Managing Diabetes: The Nurse Practitioner’s Role
Diabetes has reached epidemic levels in the US, making successful management a high priority in a health care system struggling to simultaneously improve care and lower costs. Ideal diabetes management places nurse practitioners (NPs) at the center of a team of clinicians, each with an equally important role to play, because NPs have training in all of these roles.
Like our physician colleagues, we have learned to diagnose, develop a plan of care and prescribe treatments. Like our RN and dietitian colleagues, we are expert in administering treatments, teaching patients self-management and maintaining close communication between visits. At different times, in different settings, we might apply some or all of these skills, depending on scope-of-practice laws and the policies and practices of each particular clinic, but having all of these skills at our fingertips makes us uniquely well suited to overseeing the management of this chronic illness.
It Begins with Trust
Perhaps our most important skill is the ability to build a trust-based relationship with the patient and the patient’s defined support system.
This is important clinically – and was underscored by the landmark Diabetes Control and Complications Trial of the mid-1990s – because so much of effectively managing diabetes is behavioral. Trust, therefore, is essential because behavioral interventions depend on patients revealing their daily successes and struggles living with and managing a very complicated and relentless chronic disease.
Once we understand the importance of trust, it shifts how we think about intervening. Sensitive, nonjudgmental empathy is crucial, because the patient’s process is often fraught with self-judgment as he or she struggles to achieve desired glucose, weight loss, exercise and other goals. There is often the sense among patients that they could be doing better. Sometimes this self-judgment manifests as defensive behavior; sometimes it borders on self-loathing; but there is often shame and blame in trying to manage their illness.
Another way to think about the patient’s challenges is to remember that while diabetes is manageable for most people, it exacts an enormous psychological burden on those who must deal with it day after day, month after month, year after year.
Thus, helping patients and families develop positive coping skills sometimes means simply being human and listening compassionately to their grief. Even as we directly manage patient’s biological illness, we have to remember to constantly draw on the part of our training where we learned to help patients cope with their illness by understanding their challenges and family dynamics.
Relationship Building for Behavioral Change
What does all this mean, specifically, in practice? From the outset, not only must we take a good medical, family and social history and discern the current treatment plan (including current medications and frequency of glucose monitoring), but it is also of utmost importance to know:
- How the patient and family have coped with other major stressors in their lives
- Their experience with diabetes before they or their child was diagnosed with it (e.g., did they have a family member who died secondary to diabetes complications)
- Their level of confidence in their ability to manage diabetes
- Their greatest current challenge with diabetes
The last question is especially important, and we should ask it at every visit, because the challenges change frequently. A family can be sailing along and then hit a rough patch.
For example, during childhood diabetes is never stable, and during normal adolescence many teens don’t want to deal with their condition. A teenager might say, “I don’t want to check my blood,” and often parents struggle to apply their usual parenting approaches, because they feel sorry for their child and hesitate to reinforce the rules the same way they would if the child refused to do his or her homework. This can cause some very difficult family dynamics.
That’s why the NP’s skill at building trust and counseling parents is critical. It’s why I don’t go straight to blood sugar management when I meet with families. In general, I don’t have families open the logbook – the blood sugar record – until the end of the visit. I first find out how they’re doing, so I can help them understand and work through changes in both the disease and their relationships.
This involves not only asking questions and listening, but also giving families realistic expectations about the uniquely dynamic nature of diabetes in the context of child development. Effective two-way communication is part of building the relationship, and this often involves drawing on what we know about approaches such as motivational interviewing, problem solving and family negotiation.
Communication and Teamwork
Last but not least, communication extends to working effectively at the center of team-based care. Sometimes this can mean ensuring that everyone involved is clear on the patient’s status and next steps, but it can also mean understanding when we need – and how best – to consult with a physician on difficult medical cases, such as when a child requires excess insulin, which may indicate other metabolic disorders or something esoteric on the medical side. How often to consult with a physician depends on experience, but a beginning NP will likely ask for consultation frequently.
The point is that each role is important – from the medical assistant triaging a child, to the RN or dietitian trying to teach a family about diabetes, to the endocrinologist or NP fine-tuning the insulin regimen. It is our responsibility to use our intimate understanding of all these roles to maximize the efficacy of the entire team so that we help patients and families live the full and rewarding lives they deserve.
Note: Maureen McGrath and the idea of training nurse practitioners to manage diabetes were highlighted at NBC Los Angeles on April 7, 2013.