Diabetes care policies and practices in Michigan nursing homes, 1991.

OBJECTIVE: To describe local standards of care for nursing home patients with diabetes, to characterize the care that nursing home patients with diabetes receive in Michigan, and to determine if the care provided meets local and national standards. RESEARCH DESIGN AND METHODS: In March 1991, a questionnaire was administered and chart reviews were conducted as part of the Medical Review and Nursing Evaluation conducted by the Michigan Department of Public Health. The questionnaire was completed by the head nurses at 17 skilled nursing homes to learn about local institutional standards of care. Chart reviews were conducted on a sample of five patients with diabetes from each nursing home to describe the care provided and to compare it with local and national standards. RESULTS: Almost all nursing homes had some diabetes care orders or protocols. Standing orders were most often present to guide nutritional and nursing care (e.g., diet, blood glucose monitoring, foot care). Standing orders were less often present to guide medical care (e.g., blood glucose parameters to contact physician) and surveillance of complications (e.g., eye exams). In general, the care provided did not meet local or national standards for diabetes care. Care practices were closer to national standards when registered dietitians (RDs) participated in meal planning and written institutional policies existed. CONCLUSIONS: In this sample of Michigan nursing homes, those with RDs and standing orders provided care more in keeping with guidelines. There is room for improvement in diabetes care practices in nursing homes. It may be time for diabetes-related organizations to re-examine standards for diabetes care in nursing homes.

Feasibility of adjustment of insulin dose by insulin-requiring type II diabetic patients.

Type II (non-insulin-dependent) diabetes accounts for most of the diabetes morbidity and expense, yet no systematic study of the effects of intensification of treatment by such patients who require insulin treatment has been conducted. Therefore, patients were recruited from our diabetes clinics, and by random assignment, experimental and control groups were created (n = 26 and 27, respectively) that were not different at 0 mo regarding 20 demographic, physiological, and treatment variables. Experimental patients practiced an algorithm for adjustment of insulin dosage based on daily prebreakfast capillary blood glucose (CBG) measurements and any symptomatic hypoglycemia. At 2-, 4-, and 6-mo visits, records of CBG measurements were available to the physicians (n = 7), who changed insulin dosages of both groups ad libitum. Feasibility of the experimental treatment is evidenced by study completion by 87% of enrollers, monitoring on 88% of days, accuracy of CBG recording (recorded as percentage of memory meter value, 100.8), weight gain not exceeding that of control subjects, practice of treatment algorithm to effect changes in insulin dosage, modest increase in frequency of mild insulin reactions, and a decrease of glycosylated hemoglobin into the normal range.

The third version of the Diabetes Attitude Scale.

OBJECTIVE: The objective of this study was to develop a third version of the Diabetes Attitude Scale (DAS-3) that is congruent with current scientific knowledge about diabetes, has improved subscale internal reliability scores, and is shorter than the earlier versions of this instrument. RESEARCH DESIGN AND METHODS: The second DAS was revised and rewritten by a panel of diabetes experts, including patients, associated with the University of Michigan Diabetes Research and Training Center. The revised version of the instrument was sent to physicians, nurses, dietitians, and patients with diabetes. Completed and usable questionnaires were obtained from 384 patients with diabetes, 321 physicians, 540 nurses, and 569 dietitians. The total number of surveys used for these analyses was 1,814. RESULTS: The study resulted in a revised DAS with 33 items and five discrete subscales. The subscales were attitudes toward the following: 1) need for special training to provide diabetes care, 2) seriousness of type 2 diabetes, 3) value of tight glucose control, 4) pyschosocial impact of diabetes, and 5) attitude toward patient autonomy. Overall, the subscale reliabilities of the DAS-3 were superior to the earlier versions of the scale. CONCLUSIONS: The DAS-3 is a valid and reliable general measure of diabetes-related attitudes and is most suitable for comparisons across different groups of health care professionals and/or patients. The DAS-3 is also suitable for the evaluation of patient and/or professional education programs if those programs focus on the specific topic areas measured by the five DAS-3 subscales.

Learning to empower patients. Results of professional education program for diabetes educators.

