Advanced Nursing Practice in Diabetic Care Outcome of Empowerment in Diabetes Education

1. Rebecca Yee Man WONG RN, BN, MSc Nurse Specialist (Diabetes Care) Diabetes & Endocrine Centre Prince of Wales Hospital Hong Kong SAR Advanced Nursing Practice in Diabetic Care Outcome ofEmpowerment in Diabetes Education

2. Diabetes Mellitus • Diabetes is a chronic disease A successful diabetes treatment program requires patients’active involvement in the management of diet, exercise and medication • Making changes in their lifestyle is one of the greatest challenges patients face in controlling their diabetes

3. Diabetes Mellitus • Glycemic control is an important predictor of many of the chronic complications of diabetes ADA Position Statement 2001

4. Diabetes Control and Complications Trial (DCCT) Significant risk reduction with tight glucose control Reductions in microvascular complications with HbA1c = 7.2% : - 76% retinopathy - 60% for neuropathy - 56% for nephropathy N Eng J Med 1993;329:683-689

5. United Kingdom Prospective Diabetes Study (UKPDS) For every 1% reduction in the HbA1c, there is a 35% reduction in microvascular complications: - Control group 7.9% - Intervention group 7% Lancet 1998;352:837-853.

6. Results of Diabetes Self-Management Education (DSME) on Glycemic Control • Systematic review reports of 31 published, randomized controlled trials to ascertain the efficacy of diabetes self-management education (DSME) in adults with type 2 diabetes • Examine the effect of baseline HbAlc, follow-up interval and intervention characteristics on HbAlc • HbA1c improved with DSME, with an average change of 0.76% Norris et al., 2002

7. Results of Diabetes Self-Management Education (DSME) on Glycemic Control HbA1c was lowered in patients who received education from dieticians or diabetes nurses than those who had not (7.9% vs 8.7% ) Chan et al., 2000 Patients discharged early and received a follow up programme by diabetes nurse specialist had a decrease in HbA1c at 24 weeks when compared with those who remained in hospital until the glycemic control is stable (7.6% vs 8.1%) Wong et al., 2004

8. Intensive Insulin Therapy Program (IITP) in PWH Pilot program started since 1998 Saturday morning session in Diabetes Centre Target groups : - Type 1 and Type 2 patients with multiple dose injection per day (MDI), - BD injection pending to MDI - Patients with insulin pump

9. Intensive Insulin Therapy Program (IITP) in PWH Our Objectives To offer Diabetes self care knowledge and skills To enhance participants’ self-efficacy in disease management To facilitate peer group support and sharing

10. Intensive Insulin Therapy Program (IITP) in PWH Contents of the Empowerment program : • Patient contract • Intensive education • Group sharing • Clinic follow up • Lunch together

11. Intensive Insulin Therapy Program (IITP) in PWH Patients with insulin pump are designated as group leaders to lead the experience sharing DM nurses as partners to provide information on diabetes self care knowledge and skills Other health care professionals such as dietitians, doctors to give education on specific topics

12. Intensive Insulin Therapy Program (IITP) in PWH Topics of the IITP Education Program: Diet : food exchange, food labels, glycemic index, dining out Exercise and weight reduction Insulin dose adjustment Self Monitoring of Blood Glucose (SMBG) Acute complications : Diabetic ketoacidosis, Hypoglycaemia Special issue : traveling, sick day management Stress management

13. Intensive Insulin Therapy Program (IITP) in PWH Mode of education delivery - Group - Role play - Games - Competition Program duration • - 22.9 ±11 months • - 6.74 ± 2.9 visits

14. Intensive Insulin Therapy Program (IITP) in PWH A summary of subjects’ characteristics n=39

15. Intensive Insulin Therapy Program (IITP) in PWH Before joining the programme Upon completion of the programme P value HBAlc(%) 8.7  1.7 7.8 1.4 p<0.0001 BW(kg) 60.7  10.6 62.6  10.6 p<0.001 BMI 22.8  4.2 23.6  4.2 p<0.001 Results

16. Intensive Insulin Therapy Program (IITP) in PWH Conclusion Up to 12/2005, total no. of patients on multiple dose insulin injection (>4 times injection per day) : 258, increase in 10 folds at 5 years Friday afternoon session in diabetes specialist clinic Group education session and experience sharing Clinic follow up visit

17. Intensive Insulin Therapy Program (IITP) in PWH Picture of Peer Group Education Session

18. Intensive Insulin Therapy Program (IITP) in PWH Picture of Peer Group Education Session

19. Weight Management Program for Patients with Diabetes in PWH Pilot programme:12.2003-3.2004 (14 weeks) Target group : type 2 patients with BMI over 25 Organised by DM nurses and social worker from Centre of Rehabilitation Network

20. Weight Management Program for Patients with Diabetes in PWH Our Objectives To facilitate participants in learning various weight management skills and knowledge. To enhance participants’ self-efficacy in disease management. To promote lifestyle modification through psychosocial interferences by group dynamic and peer support.

21. Weight Management Program for Patients with Diabetes in PWH A total of 7 sessions Each session was focused on different themes - general concepts - individual counseling - exercise, diet therapy - lifestyle modification - stress management - common myths • Diabetes self-care knowledge was incorporated

22. Weight Management Program for Patients with Diabetes in PWH Contents of the Program : - Lecturing - Practicum - Sharing - Therapeutic Games

23. Weight Management Program for Patients with Diabetes in PWH Mode of delivery: • Telephone follow-up by social worker in between of visits • Weekly peer-group partner’s phone contact • Learning contract • Biweekly objectives were set with participants

24. Weight Management Program for Patients with Diabetes in PWH Pre & Post Assessment tools : Diabetes knowledge score (DKN) Self-efficacy rating on disease management Health parameters e.g. BW, HbA1c and lipids profile.

25. Weight Management Program for Patients with Diabetes in PWH Overview of the patient group: • Total no. of patients : 6 • Female : 6 • Occupation : housewife • Age: 45-53 • Initial BW: 68.9kg-93.9kg • Initial BMI: 30.8-35.7kg/m/m

26. Weight Management Program for Patients with Diabetes in PWH Results

27. Weight Management Program for Patients with Diabetes Twelve aerobic training studies and two resistance training studies were included (total 504 subjects). Post intervention HbA1c was significantly lower in exercise than control groups (7.65 vs. 8.31%). But post intervention body weight did not differ between exercise and control groups. Boule et al 2001 Type 2 diabetes

28. Weight Management Program for Patients with Diabetes in PWH • A significant improvement in health parameters should be proven in the future programme. • Mutual-aid support group (fit 形糖) was set up in 5/2004 • Frequency of group meeting : once a month • No. of attendance per visit : 25 – 35 patients • Patient as group leader to lead other patients to do exercise and experience sharing • DM nurses and social workers as partners to provide update information regarding diabetes related knowledge and psycho-social support Conclusion

29. Weight Management Program for Patients with Diabetes in PWH Patient-led Exercise Session

30. Weight Management Program for Patients with Diabetes in PWH Patient-led Discussion Session

31. Weight Management Program for Patients with Diabetes in PWH Patient-led Discussion Session

32. Constraints of the Empowerment Program Healthcare Administrators • Acute, symptom-driven patient-care • Limited resources Practitioners • DSME program is complex • Limited resources • High volume patients load • No time

33. Constraints of the Empowerment Program Patients • Ability to comprehend the materials • Lifestyle; socio-cultural, health belief • Motivation and collaboration • Financial issue

34. We are each of us angels with only one wing, and we can only fly by embracing one anotherLuciano de Crescenzo

35. Thank YouforYour Participation