LINDA SMITH, 42, is back in your clinic on a busy day, and you know you're in for a challenge. Ms. Smith has type 2 diabetes and her most recent hemoglobin A1C (A1C) level was 9.2% (the goal for patients with diabetes is 7%), her body mass index (BMI) is 29 (a BMI of 25 to 29 is considered overweight), and she's taking maximum doses of three oral antidiabetic medications. She smokes, rarely checks her blood glucose levels, and frequently misses clinic appointments. She has hypertension and is beginning to show signs of cardiovascular disease and peripheral neuropathy.
Ms. Smith has been your patient for years. You've told her many times what she needs to do to care for her diabetes, and she always agrees to do better, but the results are painfully evident to you both. Frustrated and discouraged, you'd love to have a new way of working with her.
Patients like Ms. Smith represent an all-too-common scenario in chronic disease care. The traditional approach—telling Ms. Smith to bring her A1C down, lose weight, stop smoking, start to exercise, and check her blood glucose at least twice a day—isn't producing results, and you know that's not likely to change. Fortunately, you recently learned about an alternative approach called empowerment that's helping many patients.1-5 Today, you're going to try some of the strategies you learned with Ms. Smith.
In the context of diabetes, empowerment is defined as helping patients discover and use their innate ability to gain mastery over their disease. Patients clearly understand this tenet, as evidenced when they make statements like, “You can teach me, but you can't make me.”
Most patients with diabetes provide 99% of their own care and are responsible for the many day-to-day decisions that they make as part of managing their condition. This means that the patient is in charge. As the nurse, you're her educator and collaborator.
Interest in empowerment grew out of recognition that the traditional compliance or adherence models of diabetes care and education don't always work. Thus, this is not a new way of looking at adherence or a new method of trying to get patients to follow their treatment plan, but a different paradigm for providing diabetes care.5 Let's look at the old way and how the new method has evolved.
Reviewing the traditional method
The traditional education model was developed to teach patients with acute diseases in hospitals, where patients were cared for primarily by nurses and physicians. Healthcare professionals made the decisions and assumed responsibility for the outcomes based on their clinical knowledge and experiences with other patients with similar diseases. But this approach showed little regard for the real-world challenges patients face.
As nurses, we often adopt a maternalistic approach, trying to persuade our patients to do what they're told for their own good. Although our motives are good, taking this approach simply doesn't fit with the realities of chronic disease, where patients must make choices and decisions on their own throughout the day. By attempting to change our patients' behavior by telling them what to do, we're sending the message that they're not competent to manage their own lives and health.
The results can be frustrating for patients and nurses alike. Patients are frustrated that their concerns and issues aren't acknowledged or addressed, and we're frustrated because we feel responsible for our patients' behavior and outcomes.
A key difference in empowerment is the understanding that as healthcare professionals, we're responsible to our patients rather than for our patients' outcomes.
Multiple studies have shown that using empowerment-based strategies can improve metabolic and psychosocial outcomes among patients with diabetes.2,3 Nursing interventions include addressing patient-identified concerns, problem solving, and self-directed goal setting.1-4 A method for implementing these strategies in a patient-care situation is called the LIFE approach.6 LIFE provides a framework that addresses the fundamental skills of empowerment in an easily understood, patient-centered manner:
- Learn about diabetes and how it affects the patient personally.
- Identify three guiding principles: role, flexibility, and targets.
- Formulate a personal self-management plan.
- Experiment with and Evaluate the plan.
Now let's take a closer look at each component.
Most diabetes education is directed at providing patients with clinical information; however, integrating the clinical, behavioral, and psychological components of diabetes is more effective. Use active listening strategies to help your patient devise a plan that fits her life, rather than expecting her to adapt her life to accommodate diabetes. For example, when discussing meal planning, ask your patient to identify how she plans to handle social and other situations and feelings of being deprived or left out. Also ask about the amount of family involvement she wants and can expect to receive and how she'll handle it when her best efforts don't result in the weight loss or blood glucose numbers she expected.
She needs to understand how diabetes affects her decisions and behavior. This requires honest reflection on her part and a high degree of respect, sensitivity, empathy, and understanding on your part. Healthcare professionals are experts about diabetes and can offer valuable suggestions. But the patient is the expert on her life and the physical, emotional, and practical effects of diabetes. Ask her about her concerns, feelings, priorities, other life stresses, and goals.