The patient empowerment approach to diabetes education is intended to enable patients to make informed decisions about their own diabetes care and to be fully responsible members of the health-care team. Facilitating patient empowerment requires a specific set of skills and attitudes on the part of diabetes educators. A professional education program designed to facilitate the acquisition and enhancement of the requisite skills and attitudes was designed, implemented, and evaluated. The program involved adhering to a simulated diabetes care regimen for 3 days followed by a 3-day intensive skills-based workshop. The 23 educators who participated in the first two offerings of this program made significant gains in their counseling skills and demonstrated a positive change in attitude.

The Diabetes Empowerment Scale: a measure of psychosocial self-efficacy.

OBJECTIVE: The purpose of this study was to assess the validity, reliability, and utility of the Diabetes Empowerment Scale (DES), which is a measure of diabetes-related psychosocial self-efficacy. RESEARCH DESIGN AND METHODS: In this study (n = 375), the psychometric properties of the DES were calculated. To establish validity, DES subscales were compared with 2 previously validated subscales of the Diabetes Care Profile (DCP). Factor and item analyses were conducted to develop subscales that were coherent, meaningful, and had an acceptable coefficient alpha. RESULTS: The psychometric analyses resulted in a 28-item DES (alpha = 0.96) with 3 subscales: Managing the Psychosocial Aspects of Diabetes (alpha = 0.93), Assessing Dissatisfaction and Readiness To Change (alpha = 0.81), and Setting and Achieving Diabetes Goals (alpha = 0.91). Consistent correlations in the expected direction between DES subscales and DCP subscales provided evidence of concurrent validity. CONCLUSIONS: This study provides preliminary evidence that the DES is a valid and reliable measure of diabetes-related psychosocial self-efficacy. The DES should be a useful outcome measure for various educational and psychosocial interventions related to diabetes.

Influencing the attitudes of medical students toward diabetes. Results of a controlled study.

OBJECTIVE: To determine the effect of two educational interventions on the diabetes-related attitudes of medical students. RESEARCH DESIGN AND METHODS: We studied 67 junior and senior medical students who were participating in the University of Michigan Medical School's Family Practice elective clerkship. Students were assigned to one of two interventions. The first was a 1-wk living-with-diabetes behavioral simulation that involved injections, blood glucose monitoring, diet, exercise, and record keeping. The second intervention involved reading an autobiography about living with diabetes and viewing a videotape about the psychosocial impact of diabetes. RESULTS: No differential impact was found between the two interventions. However, both interventions were followed by a modest positive change in the attitudes of the medical students (which were very positive to begin with) toward the importance of patient autonomy and the value of the team approach to diabetes care. The attitude gains persisted at follow-up for patient autonomy but returned to baseline for team care. CONCLUSIONS: This study suggests that these two educational interventions resulted in modest increases in the already positive attitudes of medical students toward the importance of patient autonomy and team care in diabetes. However, because the study did not include a group that received no treatment, we cannot be certain on this point. The attitude gain related to team care did not persist at follow-up. These findings are consistent with classical attitude research, which suggests that attitudes are sensitive to influences such as these interventions, but that attitude changes may not persist when those influences are changed or withdrawn. We were not able to find a differential impact between the two interventions and suspect that the general nature of the DAS used as the dependent measure may not have been sensitive enough to capture such a differential impact.

Patient empowerment. Results of a randomized controlled trial.

OBJECTIVE: The purpose of this study was to determine if participation in a patient empowerment program would result in improved psychosocial self-efficacy and attitudes toward diabetes, as well as a reduction in blood glucose levels. RESEARCH DESIGN AND METHODS: This study was conducted as a randomized, wait-listed control group trial. The intervention group received a six-session (one session per week) patient empowerment education program; the control group was assigned to a wait-list. At the end of 6 weeks, the control group completed the six-session empowerment program. Six weeks after the program, both groups provided follow-up data. RESULTS: The intervention group showed gains over the control group on four of the eight self-efficacy subscales and two of the five diabetes attitude subscales. Also, the intervention group showed a significant reduction in glycated hemoglobin levels. Within groups, analysis of data from all program participants showed sustained improvements in all of the self-efficacy areas and two of the five diabetes attitude subscales and a modest improvement in blood glucose levels. CONCLUSIONS: This study indicated that patient empowerment is an effective approach to developing educational interventions for addressing the psychosocial aspects of living with diabetes. Furthermore, patient empowerment is conducive to improving blood glucose control. In an ideal setting, patient education would address equally blood glucose management and the psychosocial challenges of living with diabetes.

