on self-treatment, a number of psychological variables including patient characteristics, social and familial factors, environmental factors and behavioural contingencies should also be considered (Cox & Gonder-Frederick 1992). Previous studies demonstrated that clients with higher self-efficacy have better self-management and more effective coping and fewer hospital admissions (Shiu & Wong 2002). Delamater et al. (2001) expressed that to promote older people in self-caring, we should be concerned with the patients' sense of empowerment, self-management skills in self-efficacy, self-care behaviours, glycaemic control, patient satisfaction and quality of life. Older people need a continuous reinforcement and support in their treatment and the main goals of diabetes care are good metabolic control, minimization of diabetic complication and a good quality of life (Toljamo & Hentinen 2001).

Sigurdardttir (1999) conducted a study that identified the different roles of the diabetes nurse: educator, promoter of physical skill acquisition, psychological supporter, advocate of individualized care, promoter of self-care, 'safeguard' in assessing and ensuring patient safety. The diabetes nurses' intervention provides re-education and reinforcement on compliance such as in medication adjustment, meal planning and exercise. With close follow-up with a diabetes nurse, knowledge improves through education, which improves the compliance rates of self-care management programmes (Norris et al. 2001). Follow-up visits for reassessment and review of educational needs and behavioural principles should be encouraged. Diabetes nurses assist patients to reflect, acknowledge emotions, identify temptations, determine boundaries and subsequently gains in self-confidence, counterbalancing, assist with life change (Whittemore 2000). They provide greater levels of social support, especially diabetes-related support from spouses and other family member, which has been associated with better regimen adherence (Delamater et al. 2001). Apart from being an educator, psychological supporter, individualized care provider and self-care promoter, the diabetes nurse can promote the health of diabetics; engaging consumers' role into care can improve patients' quality of care (Hibbard 2003) as well.
Hibbard's model on the quality of care

The mode of Hibbard (2003) identified three roles that consumers can play in improving the quality of their care: informed choice role, co-producer role and evaluator role (see Fig. 1). Her model has been discussed by Gasparini et al. (2004) and Werner and Asch (2005) and agreed that healthcare consumers can play a primary role in promoting the choice of therapeutic interventions and the quality of care if they involved as co-producer and assessors of the therapies they undergo. These three roles have the potential directly or indirectly to improve care and produce better care and better health outcomes (McGlynn 2003). These three roles on the contribution on the improvement of care are described below.

Graphic
Figure 1 Hibbard's theory (Hibbard 2003) of three roles that contribute to the improvement of care.
The informed choice role

The consumer has a wide variety in choosing the high quality of care (McGlynn 2003). The health care professions' qualifications, patient–provider relationship, ability to choose, access, cost and coverage are the areas that the patient meant by quality. Healthcare professionals provide all relevant treatment options and their benefits and risks enable the patient to make an informed treatment decision.
The co-producer role

Lorig et al. (1999) suggested that the self-management education intervention was successful in increasing healthful behaviours, maintaining or improving health status and decreasing rates of hospitalization. Education on the self-management is concerned for patients with diabetes and focused on the skills needed for the day-to-day functioning of the individual and the daily monitoring of their glycaemic control (Von Korff et al. 1998, Lorig et al. 1999, Gasparini et al. 2004). Patients play an active and indispensable part in diagnosis and treatment. In a chronic illness like DM, collaborative management should be established between the patients and healthcare providers with a shared goal and a mutual understanding of roles and responsibilities (Charles et al. 2003).
The evaluator role

This refers to the patients' perspectives in measuring the performance of health care. In evaluating the outcome of care, it gives an opportunity to improve the care provided for the patient, additional information about the treatment; skills in self-management, encouragement and support should be made for improving the care. There are several ways to use consumer information to improve the quality of medical care including providing feedback to consumers to facilitate choice; providing feedback to plans and clinicians to improve internal quality; using information from consumers to set standards for services and marketing; and establishing rules and regulations based on consumers' values (Cleary & Edgman-Levitan 1997).
Purpose

The aim of this study is to determine the effectiveness of a diabetes nurse clinic intervention in controlling the poor glycaemia of older patients with type 2 diabetes. Three specific research objectives were formulated:
1. Is there any improvement in diabetes control after a 12-week nursing intervention in terms of biomedical and psychological variables?
2. Is there any difference between the nurse follow-up and control groups after 12 weeks in terms of the biomedical and psychological variables?
3. Is there any difference between the nurse follow-up and control groups after 12 weeks in terms of healthcare utilization?
Methods
Design

