Clinical Nurse Specialist:
Patients and Clients: Editorial
CARROL A. ALVAREZ is affiliated with the University of Washington, Seattle
I have two family members who have diabetes. These men are both intelligent and hold responsible jobs in which they supervise others. However, they can regularly be considered non-compliant with elements of their diabetic care. In one instance, despite having had complications and the removal of a toe, the one individual does not routinely check his feet, does not wear special shoes, and periodically goes barefoot.
In psychiatry, when working with patients newly diagnosed with a chronic mental illness, we often use diabetes as a comparison. Both diabetes and chronic mental illnesses are imbalances of chemistry, often with a genetic component, that require lifetime monitoring and medication. Newly diagnosed patients with chronic psychiatric illness struggle with the idea that they will have to take medication for the rest of their lives. The comparison with diabetes is made to normalize and decatastrophize this concept.
However, additional similarities-those of acceptance-may be present in the two patient groups (and in all patients with chronic illness). In the survey by Willoughby and Burroughs, 23% of those patients seen in the foot care clinic who receive regular education about maintaining the health of their feet were nevertheless checking for lesions only once a month or less. When compared with the control group, the foot clinic patients were more likely to have some type of foot pathology, presumably making them more sensitive to the need for monitoring.
However, chronic illness has real and symbolic impacts on living that are uncomfortable. Mental illness and diabetes and multiple sclerosis and coronary artery disease all represent a change in the person's self-image, an abrading of the concept of oneself as whole and healthy and immortal. Chronic illnesses require changes in routines, which are often lengthy and uncomfortable additions to daily routines. Not only are the additions an intrusion on the day, but they are also regular reminders of the illness, of the lack of wholeness. Patients frequently respond by denying the presence of the illness, minimizing its importance, trying to compartmentalize it to a small and inconsequential portion of daily life, or distorting the meaning or requirements of the illness. These responses represent ongoing attempts to adjust to the presence of the illness rather than a stage in the process of acceptance. Even patients who seem to have accepted their illnesses may bounce among various attitudes about and accommodations to their disease processes.
This suggests, as does the foot clinic survey, that even with motivated patients and ample education there will be a need for the kind of supplementary monitoring and early intervention the clinic supplies. The self-referred and primary provider referred group appears to represent a more at-risk group than the control group. Clinical nurse specialists in clinics such as the one described can potentially decrease the costs associated with complications of chronic illnesses, such as limb amputation in diabetes. Willoughby and Burroughs note that the next step will be to show this cost decrease by comparing outcomes over time of the clinic group and a more evenly matched control group.