The reliability and validity of a brief diabetes knowledge test.

OBJECTIVE: To examine the reliability and validity of a brief diabetes knowledge test. The diabetes knowledge test has two components: a 14-item general test and a 9-item insulin-use subscale. RESEARCH DESIGN AND METHODS: Two populations completed the test. In one population, patients received diabetes care in their community from a variety of providers, while the other population received care from local health departments. Cronbach's coefficient alpha was used to calculate scale reliability for each sample. To determine validity, patient group differences were examined. It was hypothesized that test scores would be higher for patients with type 1 diabetes, for patients with more education, and for patients who had received diabetes education. RESULTS: The coefficient alpha s for the general test and the insulin-use subscale indicate that both are reliable, alpha > or = 0.70. In the community sample, patients with type 1 diabetes scored higher than patients with type 2 diabetes on the general test and the insulin-use subscale. In the health department sample, patients with type 1 scored higher than patients with type 2 on the insulin-use subscale. For both samples, scores increased as the years of formal education completed increased, and patients who received diabetes education scored higher than patients who did not. CONCLUSIONS: Although the samples differed demographically, the reliability and validity of the test were supported in both the community and the health department samples. This suggests that the test is appropriate for a variety of settings and patient populations.

The influence of treatment modality and ethnicity on attitudes in type 2 diabetes.

OBJECTIVE: The study examines diabetes attitude differences by treatment modality (insulin vs. no insulin), race/ethnicity, and the interaction of these two variables for people with type 2 diabetes. RESEARCH DESIGN AND METHODS: Data were collected with the Diabetes Care Profile (DCP), an instrument that assesses psychosocial factors related to diabetes. Participants (n = 672) were recruited in the metropolitan Detroit, Michigan, area from 1993 to 1996. A total of 68% of these participants were African-Americans with type 2 diabetes, and 32% were Caucasians with type 2 diabetes. Analyses of covariance were performed to examine the effects of race/ethnicity, treatment, and their interaction for each DCP scale. RESULTS: The four patient categories (two ethnicities by two treatment modalities) differed by age, years with diabetes, education, and sex distribution. Treatment modality had a significant effect on 6 of the 16 DCP scales (Control, Social and Personal Factors, Positive Attitude, Negative Attitude, Self-Care Ability, and Exercise Barriers). Ethnicity was a significant effect for three scales (Control, Support, and Support Attitudes). The interaction of race/ethnicity and treatment modality was a significant effect for two related attitude scales (Positive Attitude and Negative Attitude). CONCLUSIONS: The results suggest that attitudes toward diabetes are similar for African-American and Caucasian patients with type 2 diabetes. The results also suggest that treatment modality has a greater effect on attitudes than either race/ethnicity or the interaction effect. However, Caucasian patients using insulin differed from the other patient groups by having the least positive and the most negative attitudes regarding diabetes.

A prospective study identifying risk factors for discontinuance of insulin pump therapy.

OBJECTIVE: To identify characteristics of adult patients at baseline associated with duration of subsequent, continuous, subcutaneous infusion of insulin treatment (pump therapy) of type I diabetes. RESEARCH DESIGN AND METHODS: For 6 wk, patients followed a standardized conventional therapy and kept a record of insulin dosages, capillary blood glucose concentrations, and symptomatic hypoglycemia. They were then hospitalized. Additional baseline data were obtained and pump therapy was started. Survival analysis was used to determine the relationship between baseline independent variables or risk factors and duration of pump therapy, which is the dependent variable. RESULTS: Of the 68 participants, 33 (49%) terminated pump therapy after an average of 9.9 mo of treatment. Two models (each P < 0.00005) were developed that exhibited a high degree of consistency. Of the 6 variables, 5 were common to both models (HbA1, autonomic neuropathy, mean amplitude of glycemic excursions, frequency of symptoms of hypoglycemia when blood glucose was < 70 mg/dl, and erythema at injection sites). The sixth variable in model 1 (insulin dosage) was replaced in model 2 by a variable, Adult Self-Efficacy for Diabetes, which was obtained on the 33 more recently enrolled patients; this variable related to patient perceptions of self-care behaviors. CONCLUSIONS: We found that, at baseline, the presence of a high concentration of HbA1 and a low estimation by the patient of their ability to treat the disease portend failure of insulin pump therapy as evidenced by its discontinuation. This effect is accentuated when clinical evidence of autonomic neuropathy is observed. These findings offer guidance in selecting patients with type I diabetes for insulin pump therapy.

