Diabetes and Self Management for Patients

Introduction/Background
The basis of self-management is rooted in patient-centered care. The idea behind it is that the patient will feel empowered to take ownership of his or her care process. Patient collaboration helps to get to the heart of patient-centered care, as Chiaramonte et al. (2018) note. Patient-centered care is about putting the patient’s needs first and foremost in care providing process. It means that the patient is likely to have questions, cultural inputs, unique needs and ideas about what care means to him or her. By collaborating with the patient to develop a unique and personalized care approach, the nurse can empower the patient and make the patient feel that he or she is truly part of the decision making process. Otherwise, the patient can feel disenfranchised and can feel as though he or she has not part in the process of care. The patient will not take ownership of the care process and instead will take a passive approach to self-care and rely solely on the medical professionals.
One of the main incentives of collaborative and patient-centered care is that it allows the patient to be more involved in taking ownership of his or her own health: rather than just going to the health care provider and asking to be “fixed,” the nurse and the patient work together to develop a plan that touches on everything from treatment to lifestyle rearrangement. The aim is to get the patient involved in taking care of his or her own health in such a way and to such an extent that the patient becomes empowered to do more, know more, and be healthier all the way around. Increasing the patient’s health literacy through collaboration is one of the best ways to ensure that this goal is reached on a patient to patient basis year round.
The degree to which nurses are able to collaborate with patients to teach self-management of treatment can be seen as the degree to which patient-centered care, and quality care by extension, is provided. For patients with type 2 diabetes (T2D), it is important that they exercise self-management so that they can take ownership of their bodies and the treatment process and thereby lead a healthier life (Powers et al., 2017). Understanding the barriers that nurses face in teaching or promoting self-management of T2D can help to improve patient collaboration and the enable nurses to achieve the goal of teaching self-management of T2D to patients that they may reach that level of empowerment as patients who take ownership of their care. Currently, nurses struggle to teach self-management of T2D to patients (Majeed?Ariss, Jackson, Knapp & Cheater, 2015). Knowing why this is so can be the first step in helping nurses to overcome the challenges they face in teaching self-management of T2D.
Research Question
The research question for this study is: What are nurses’ views of barriers to self-management of T2D?
The purpose of this question is to find out what nurses see as the main obstacle in collaborating with patients to train them in self-management. The idea is that by understanding what nurses see as the main challenges, solutions to their struggles can then be developed. Unless one knows what the problem or the pain points are, there is no way to provide relief or overcome the obstacle.
Terms
For the purposes of this critical appraisal certain terms are defined as follows:
Self-management: the management of one’s care by oneself; the taking of responsibility and accountability for one’s own health and well-being.
Barriers: obstacles to care that can take virtually any form—social barriers, personal barriers, identity barriers, knowledge barriers, support barriers, emotional barriers, and so on.
Patient-centered care: care that is oriented specifically to and uniquely designed to meet the needs of the individual patient.
In the next section, a discussion of the literature search method will be provided. Following that is the critical appraisal of relevant literature on the topic of nurses’ views of barriers to self-management of T2D. At the end is the conclusion and recommendations section.
Literature Search Method
This literature review of all English language literature on nurses’ perceptions of barriers to self-management of T2D was undertaken by searching for publications on the subject via Google Scholar. Google Scholar has been found to be a helpful method of searching various databases to find relevant peer-reviewed literature on many subjects (Jasco, 2005; Beel, Gipp & Wilde, 2010; Schultz, 2007). Databases included in the Google Scholar searches were Medline, The British Nursing Index and other health related databases and journals, books, and papers from conferences. The following key word searches were used: “diabetes self management,” “t2d self-management,” “obstacles t2d self-care,” and “nurses perspective t2d self-management”: The last electronic search was undertaken on February 1, 2019. A summary of the results of the literature search, including a record of what was found and what was selected for critical appraisal should are provided as an appendix.
Critical Appraisal of Literature
The literature pertaining to this subject is very robust with several studies having been conducted within the past 15 years that help to provide deep insight into nurses’ perceptions of barriers to care for self-management of T2D. The following studies were evaluated for this critical appraisal.
According to Pun, Coates and Benzie (2009), health care providers view the barriers to the self-care of type 2 diabetes (T2D) to be “psychosocial, socioeconomic, physical, environmental and cultural factors” (p. 4). Nurses also noted that patient attitudes towards diabetes were often a barrier to self-care as was the complexity of the management process (Pun et al., 2009). If the patient lacked a support system, this too served as a barrier, according to the study. Other factors included poor communication, as providers and patients placed different degrees of importance on different barriers to self-care—so neither is on the same page when communication breaks down. This study was very helpful in highlight what nurses view as barriers to self-management as it focused specifically on challenges that nurses perceived and experienced. Those challenges were related to the researchers using interviews and survey methodology to allow for a triangulation of data sources, giving the study a great deal of credibility and trustworthiness. This was the most helpful study for answering the research question posed above.
Another helpful study was the one by Nagelkerk, Reick and Meengs (2006), in which the researchers noted that perceived barriers to T2D self-management were a lack of understanding about the process of care on the patients’ part, and a feeling on the part of patients that their providers were not giving them enough support for them to effectively engage in self-management. Nurses who viewed these barriers felt that patients who were challenged by them needed more time, consideration, support, and education. Nurses believed patients could benefit from a boost in their health literacy on this matter. This study’s findings were convincing and helped to show how much consideration patients actually need from nurses in order to reach a level where they can genuinely care for themselves.