Most patients with diabetes experience a high degree of emotional distress that continues throughout their lives but is rarely addressed by professionals.7 In talking with Ms. Smith, you learn that she's recently separated from her husband and that, except for her son, her other family members live some distance away. She feels isolated and extremely stressed. Ask her to identify sources of emotional and practical support for dealing with this chronic stress, such as the church in which she's active.
Identify the guiding principles
In this step, help your patient identify the ground rules for how she'll manage her diabetes.
Role. First, your patient must decide how actively involved she wants to be in creating her self-management plan. There's no right or wrong approach, and her level of involvement may change over time. For example, some patients want to leave medication recommendations to the prescriber but make their own decisions about meal planning.
Flexibility. Some people find it easier to follow a strict meal plan and timetable. Others want the ability to change their daily routines to suit their own schedules. Once again, your patient has a choice to make and needs to appreciate the costs and benefits of various options. For instance, more flexibility may require more daily decisions, more injections, and more-frequent blood glucose monitoring. A rigid plan requires more self-discipline at mealtimes, and the patient must be willing to eat and exercise on a consistent schedule. Ms. Smith works in a convenience store and her schedule varies, so flexibility is very important to her.
Targets. Help your patient set interim targets to bring her closer to the recommended targets for A1C, BP, cholesterol, and weight. Ms. Smith, for example, may choose as a target that her next A1C level will be down by 0.5 percentage points (from 9.2% to 8.7%) in 3 months.
Formulate the self-management plan
Your patient needs to consider and choose from the many options for treating diabetes—meal planning, exercise, medications, insulin, blood glucose monitoring, stress management, problem solving, and emotional support—and understand how these strategies can be incorporated into her life. Ms. Smith has limited health insurance and can't always afford her medications. Her son has severe asthma, and she sometimes goes without her medications to pay for his.
The last step of the LIFE process recognizes that all of the steps are fluid and continuous. Much of the plan will be trial and error. Help your patient formulate a plan by asking questions that will help her create behavioral or action goals:1,3
- Explore the problem: “What's hardest or is causing you the most distress in caring for your diabetes? Why do you think that is? What have you tried to address this problem?”
- Clarify feelings: “What are your thoughts or feelings about this issue?”
- Develop a plan: “Where would you like to be in 6 months regarding this problem? In 3 months? What one step can you take to reach that long-term goal?”
- Commit to action: “How important is it to you to reach that goal? How confident do you feel that this is attainable?”
- Experiment with the plan and evaluate the results: “How did it go? What did you learn as a result?”
Help your patient understand the experimental nature of setting goals. Even if something doesn't work, she'll learn from the experience. You can help her understand the reasons a part of the plan isn't working and ask her to think about what she might do differently next time.
Sometimes the plan doesn't work because the patient ignores it. Some people may refer to this as “cheating,” but in reality it's a choice that your patient has the right to make. Don't make judgments about her choices. Your role is to help her reflect on her decisions and their consequences using the same four-step approach.
A fresh start
So now back to Ms. Smith. You ask what's hardest for her about her diabetes, what her current emotional state is, and what's important to her in managing her diabetes. By conducting a more patient-centered assessment, you learn about her work and home life and that she feels overwhelmed and frightened about how she'll manage without her husband's financial support. She's also frightened that the health complications she's beginning to experience will affect her ability to support and care for her son.
Because Ms. Smith identifies her anxiety over her situation as her top priority, offer her information about local free mental health services. Ms. Smith chooses as her goal for the week that she'll contact a social worker for help with her financial issues, stress, and anxiety. Ms. Smith will call you after this conversation and let you know how it went. As Ms. Smith leaves, you feel for the first time that you've truly helped her and that she's taken the first step toward managing her diabetes.
What's in a name?
Because the term noncompliance sounds patronizing and judgmental, many healthcare professionals use the softer term nonadherence when a patient fails to follow treatment recommendations. But this wordplay doesn't really address the issue because both words mean the same thing: disobedient. And this is a word most adults don't respond well to, based on the large literature on noncompliance. A more accurate description of noncompliance or nonadherence is two people working toward different goals.1
The solution? Acknowledge to your patient that the treatment plan isn't working. Let her know that this doesn't mean that she's a bad patient or a failure, but simply that you need to work together to find a new approach that will fit her life and goals better. As nurses, our job is not to tell patients what to do, but to collaborate with them until we develop a plan that gets better results.