Overcoming obstacles: collaboration for change.

Effective diabetes care requires a partnership between prepared, proactive practice teams and informed, activated patients. Diabetes education helps to overcome many of the barriers to effective self-management by enabling people with diabetes to make informed decisions about their day-to-day self-care. Both psychosocial and health outcomes have been improved through a variety of training programmes; however, education must be coupled with ongoing self-management support if these benefits are to be sustained. The principal goal of diabetes education has undergone a major shift over the past few years--evolving from primarily didactic interventions, focused on encouraging patients to adhere to the prescribed therapy, towards more interactive learning that supports people in making informed, self-directed decisions.

Compliance and adherence are dysfunctional concepts in diabetes care.

Recognizing that adherence and compliance are dysfunctional concepts is not a passing fad or the latest trend in behavioral approaches to diabetes care and education. Shifting from the acute-care/compliance-focused paradigm to an empowerment/collaborative approach requires a new vision of diabetes education and a new definition and enactment of the roles of educators and patients. Our practice is always an expression of our vision; therefore, if our vision is transformed, our practice will most likely change to reflect our vision. Eliminating the concepts of adherence and compliance makes it possible for our patients to discover and actualize their personal responsibility for their diabetes self-management. Also, it helps us to practice diabetes education as win-win collaboration among equals.

Theory is the cart, vision is the horse: reflections on research in diabetes patient education.

PURPOSE: In this paper, we examine the nature of vision and the role it plays in helping educators identify and use theories productively. We also discuss the role of theory in diabetes education and provide criteria for selecting appropriate theories. METHODS: The vision of diabetes education developed at the Michigan Diabetes Research and Training Center was used to illustrate how our vision has influenced our use of educational and behavioral theories. RESULTS: Both our vision and our theoretical assumptions should be articulated, discussed, debated, and studied. CONCLUSIONS: Diabetes patient education research can systematically contribute to the development of a sound, coherent, and progressive body of knowledge that will truly serve diabetes patient education.

Diabetes patient education research: an integrative literature review.

PURPOSE: The purpose of this study is to summarize the accumulated state of knowledge in the area of diabetes patient education research and highlight important issues that research has left unanswered. METHODS: An integrative literature review was conducted on the topic of diabetes patient education between the years 1985 and 1998. Keywords used in the computerized search were diabetes mellitus, patient education, health education, research, and behavior change. The databases searched were MEDLINE, CINAHL, HealthSTAR, EMBASE, and CHID-HE. A total of 78 papers were reviewed. RESULTS: Most studies lacked a theoretical framework and the majority of studies were conducted in an outpatient setting. HbA1c was the most frequently employed outcome measure, with little, if any, description of the interventions. CONCLUSIONS: Much has been learned in terms of the effectiveness of diabetes education on improving knowledge. However, other topic areas and outcomes need further exploration.

Adapting a diabetes patient education program for use as a university course.

A study was conducted to determine if a patient education program, "Life With Diabetes," could be converted to an undergraduate course. The course consisted of seven 2-hour sessions with presentations by a physician, dietitian, psychologist, and clinical nurse specialists. Topics included definition, treatment, nutrition, monitoring, children, older adults, and patient empowerment. A total of 52 students (45 without diabetes, 7 with diabetes) have completed this one-credit course. A patient diabetes knowledge test and a 50-item Diabetes Attitude Survey were administered before and after the course. For the students without diabetes, mean knowledge posttest scores improved significantly, and significant changes were seen on the attitude subscales, with posttest scores moving closer to those of a national panel of diabetes experts. Students with diabetes scored closer to the national panel on the pretest and improved significantly only on the patient autonomy subscale. This course measurably improved knowledge and attitudes among undergraduates, suggesting that a patient education program can be adapted successfully to provide additional training opportunities for diabetes education programs.

