Concluding Thoughts

This chapter has summarized the processes that led the authors to recon-ceptualize diabetes education and care. We have described how we have taken our colleagues down the same path, through our training workshops. We have highlighted the research, both our own and that of our colleagues, which we feel provides evidence for the effectiveness of this approach. We as a group are convinced, on philosophical, theoretical, experiential and evidential grounds, that this approach must be comprehensively tested in the world of diabetes care.

Some readers may feel that this chapter has not touched their world of diabetes care, for example: How does this approach affect your practice? Does this take more time and resources? Does this replace diabetes education programmes? Therefore, we would like to end by presenting the story of one clinician's experience using this approach.

Helen is a 20 year-old single female, diagnosed by her GP, who had had type 1 diabetes for 2 years when she was admitted to intensive care for 24 hours in severe diabetic ketoacidosis, with no concurrent illness. Whilst still an inpatient, conversations revealed that Helen had, over the previous few months, reduced the number of injections she was taking. She said that this was initially because the injections were painful, but that as a consequence of weight loss following insulin skipping, she had persisted with this behaviour. Following discharge she was taught the relationship between circulating insulin levels, blood glucose levels and ketoacidosis. For the next few weeks she appeared to be managing her diabetes effectively. Subsequently, she self-referred to the diabetes nurse specialist, complaining of backache, after her GP had failed to diagnose any pathology. Her random blood glucose was 25 mmol/l, and her urine was positive (+ + +) to ketones.

STOP: Please now take a few moments to think about your plan of action at this time.

Using the approach advocated in this chapter, Helen was first asked what her explanation of the pain was, but she had no causal explanation. After listening to Helen describe her health over the last few days, the clinician reflected back to Helen the set of symptoms she was experiencing (polyurea, fatigue, polydypsia, kidney pain, tender and sunken eyes). Helen was then encouraged to explore what these symptoms meant to her, in relation to her experiences of living with diabetes. Discussing these symptoms led Helen to reveal the amount of insulin she had administered over the past few days, and she acknowledged the probable association between her current health and lack of insulin. The possible management options were then explored with her, including admission to hospital. Helen chose to go home, take some insulin, measure her blood sugars and contact the diabetes centre if further assistance was required. The next morning Helen rang and asked for further information about controlling high blood sugars—despite administering her usual doses of insulin, her blood sugars were still high (> 20).

STOP: Please now take a few moments to think about your usual plan of action at this time.

In response to statements about her current insulin not working, the clinician checked Helen's level of understanding, specifically the need to use higher-than-normal dosages of insulin during period of hyperglycaemia. This enabled Helen to suggest a number of potential options, which were discussed with the diabetes nurse. As Helen was still experiencing the symptoms of hyperglycaemia, she chose to take an additional shot of insulin and increase her normal dosage for the next 24 hours. Throughout this 48 hour period, the diabetes nurse specialist gave no advice or recommendations to Helen; rather, she described the various options and probable outcomes for each potential solution that Helen raised. All information that was given to Helen was given only in response to her requests. Helen was informed that the diabetes nurse specialist would be happy to see her if she wanted to talk further about her insulin management. Helen dropped in to the diabetes centre the following day.

STOP: Please now take a few moments to think about your plan of action at this time.

After a little wait, Helen met with the diabetes nurse specialist. After asking 'Helen, why are you unhappy?', Helen revealed that she felt that people were perceiving her as fat. This made her feel angry, frustrated, she 'just could not be bothered', which resulted in missed insulin injections. Over the next few days, she managed her diabetes markedly more effectively (blood glucose levels 10-14 mmol/l). Furthermore, she acknowledged the need for further help and the possibility of psychological support was discussed.

A number of key points should be noted from this case study:

• Helen was the individual who solved her own problems (this works to increase her confidence, competence and esteem).

• Helen received detailed technological and physiological information (this information was not only received, but processed, acted upon and reinforced through experiencing the results of her decisions).

• Helen has acknowledged her emotional struggle with diabetes and is considering psychological support (interpersonal therapy requires an active acceptance and desire to work at difficulties to succeed; this is difficult to achieve through clinician-driven referrals).

• Helen remained out of hospital, improved her self-care, started to enhance her emotional well-being and successfully reduced her blood glucose levels.

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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