This is a quasi-experimental design with pre- and follow-up tests. The study was conducted in a regional acute hospital in Hong Kong. The hospital had both a diabetes clinic and a diabetes nurse clinic that care for the patients with diabetes. Subjects were recruited from these two clinics. Patients under the care of the diabetes clinic were recruited as the control group whereas patients with diabetes care by the diabetes nurse were the nurse follow-up (intervention) group.
Sample

The study used the HbA1c levels, as the primary outcome, and the two independent samples t-test to calculate the required sample size. The effect size (=0·46) was based on a study by Piette et al. (2000), which investigated patients with diabetes using computer software nQuery Advisor (2000). A total of 150 subjects (75 for each group) were required; this achieved 5% alpha and 80% power. The guidelines for the inclusion and exclusion criteria were based on Aubert et al. (1998), Thompson et al. (1999) and Wong (2003). The inclusion criteria are age over 65 years, type 2 diabetic patients, with HbA1c over 8·5% with no concurrent illness like acute infections, and can speak and understand Cantonese. Those patients who are the residents of a home for older people, patients referred to another hospital during next visit due to their addresses are out of western cluster, their diabetes complicated with uncontrolled hypertension (blood pressure >180/110), and patients had unstable angina, myocardial infarction in the past three months, late-stage diabetic complications or other chronic conditions such as severe immunodeficiency or cirrhosis were excluded in this study.

After getting ethical approval from both the university and the hospital, the study commenced from August 2003 to March 2004. Recruitment took place three days for every week to ensure that subjects being recruited were randomly selected. Three random numbers were generated every week by the software Research Randomizer (2003). Every week, it generated one set with three unique numbers from 1 to 6 (1 = Monday, 6 = Saturday) for both clinics with a total of 12 sets for the three months. On the selected day and under the inclusion criteria, patients with diabetes from both clinics were invited to join the study. If willingness was indicated, the patient was asked to sign the consent form and was orientated to the requirements and time line for the study as described on the consent form. Week 0 was set on the day of the clinic visit, at which all baseline information was collected. Twelve weeks after the first visit, the same outcome measures were collected. In total, 150 subjects were recruited to the study, and all of them had their follow-ups as scheduled (Fig. 2).

Graphic
Figure 2 Workflow of the study.
Instrument

The instrument consists of three parts. Part 1 was used to collect subjects' demographic data including sex, age, years of diabetes, family history of DM, living partner, smoking and drinking status, activity of daily living (ADL), social allowance and the treatment group. Part 2 was used to collect two main outcome variables: (i) biomedical variables: HbA1c, systolic blood pressure (SBP), diastolic blood pressure (DBP), and weight (kg), and (ii) episode of health care use like admission or Accident and Emergency Department (AED) attendance. Part 3 was use to collect the psychological variables. The patients' evaluation of the quality of diabetes care (PEQD) instrument was adopted (Pouwer & Snoek 2002). This instrument had 13 items with responses on a 5-point Likert scale ranging from 'poor' to 'excellent' (1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent) on patients' perspective on the quality of care they received. To examine the content validity of this instrument for Hong Kong DM patients, four experienced diabetes nurses and one endocrinologist were invited to validate the 13 items based on a 4-point scale (1 = irrelevant, 4 = very relevant). In our final version, only 10 items were included in this Chinese version. These 10 items can be categorized into the informed choice role, the co-producer role and the evaluator role, which engage the consumer in their care. The content validity index (CVI) ranged from 0·8 to 1·0 and the average was 0·89. According to Portney and Watkins (1993), a CVI >0·75 is considered a satisfactory level and our results were good enough to apply to the study. A convenience sample of six older patients with diabetes was conducted to test for test–retest reliability with two weeks time. The Spearmen ranked correlation was performed with rs = 0·81 (P <>0·70 is considered satisfactory, the results were interpreted as highly reliable (Pilot & Hungler 1995). Afterward a pilot study with seven recruited older patients with diabetes was conducted to examine the nursing intervention. No particular problems occurred during the pilot study, which suggested that no further discussion or amendment was needed.
The intervention programme

