Clinicians expect much of people with diabetes. To prevent blindness, renal failure, and other serious complications, we ask them to follow a meal plan, exercise regularly, and take medication. New treatments and technologies help prevent complications but make self-care more complex. Unfortunately, methods for monitoring the blood glucose level and administering insulin are still somewhat primitive: they simply cannot mimic the body's perfect, highly responsive system. Even the most conscientious patients may still have labile blood sugars, causing them frustration and leading clinicians to think that the patients aren't properly managing their care.
For those with diabetes and comorbid conditions (such as heart disease, retinopathy, or depression), self-care can be even more challenging. Someone who is depressed may be less likely to perform self-care. Poor vision makes it hard to measure the correct amount of insulin or get a blood sample onto a test strip. Those with multiple disorders may have to contend with additional dietary restrictions and numerous medications.
Clinicians often label as noncompliant patients who don't follow their self-care regimen. Whose job is it to translate the regimen into a language each patient can understand? Is it possible that nurses and other diabetes professionals ask patients to perform these tasks without having, step-by-step, taught and coached them to use the skills needed? Do nurses give patients the support they need to care for themselves when the challenges seem overwhelming?
Motivating and coaching patients with diabetes requires a good relationship, a nonjudgmental attitude, good communication skills, compassion, and easy accessibility for patients. It also requires knowledge and skill in using evidence-based advances in treatments and self-management. The challenge of educating and motivating the millions of people who have diabetes can be addressed by teaching all nurses the strategies that facilitate self-care.
Having more nurses who are well trained in diabetes care, no matter what field or subspecialty they work in, will help address the needs of the growing population of people with diabetes as well as their family members, who may be at high risk for the disorder. That way, patients with diabetes will receive support when they seek any kind of health care. Diabetes affects every population. In what settings won't a nurse encounter diabetes?
Nurses must lead the way. This means, first, that all nurses should become experts by making diabetes self-care training a requirement and competence in teaching diabetes self-care a nursing standard of care. Training in diabetes care should be part of initial nursing education programs and, because of the fast pace of advancement in research and technology, it should be updated regularly. Education programs should conform to standards of care and enhance the competencies of all nurses. These programs must include actual clinical experiences, supervised by well-trained diabetes clinicians, to enhance nurses' confidence about teaching and coaching people with diabetes. Mentoring could develop these skills in generalist nurses. After completing a training program for educators, that educator should receive or be allowed to sit for an exam for certification.
Nurses will learn skills that can be applied to other patients who have chronic conditions requiring significant self-care, such as those with congestive heart failure. Determining the best ways to promote self-care management that requires changes in health behaviors (such as eating or exercising) is the major challenge confronting health care providers and our health care system. Part of this challenge involves how clinicians work with patients, as well as whether reimbursement and health policies adequately support patient education.
To encourage nurses to take a leadership role in diabetes care, AJN, the American Association of Diabetes Educators, the American Diabetes Association, and the Joslin Diabetes Center convened an invitational symposium in September 2006 to examine the state of the science of diabetes self-care management, with an emphasis on exploring what nurses can do to help patients manage the disease and prevent its sequelae. This report presents the work of the meeting's participants. It makes recommendations for nurses and others concerned about this epidemic. We urge you to determine what you can do to act on our recommendations.