Nurse Or Diabetes Educator Followup

Following the examination, the nurse, nutritionist, or diabetes educator meets briefly with the patient to review and clarify specific goals for behaviour change and develop problem-solving strategies. It is critical— and often inadequately implemented—to consider the patient's perspective and readiness to change during this process. Anderson and colleagues have written extensively on patient empowerment and patient-centred approaches to enhancing diabetes self-management14,32. Patients will be unlikely to make behaviour changes if: (a) they are not motivated to do so; (b) they do not understand the importance of the recommended behaviour in managing their diabetes; or (c) they do not have the necessary skills to carry out the behaviour. Optimally, the goal(s) should be generated by the patient and then worked into a specific behavioural plan in collaboration with the nurse or educator. Using principles of behaviour change, this means that the goal(s) should be specific, manageable and measurable, that the patient should understand the importance of the behaviour in managing diabetes, and that he/she should be educated in the skills necessary to perform the behaviour74-79.

Once a plan for a specific behaviour change is agreed upon, the next step is to ask the patient to identify the things that are most likely to interfere with following the plan. Help the patient to come up with at least two practical solutions to these barriers. One of the most common barriers to self-care, even for the most motivated patients, is returning to a home, work, and neighbourhood environment that does not support the self-management goal (there are brief questionnaires that can be used to structure this discussion)80,81. A number of studies have evaluated patients' 'barriers' to self-management80,82. Rather than labelling the patient as 'non-compliant', an attempt should be made to understand the factors that interfere with the identified goal. Commonly reported barriers include lack of family support, stress, being busy, being away from home, lack of insurance reimbursement (e.g. for glucose testing strips), and lack of convenient, safe, low-cost places to exercise. Glasgow et a/.82 and Glasgow81 have reported that most patients experience the highest frequency of barriers to dietary and exercise adherence and the fewest to medication taking, and that patients' self-reported barriers to adherence are prospectively predictive of their level of diabetes self-care. These findings suggest that helping patients to identify barriers to self-management and develop strategies to overcome these barriers should increase the success of their diabetes self-management activities.

Finally, it is also important to assist the patient in accessing support for his/her new behaviour. This might entail referral to diabetes education classes or a support group, related reading materials, and often a follow-up telephone call to check on progress between visits. Finally, the self-management goal and plan for achieving it should be recorded (Figure 6.4), with a copy given to the patient and another placed in the chart so that it can be followed-up during the next visit.

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