The diabetes nurse clinic was run by a group of trained diabetes nurses. They initiated daily operation of the clinic and were supervised by endocrinologists. Each patient visit was around 30 minutes, during which patients' home blood sugar monitoring (HBSM) results were reviewed, and subsequent adjustment on medication, meal planning, and exercise were reinforced. Patients were reassured and rapport was built between two parties. Patients were followed up monthly and two weekly telephones follow-up to see the effectiveness of the adjusted treatment. Apart from measuring the biomedical variables – HbA1c, blood pressure, body weight in each visit – the PEQD instrument was used to collect the quality of care data. The intervention programme was given to patients during each visit with an emphasis on self-management behaviours, communicating the importance of lifestyle changes, providing attention and feedback on patient's monitoring and record keeping while following a study protocol based on the Hibbard's model (Hibbard 2003) as listed below:
1. The informed choice role: Nurses would inform and advise patients of the availability, expectation and their entitlement to quality diabetes care. A clear picture of diabetes self-management education – availability of the service support – was shown to the patient. In managing older people, nurses should concentrate on the informed choice role since from the elders' physical and psychological changes, they rely more on others' help and advice instead of initiating their own health choices.
2. The co-producer role: Subsequent actions and interventions would be implemented as listed below:
* Prevention: In preventing the diabetic complications, patient education on self-management on items like dietary advice, oral anti-diabetic drugs, insulin injection, exercise and management of hypoglycaemia or hyperglycaemia would be given. During each visit, education like the signs and symptoms of complication, risk factors and self-management would be reinforced.
* Shared decision-making: The framework included information exchange, deliberation about treatment options, and agreement on the treatment to implement (Charles et al. 2003). The nurse would provide effective patient-centred education for the patients; apply educational theories to enhance diabetes self-care and informed decisions about their health and quality of life. Shared decision-making depended on the cognitive ability of the client in deciding which treatment option was for his preference. For the older people, it much relied on their cognitive ability and the reliable of their caregivers and hoped that both the elderly client and their caregivers could take part in their treatment plan and set the achievable goals.
* Collaborative care for chronic illness: The nurse would use the behavioural techniques to improve the patients' self-care in chronic illness. The nurse would set the short-term, achievable goal with the patients and their caregivers during each visit, motivate the patient to participate in the care programme, get their feedback, self-monitor and provide social support. For the older people, it was important to assess their readiness to learn and involve their caregivers to participate, break the multiple steps into small, manageable ones. Reinforcement would be done in every visit, taking into consideration in having their feedback in treatment plan and identifying the misunderstandings.
* Self-management: During each visit in the diabetes nurse clinic, the nurse would reinforce and reassure the concept of the self-management treatment programme. For older patients, the core content of the self-management programme would be emphasized, further correlated health problems like emotional distress, cardiac, renal and orthopaedic would be considered and referral made.
3. Evaluator role: The diabetes nurse would monitor the quality and outcomes of the care given in order to demonstrate the professional responsibility and accountability as to fulfil the evaluator role of the patient. The diabetes self-management education was entitled in using a continuous quality improvement process to evaluate the effectiveness of the education experience provided and determine opportunities for improvement. The diabetes nurse evaluated the feedback from patients with diabetes about the delivered care, standard of the treatment and their individualized plan. Evaluating goals and interventions on a regular basis from the client's view was crucial to optimal self-management in type 2 diabetic patients.
Statistical analysis

Non-parametric tests were used for all the data analysis because most of the outcome measures (e.g. HbA1c, weight, PEQD scores) were not normally distributed according to the Kolmogorove–Smirnov tests. The analyses were divided into two parts. In part 1, descriptive statistics were used to compare demographic variables differences between groups (e.g. chi-squared or Fisher's exact tests and Mann–Whitney U-test). In part 2, for between-groups comparison at each time period, the Mann–Whitney U-test was used. For within-group (baseline vs. follow-up) comparison, the Wilcoxon-signed rank test was used. Difference between baseline and follow-up outcome was also calculated and used to compare any difference between groups in terms of changes. No subjects were lost to follow-up and all had collected information at each time period, so that, no missing values need to replace in this study. All the data were analysed using SPSS (2002) and a significant value was set when P < 0·05.
Ethical issues

The study was approved by the ethics committee of the university and the hospital. A written informed consent was obtained from the participants before the collection of demographic data. The patients were reassured that they could refuse to participate in the study and that they could withdraw at any time without jeopardizing the standard of their care. The participants were free to ask questions about the study at any time. Confidentiality of the collected data was maintained throughout the study.
Findings
Comparison of samples' characteristics

A total number of 150 participants (nurse follow-up = 75, control = 75 cases) met the inclusion criteria and were recruited in the study between August 2003 and March 2004. Table 1 presented demographic variables of the sample. The mean age of the sample was 71·9 years (SD = 5·1, range 65–84) and their mean years of DM was 15·1 years (SD = 8·0, range 1·0–48). Most subjects were female (n = 95, 63·3%), no family member had DM history (n = 121, 80·7%) and were not living alone (n = 45, 75·0%). Six-seven per cent of the subjects (n = 101) were receiving some form of financial support from the government. As for health-related habits, only 6·0% (n = 9) and 8·0% (n = 12) of the subjects were current drinkers and smokers respectively. Only 2·7% (n = 4) and 10·0% (n = 15) of the subjects had dependent and partial dependent ADL status respectively. Further comparisons were made between the two groups for all these demographic variables, and results showed that no significant differences were found.

