INTRODUCTION
Scotland faces an increased prevalence of diabetes and other chronic diseases which necessitates health promotion activities (Department of Health, 2006). Helping people to lead a healthier and longer life is one of goals of the Healthcare Quality Strategy for NHS Scotland (HQSN) (Scottich Government, 2010). The strategy was developed in order to ensure that patient care is person-centred, safe and effective.
Finding ways to improve individual lifestyle can be a challenging task yet the nurse's involvement was found to have a positive impact on health outcomes (DeKleijn, 2008). The assignment reflects on my involvement in health promotion in order to improve the quality of patient care which the HQSN postulates. I use the Driscoll (1994) framework for the critical evaluation. It has a simple structure and unlike the other models it does not suggest that reflection is a cyclical process with step-by-step stages. According to Jasper (2003) this model requires movement from the theory to action based in experience.
WHAT?
During my community placement I spent one day with a diabetic nurse and participated in a diabetic reviews. One of them was particularly memorable as I joined the nurse in her health promotion activities. For the purpose of this assignment I use a pseudonym 'Mrs Brown' to protect the patient confidentiality, in accordance with the Data Protection Act (1998).
Mrs Brown was a 64 years old lady with type 1 diabetes who came to discuss her diabetes management. The doctor suggested the increase of insulin but Mrs Brown was reluctant to do this. She was overweight and insulin can cause weight gain although the causes are still unclear (Russel-Jones and Khan, 2007). One way of solving the problem is increasing insulin sensitivity through proper diet and exercise (Miles, 2007), and Mrs Brown was determined to achieve her goal through dietary restrictions.
Developing a healthier lifestyle is an integral part of diabetes management (Mellor, 2012). Excess body weight, particularly in the abdominal area, is linked to diabetes, and a healthy diet may help to maintain the appropriate BMI (Coe, 2010; Thornton, 2009). There is also evidence of significant reduction in glycated haemoglobin (HBA1C) with the weight loss (SIGN, 2010). Yet focusing on a healthy diet proved difficult for Mrs Brown because of a
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stressful period in her life. Her own suggestion was a diary of food intake. She felt it could help her to control overeating which is supported by some evidence (Davies, 2008).
Mrs Brown was focused exclusively on dietary interventions while the evidence suggests both diet and exercise in diabetes management and weight control (Coe, 2010; Plotnikoff et al, 2010). Exercises increase peripheral muscle glucose intake and may have an effect on genes specific to diabetes and obesity - therefore can be the right solution for people struggling to control diet (Annan, 2011 ;Clancy and Nevell, 2011). Although there is conflicting evidence about the benefits of exercise on glycaemic control in type 1 diabetes, physical activity can help to lose weight and improve mood (Annan, 2011; Madden, Loeb and Smith, 2008; Miles, 2007). Therefore I concentrated my health promotion attempts on encouraging Mrs Brown to be more physically active.
SO WHAT?
Participating in health promotion activities was my contribution to one of the HQSN goals which is shifting focus from cure to prevention. Diabetes can lead to a number of macro-vascular and microvascular complications and the risk may be mimimised by changes in lifestyle (Hill, 2011). I felt I had the evidence-based knowledge to join the diabetic nurse without undermining her efforts. The challenging part was to develop a rapport with Mrs Brown during a one hour session and turn figures, polices and recommendations into a meaningful message that would fit into her life and preferences. Preaching and patronising goes against the professional requirement of respect for the person, and against the ethical principle of autonomy; it is also ineffective. Self-care and empowermente were found to improve compliance, self-efficacy and blood sugar levels therefore individualised interventions are recommended by the guidelines (Coe, 2010; Davies, 2006; Lambe, Connoly and McEvoy, 2008; National Institute for Health and Clinical Excellence, 2011; Scottish Intercollegiate Guidelines Network , 2010).
An individualised intervention proved to be a difficult task. Nurses are professionally and legally bound to provide health advice and information as part of their duty of care but there is always the risk of imposing societal rather than personal goals (Redman, 2008). I felt the pressure to steer Mrs Brown towards the targets of 150 min of physical activity per week and 300 min for people wanting weight loss (Scottish Government, 2008; World Health Organisation,2010). I was not sure how to achieve the intervention aims while
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respecting Mrs Brown's personal choices.
It helped that I felt a lot of respect for Mrs Brown. It must have been difficult to live with type 1 diabetes for twenty years. It is the diabetic patient who has to deal with the conflict between personal goals and the demands of diabetes (Watts, O'Hara and Trigg, 2010). Despite difficulties Mrs Brown was motivated and it helped me to let my expectations go and try to learn instead how it feels to live with diabetes. I think I contributed to the HQSN goal of compassionate care by turning the health promotion into an empathetic dialogue. Research suggests that patients expect understanding, sympathy, an opportunity to talk and to be acknowledged for their expertise (Escudero-Carretero et al, 2007). They also prefer dialogue between two adults to an uneven relationship between the nurse and the patient (Persson and Friberg, 2009). I discovered for myself how a simple chat allowed me to build a relationship and then turn the conversation to more important matters. Chatting helped me to discover that fears of straining a knee after replacement surgery contributed to Mrs Brown's reluctance to exercise. I used my experience from placement in the orthopaedic ward to provide reassurance and steered the conversation towards some exercises or activities that Mrs Brown might enjoy and easily fit into her daily life. Mrs Brown chose stretching exercises and walking. Walking is particularly promising as it increases fitness, helps to decrease body weight and blood pressure, and is acceptable for people who are inactive (Darker et al, 2010).