Predictors of adherence to nutrition recommendations in people with non-insulin-dependent diabetes mellitus.

The purpose of this study was to determine how the components of psychosocial adjustment to diabetes predict adherence to nutrition recommendations based on self-reported successful completion of contingency contracts. The relationships between the components of psychosocial adjustment and adherence to nutrition recommendations were examined in a convenience sample of patients with non-insulin-dependent diabetes mellitus participating in a contingency contracting intervention with nurses. Patients completed a standardized instrument, the Diabetes Care Profile, at the time they were enrolled into this randomized clinical trial. High and low levels of adherence to nutrition recommendations were identified by a median split of the number of contingency contracts completed for adherence to nutrition recommendations. Subjects who reported higher regimen adherence and a higher support ratio (received more diabetes-specific social support than desired) were significantly less likely to engage in contingency contracting for adherence to nutrition recommendations.

Perceived effectiveness, cost, and availability of patient education methods and materials.

To determine the efficacy of and need for patient education methods and media, a needs assessment was sent to 816 members of the American Association of Diabetes Educators. Respondents (n = 325, 40%) included 62% RNs, 36% RDs, 1% other; 62% CDEs. Their mean number of years experience in diabetes education was 8.5, and 99% routinely provided patient education. Respondents indicated that videotapes and slide tapes were the most educationally effective media and books and audiotapes were the least effective. Booklets and videotapes were the most cost-effective and computer-assisted instruction the least effective. While respondents perceived one-to-one counseling, skills training, and diabetes content sessions to be the three most educationally effective methods, support groups and large and small discussion groups were seen as the three most cost-effective educational methods. Among nine potential barriers to quality patient education listed, educators rated lack of third-party reimbursement as a major barrier most frequently and national availability of quality education materials as a barrier least frequently.

Guidelines for facilitating a patient empowerment program.

The traditional medical treatment model often ignores the emotional, spiritual, social, and cognitive aspects of living with a chronic disease such as diabetes. Empowerment programs address these psychosocial areas by helping individuals develop skills and self-awareness in goal setting, problem solving, stress management, coping, social support, and motivation. Although many diabetes educators have been taught to use an empowerment curriculum to facilitate self-management, there is minimal research concerning the actual process of providing such programs to patients. We evaluated an empowerment curriculum (Empowerment: A Personal Path to Self-Care) with a diverse group of individuals with diabetes to determine the key elements of planning and implementing a successful diabetes patient empowerment program.

The diabetes education experience of randomly selected patients under the care of community physicians.

The purpose of this study was to describe the diabetes education and nutritional counseling received by patients under the active care of community physicians. The study population consisted of 440 patients with diabetes from the practices of 68 primary care physicians in eight Michigan communities. Fifty-eight percent of the sample reported having received diabetes education, and the mean number of years since the most recent education was 4.15 years. Sixty-six percent reported having seen a dietitian. Patients who had received diabetes education scored higher on a basic diabetes knowledge test (70% correct vs 60%) than patients who had not received diabetes education. From 1981 to 1991, a decline was observed in the percentage of patients who reported having received diabetes education (70% to 58%). Although patient education is an integral part of comprehensive diabetes care, too few patients are receiving it. Furthermore, diabetes education often results in less-than-optimal levels of knowledge. The situation has deteriorated over the past 10 years, and patients who are not on insulin typically are the least well served.

Participation in a diabetes education and care program: experience from the diabetes care for older adults project.

There is very little reported information concerning the participation of older adults in diabetes education and care programs, factors related to their attendance, and the influence of attendance on program outcomes. In this study, which was part of a larger study of insulin therapy, subjects (> or = 65 years old) assigned to the intensive management group (n = 53) were provided with educational sessions during the 18-month study period. Data for this group were examined to determine factors that influenced enrollment and attendance. Attendance rates for individual participants averaged 72% during the first 6 months and 68% during the subsequent 12 months. Demographic factors, baseline knowledge test scores, and baseline glycosylated hemoglobin levels did not significantly influence participation. Greater distance from the clinic and shorter time using insulin were significantly related (P = .05) to attendance. Perceived benefits of the program included diabetes education (45%), glucose control (23%), and interacting with others who have diabetes (23%).