Graphic
Table 1 Comparison of the characteristics by groups
Comparison of biomedical outcomes

Table 2 displays the mean and change from baseline to follow-up (=follow-up - baseline) values of four biomedical outcomes: HbA1c, SBP, DBP, and body weight, by groups. As shown in Table 2, for the control group, there was a significant drop in the SBP (P = 0·003), and the DBP (P = 0·05), but no significant differences in the HbA1c (P = 0·861) and body weight (P = 0·770). For the nurse follow-up group, there was a significant drop from the baseline to follow-up in the HbA1c (P < 0·001) but no significant differences in the SBP (P = 0·421), DBP (P = 0·219) and body weight (P = 0·073). At the baseline, there were no significant differences between the groups in all outcomes except SBP (nurse follow-up: mean = 145·9, SD = 22·3; control: mean = 155·3, SD = 19·7; P = 0·007). At the follow-up, there were significant differences between the groups in HbA1c (nurse follow-up: mean = 8·7, SD = 1·3, control: mean = 9·3, SD = 1·1; P < 0·001), but no significant differences were found between groups in SBP (P = 0·333), DBP (P = 0·655) and body weight (P = 0·474). When using change from baseline to follow-up to make comparison, there were significant differences between the groups in SBP (P = 0·012) and HbA1c (P < 0·001).

Graphic
Table 2 Comparison of biomedical outcomes variables by groups
Comparison of psychological outcomes

Table 3 shows the mean values of the psychological outcomes at baseline and follow-up and its change values from baseline to follow-up. The PEQD was categorized into three aspects: informed choice role, co-producer role and evaluator role. As shown in Table 3, there was a significant improvement from the baseline to follow-up for the informed role in both groups (nurse follow-up: P = 0·042; control: P = 0·033). There was a significant improvement in overall items from the baseline to follow-up in both groups (nurse follow-up: P = 0·018; control: P = 0·018) respectively. However, there was no significant difference from the baseline to follow-up in either group for the co-producer role (nurse follow-up: P = 0·111; control: P = 0·739), evaluator role (nurse follow-up: P = 0·219; control: P = 0·05) and change from baseline to follow-up results between three roles.

Graphic
Table 3 Comparison of psychological outcomes variables by groups
Comparison of healthcare utilization

Table 4 displays the types and number of health utilizations by the subjects during the 12 weeks of the study. Of the total number of subjects, 20·0% (n = 30) had used healthcare services during the 12-week period. There was a significant difference between the nurse follow-up group and the control groups in the total healthcare use (P = 0·002). The results showed that fewer subjects in the nurse follow-up group (n = 7, 9·3%) had used healthcare services than the subjects in the control groups (n = 23, 30·7%). However, for those who used healthcare services, no significant differences were found for the type of services: admission, and AED attendance between groups (P = 0·086).

Graphic
Table 4 Comparison of the health care utilization (12 weeks) by groups
Discussion

This study supported the positive effects of nurse follow-up groups for older patients with diabetes. This study compared the effects of diabetes nurse follow-up and routine care in maintaining glycaemic control by engaging the consumers into quality of care. Findings suggest that both the nurse follow-up group and the control group had an improvement of HbA1c and SBP over time (in 12 weeks only) respectively. The nurse follow-up group (8·7%) had a better improvement than the control group (9·3%) in 12 weeks in HbA1c (P < 0·001). The effect of nurse follow-up on the glycaemic control, as revealed in this study, is supported by other studies. Wong (2003) conducted a study between the diabetes nurse specialist and the standard care and showed a significant improvement in HbA1c (from 9·3% to 8·3%, P < 0·001). Aubert et al. (1998) demonstrated that a nurse-implemented diabetes management programme gave a mean difference of 1·7% in HbA1c when compared with the control group. The decrease of 1% in HbA1c was associated with a significant risk reduction in any diabetic complications, in particular, microvascular disease (United Kingdom Prospective Diabetes Study Group 1998). HbA1c is an important clinical indicator in reflecting patients' glycaemic control in the past 6–8 weeks. The normal range of HbA1c is 4·6–6·4%. According to the Hong Kong Endocrinology, Metabolism and Reproduction (2000), the ideal control of HbA1c should not be greater than 8·3%. Though the results in both groups did not show a significant result, a gradual drop in HbA1c over 12 weeks did show the effectiveness of a nurse clinic in assisting patients to achieve better glycaemic control. A significant drop was found in the control than the nurse follow-up group on the SBP in terms of the change from baseline to follow-up values. The results were supported by Vrijhoef et al. (2001) while they showed that there was a significant decrease in SBP in the control group but not in the intervention group. The diabetes nurse gives advice on lifestyle modification that includes a low salt diet and cesation of smoking in order to passively control their blood pressure.