Bos-Touwen et al. (2015) showed in their study that nurses’ view of patient barriers to self-management of T2D depended primarily on the type of patient being treated. Since every patient is unique, their study indicated that nurses have unique experiences with each individual patient when it comes to facing obstacles to self-management. Moreover, nurses held that identifying obstacles largely depended on the patient’s own self-assessment: “Patient assessment was the key driver of tailoring, which was performed in various ways, and influenced how and the extent to which care was individualized” (Bos-Touwen et al., 2015, p. 282). This indicates that nurses need to have considerable discussion with patients before addressing challenges to self-care for the patient’s diabetes, just so that they can better see where the patient is likely to struggle and what the patient feels are going to be issues. This study was especially helpful in pointing out how important it is for every nurse to approach each patient as unique and to identify the particular needs of the patient so that the patient can actually be supported enough to engage in self-care.
The study by Sen (2005) showed that nurses require continuing education in order to be better prepared to identify obstacles in the self-management of T2D for patients. Sen’s (2005) revealed that nurses need additional training in assessment skills, knowledge, attitudes and values, and in identifying barriers to self-care. What the study revealed primarily is that nurses have not received effective training in addressing the management barriers that patients face in treating their T2D. This study was effective in illustrating how important it is for nurses to keep receiving training and not to think that just because they have their nurses certificate or degree that their work and schooling are finished. Continuing education is the foundation of quality care and nurses will not be able to engage in collaborative care unless they are steeped in training on how to teach patients self-management, as this study convincingly shows.
Mulder, Lokhorst, Rutten and van Woerkum (2015) show that nurses’ perception of barriers to effective self-management of T2D is related to communication issues, just like the study by Pun et al. (2009) indicated. Mulder et al. (2015) noted especially that “important communication barriers are lack of skills and self-efficacy, possibly because nurses work in a context where they have to perform biomedical examinations and then perform patient-centered counseling from a biopsychosocial approach” (p. 1100). When nurses fail to engage patients in the right manner, patients become locked out of the self-management process as they feel incapable of taking ownership of their own health care process. Nurses are aware of “freezing out” the patient in these instances, but lack the communication skills needed to bring the patient back into the conversation so that the patient feels supported, empowered and activated. Mulder et al. (2015) suggest that nurses must have a grounded approach in patient-centered care to be able to overcome this obstacle. This study’s findings are convincing as they are corroborated by all the other studies examined and evaluated here and the conclusions are based on a good methodology and research design as described in the study.
Conclusions and Recommendations
The generalizability of the critiqued evidence is very strong considering the different studies that were performed among various samples and the fact that all the findings pointed still to the same conclusions—namely, that 1) nurses need continuing education in order to be prepared to effectively train patients in self-management of T2D; that 2) nurses need more training in patient-centered care, as this is the basis of being able to put the patient’s needs first and assist the patient in learning to engage in self-care for his or her diabetes; 3) that nurses must identify the special needs of each individual patient and not expect all patients to be the same—which means nurses must perform patient assessments; and 4) nurses should ensure that patients have an adequate support system in place that will help them to effectively meet their goals in self-care. The evidence also had applicability as it related wholly to the area of practice concerned in this study and was strictly relevant to the issue in question.
The research question was: What are nurses’ views of barriers to self-management of T2D?
The extent to which this question has been answered by the literature critiqued above is significant. The studies showed very clearly what nurses’ perceptions are and what they view barriers to self-care of T2D to be. The findings of the critical appraisal do adequately inform the problem area and provide a solid foundation upon which some possible solutions to help in overcoming the barriers can be developed.
Additional research may be required in terms of arriving at a properly developed solution to these obstacles. The general terms under which further research might be carried out would be to conduct key word searches for information on solutions to barriers of self-management of T2D, ways nurses can improve patient self-management of T2D, and what interventions have been performed that have empowered nurses to empower patients in the self-care of T2D.
Research that could combine mixed-methodologies and use both qualitative and quantitative data streams to obtain information on what barriers are and how to overcome them could also be useful. Such research would be feasible with a grant from the government and nurses working in the field could conduct the study. It could be conducted within the single discipline of nursing and would help to shed new light on the issues of self-management of T2D in terms of what interventions work best among nurses and their opinions on the matter.
Relevant practice, research and ethical issues pertaining to the above sections are that nurses need to continue education primarily and focus on learning patient-centered care in order to be more successful in teaching self-management of T2D. More research should be conducted to give clear ideas about what interventions work best and what nurses think about these interventions used to improve patient self-care. Ethical issues would have to be considered in terms of protecting participant privacy, always obtaining informed consent and avoiding researcher bias.



References
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Bos-Touwen, I., Dijkkamp, E., Kars, M., Trappenburg, J., De Wit, N., & Schuurmans, M.
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Appendix
Relevant journal articles found: 110.
Criteria used to select top five articles: year of publication (within last 20 years), relevant key words in title of journal article
Information found within articles: 1) patient-centered care education is lacking, 2) nurses need continuing education in teaching self-management care, 3) every patient is unique and thus nurses need to be able to adapt, 4) patients need understanding of how to care for themselves, and 5) patients need support systems.