Availability and Provision of Self-management programmesSelf-management plays a key role in treatment of diabetes because on average patient spends 3 to 4 hours with a clinician in an entire year. For the rest of 8,747 hours they are managing their condition themselves. Anna will only be able to self-manage her condition if she and her family or carer receive an evidence-based well-structured type 2 diabetes self-management education. NICE states that an effective structured diabetes education programme is evidence-based and is tailored to the needs of the patient. The programme has specific goals and learning objectives and helps patient and their carer in adopting beliefs, knowledge, skills and attitude to self-manage their condition. The programme is quality assured and revised by trained, independent and competent assessor. Finally, the outcome of the programme is audited frequently.Currently NHS provides evidence-based and well-structured self-management education programmes for both type 1 and type 2 diabetes. The self-management programmes, if delivered properly, helps patient to remain healthy, live well and prevent costly and dangerous complications. To begin with, there is a need for Anna to gain knowledge, skills and have the confidence and motivation to take care of her diabetes. Diabetes Education and Self-management for ongoing and newly diagnosed (DESMOND) is a self-management diabetes programme developed by NHS. The programme is designed to support the patient in becoming expert in effective management of their diabetes. DESMOND educators are trained by the NHS and their aim is to empower diabetes patients to make their own decision. By attending in this programme, Anna will learn current information about type 2 diabetes as well as practical skills to help her manage her diabetes and weight. By attending DESMOND programme, Anna can talk about all aspects of her condition, including, medication, diet and exercise. Anna will also get a chance to meet and talk with other people who also have diabetes. DESMOND programmes are designed to be friendly and informal and patient can bring their family members with them if they want. Thus, Anna can bring her family members to raise their awareness about self-management of diabetes so that they can better support her. After completion of DESMOND Anna will have some knowledge and skills about self-management and these knowledge and skills can further be reinforced by her clinician during their consultations. Furthermore, clinician can offer Anna the choice of one to one consultation or a group consultation.Moreover, there is support available to help Anna adapt to a diet which will help her lose weight. Her clinician can refer Anna to a registered dietician to help her with creating a diet programme which helps Anna achieve better weight loss and HbA1c level. Anna will benefit from a low energy, carbohydrate and fat diet. Both low carbohydrate and low-fat diets are linked with an estimated 8 kg weight loss in six months compared to no diet. A very low energy diet programme can also be used as a part of weight management program; however, it should not be used in the long term because it can lead back to weight gain. Anna’s clinician and family should encourage Anna to increase consumption of wholegrain, vegetables, fruits and other foods which are high in fibres. Clinician should encourage Anna to increase ‘five a day’ diet. ‘Five a day’ is a campaign which encourage people to eat at least five portions of vegetables and fruit and it is associated with lots of health benefits and reduction in cardiovascular diseases, hypertension and diabetes. Finally, regular physical exercise also plays a key role in diabetes therapy. Therefore, it is important to encourage Anna to start regular physical exercise. Anna’s clinician can refer her to a professional personal trainer to devise a physical exercise programme which will take her diabetes, blood pressure, age, weight and personal circumstances into consideration. Limitation of current clinical practiceThe current therapy for type 2 diabetes focuses on keeping blood glucose low and stable. This has to be achieved via a combination of adhering to a healthy diet, regular exercise and taking diabetes medication. However, the vast majority of the patients do not achieve the target set for them. Less than 20% of type 2 diabetes patients achieve targets for HbA1c, blood pressure and lipids levels. Adopting to a new diet is often the difficult part of self-management. Regular physical exercise is equally as difficult for diabetes patients since many of them are used to a less active lifestyle. Adhering to medication is also a challenge – a study has reported that roughly 40% of patients take less than 85% of their medication. Various studies have looked into how to improve HbA1c level. However, these studies have focused on intensifying pharmacological therapy instead of focusing on psychological and social elements which cause effective and sustainable behaviour changes in type 2 diabetes.Mostly GPs and nurses provide self-management education. In nurse consultation, patients HbA1c, BMI, blood pressure and BMI are measured, and the results are discussed and compared with past measurements. The health behaviours of the patient such as diet, exercise, alcohol consumption, smoking and medication are discussed. Hence, the practice nurse acts both as a diabetes and lifestyle educator and medical expert on diabetes. Nurses are also given the responsibility to communicate with patient in such a manner that results in patients changing their behaviour, resulting in better clinical outcomes. Nurses use communication skills based on psychological theories of behaviour change to alter their patient’s behaviour. Despite the possible benefits of good communication to improve patient’s health, in reality it is very hard to persuade a patient to alter deep-rooted lifestyle habits. Thus, it is hard for nurses to change the behaviour of the patient to adopt a new lifestyle which will help them better manage their diabetes. Barriers to effective communicationThere are several obstacles for a useful communication during consultation between clinician and patient. From clinician viewpoint, the most common cited challenge to an effective self-management communication is time. A study has found that that the time clinicians spend talking self-management with patient was between 1 to 17 minutes which is not enough for an effective self-management communication. Furthermore, Lack of collaboration between clinician and patient, lack of access to resources by patient and lack of psychosocial support for diabetes patient was major barriers to an effective self-management communication. A different study revealed that clinicians feel they have not received adequate training to tackle psychosocial issues of the diabetes patients. This results in clinicians feeling frustrated and overwhelmed within the clinician-patient relationships which can be a barrier for an open self-management communication. Another barrier to effective communication reported by nurses are having difficulties developing action plans and not understanding how to adjust communication to the patient’s stage of change, which can be interpreted as low self-efficacy in relation to helping patient self-management activity. Loss of motivation by nurses is another limitation of the current clinical practice. Nurses feel powerless by repeatedly giving patients the same advices but not seeing any improvement in patient’s health – this can lead to loss of motivation. Nurses like to be seen as experts and the information they provide should be regarded as reliable and valuable. However, their expert role clashes with keeping a patient-centred approach during their consultation. They do not feel comfortable when they switch their role from expert to a facilitator of the patient’s behaviour change process.For patients, barriers for an effective self-management communication is different than that perceived by clinicians. A study found out that 30% of diabetes patients were reluctant to talk about self-management because they feared being judged or shamed for their weight and food intake or disappointing their clinicians. Patient who suffer from depression, which is common amongst diabetes patients, will be less interested talking about their problems during consultations. A different study reported that patient can feel overwhelmed during consultation by the amount of information they are given during self-management consultation. The study compared how much of the information patient remember compared to how much information clinicians provides. The study revealed that 31% to 71% of information is forgotten by patient. Many patients felt embarrassed during their weight or waist measurement, and this caused communication barrier between patient and nurse because the patient trying to evade the subject of overweight, diet and exercise.
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