From the results of the PEQD scores, we identified several factors that may contribute to decrease the quality of care for patients with diabetes. By engaging the consumer in the quality of care in a diabetes nurse clinic, the satisfaction scores are 34·4 ± 7·6 vs. 32·7 ± 7·5 in the control group, both groups showed a significant improvement in the overall items (nurse follow-up: P = 0·018; control: P = 0·018). Both groups had a significant improvement for the informed role, which implied that older people still relied on the information provision rather than shared decision-making or evaluator role. The diabetes nurse plays a crucial role in helping patients with diabetes to achieve good glycaemic control by providing a good quality of care. Pouwer and Snoek (2002) showed a significant improvement of the patients in the diabetes nurse group compared with the control group in their quality of the care. There was a significant difference in healthcare utilization between the two groups (P = 0·002). Because of acute infections like urinary tract or upper respiratory tract infections, no one suffered from hypoglycaemic attacks as the diabetes nurse education reinforced the client's knowledge on the signs and symptoms, prevention and proper management of hypoglycaemia. These reasons were given for attending AED in the nurse follow-up group. The reasons given in the control group for AED attendance and admission included hypoglycaemic attacks, foot ulcers and acute infections.

The nurse follow-up group can be an effective intervention in enhancing patient's adherence to health behaviours. These kinds of intervention supported a model of transitional care that particularly suits the care of clients with chronic illness, the goals of which were to control symptoms, prevent complications and promote a lifestyle that would delay disease progression. The informed choice role of Hibbard's (2003) study provides a comprehensive picture of an individualized treatment programme. The patient needs to be involved as a partner, the ultimate goal is to empower patients to assume responsibility for their own health that fulfil the concept of co-producer role. The nurse follow-up group provides continuous reassessment and reinforcement of the treatment process and collaborates with other healthcare professions. Although the study did not show a significant improvement in the quality of care, it did show a significant improvement in the glycaemic control. There were significant differences in the adherence to medication, HBSM, hypoglycaemia management between the nurse follow-up and control groups (Wong 2003). Subjects in the nurse follow-up group had a higher adherence to self-care, but it still depended very largely on how well the patient learned about his or her disease and treatment programme. In applying the informed choice role in the nursing education, patients are given the relevant information on how to manage their disease and have choices for their treatment.

In the diabetes nurse clinic, the diabetes nurse not only offered medical consultation but also provided nursing care to patients with diabetes. The diabetes nurse assessed patient's HBSM results, insulin injection technique, time and dosage of medication administration, the injection site and educated patients on the management of hypoglycaemia on every visit. Thus consultation was integrated with medical and nursing advice. The NHS Executive (1996) suggested that the combination of nursing and medical skills provided a more comprehensive and flexible service for patients than that provided by physicians.
Limitations

The study's time frame was limited, because only a 12-week follow-up was used to compare the effectiveness of the diabetes nurse clinic, a further long-term follow-up is required. The decisions on subject selection in the two clinics were still in the hands of the physician, a randomized control trial design would be beneficial in identifying the effects of the nurse follow-up clinic compared with the routine one.
Conclusion

The treatment plan for patients with diabetes may no longer be solely determined by the physicians' decisions as poorly controlled patients with diabetes did gain benefits from the care under the diabetes nurses. With the increasing prevalence of diabetes and the shortage of budget within the hospital, the expansion of diabetes nurse clinic should be considered. The ideas of this programme and the advanced practice nursing of the diabetes nurse are now the current and future trend in dealing with the local patients with diabetes. Evidence showed that the poor control patients with diabetes under nurse follow-up groups had significantly decreased their HbA1c. Although applying Hibbard's model into our diabetes nurse clinic did not demonstrate a significant improvement in the quality of care compared with the routine care group, still the diabetes nurse clinic is worthy and valuable in our healthcare organization.
Contributions

Study design: MFC, ASWY, ELYL; data analysis: ASWY, MFC; manuscript preparation: MFC, ASWY, MCD.
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Key words: diabetes nurse; nurse education; nurse intervention; type 2 diabetes; nurse; older people

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1 comment:

Unknown said...

I am very happy to see your blog, good article and interesting,

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