My health promotion activities were definitely successful for myself. The public expects nurses to be role models for healthy behaviours but studies suggest that 24% of nurses are overweight, 47% are not physically active 73% do not eat the recommended 5 portions of fruit and vegetables per day, 40% are binge drinking and 17% are smokers (Blake and Harrison, 2013). I contributed to this poor record as in the last year I neglected all my physical exercises and relied too much on fast food. I felt so ashamed of being a hypocrite in promoting a healthy lifestyle that it gave me the strength to improve my diet and come back to my exercise routine.
It is difficult to evaluate the outcome of a single health promotion activity but I hope that the nurse's and my interventions worked for Mrs Brown. She was motivated and lack of motivation is the main obstacle in successful diabetes management (Oftedal, Karlsen and Bru, 2010). However, lifestyle changes are a long-term process and the patient requires
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time to think it over instead of being rushed into it (Broberck et al, 2011). It was a lesson for me in listening, compromising and using chat and sense of humour to build rapport. It was also a lesson in team work with the specialist nurse which made me feel more confident about my abilities.
I think that both the nurse and I managed to avoid the ethical trap of paternalistic attitude. The diabetes nurse acted as Mrs Brown's advocate, and supported her in her decision against the doctors suggestions. She also strengthened Mrs Brown's motivation by giving praise for bringing down glycated haemoglobin. I managed to turn Mrs Brown's attention to physical activities she could enjoy doing. Mrs Brown was actively participating in her own plan of care and making all decisions. By empowering her we contributed to HQSN goal of personalised care and shared decision making in order to achieve the best possible outcomes.
I felt, however, that we missed some important clues Mrs Brown was giving about the unhealthy lifestyle of her husband. Chronic illness has an impact on the whole family therefore carers and family should be involved in diabetes education to encourage support and understanding (Eggenberger et al, 2011; SIGN, 2010; Thornton, 2009). I also never thought about group activities like walking groups. Women in particular tend to enjoy society support and group meetings (Ferrand, Perrin and Nasarre, 2008) so Mrs Brown could have benefited from such suggestions.
AND WHAT
Meeting Mrs Brown has increased my confidence in my health promotion abilities. I think that from now on I will try more to motivate people towards a healthy lifestyle. I will do it not by preaching but through chat, careful listening and with respect for the patient's autonomy and choices. Next time I will also remember about the patient's social context and the power of group support.
Participating in health promotion gave me the strenght to come back to a more healthy lifestyle myself. I felt that to be honest with the patients as postulated by the professional codes of conduct (NMC, 2008) I had to be honest with myself. Therefore I will strive to improve my healthy lifestyle before I make any attempts to change the lifestyle of others.
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CONCLUSION
The assignment reflected on my contribution to HQSN aims through delivering health advice to a diabetic patient. Although I was confident in my evidence-based knowledge the task proved difficult as it required individualised approach, skilled communication and acknowledging other people involved, like Mrs Brown's husband. The experience also made me consider the moral right of promoting a healthy lifestyle by a student nurse who is not living up to it herself.
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REFERENCES
Annan, F. (2011) The connection between better health and execrice in diabetes. Practice Nursing. Vol. 22 (1), pp. 17-20.
Blake, H. and Harrison, C. (2013) Health behaviours and attitudes towards being role model. British Journal of Nursing. Vol. 22 (2), pp. 86-94.
Brobeck, E., Bergh, H., Odencrants, S. and Hildingh, C. (2011) Primary care nurses' experiences with motivational interviewing in health promotion practice. Journal of Clinical Nursing. Vol. 20 (23-24), pp. 3322-3330.
Clancy, J. and Nevell, C. (2011) Diabetes and obesity: perspectives of the nature/nurture debate. Primary Health Care. Vol. 21 (3), pp. 31-38.
Coe, S. (2010) Nutrition related to obesity and diabetes as a public health issue. Nurse Prescribing. Vol. 8 (8), pp. 376-381.
Darker, C., French, D., Eves, F. and Sniehotta, F. (2010) An intervention to promote walking amongst the general population based on the 'extended' theory of planned behaviour: a waiting list randomised controlled trial. Psychology and Health. Vol. 25 (1), pp. 71-88.
Davies, K. (2006) What is effective intervention? - using theories of health promotion. British Journal of Nursing. Vol. 15 (5), pp. 252-256.
Davies, T. (2008) The obesity epidemic – a holistic approach. Journal of Community Nursing. Vol. 22 (12), pp. 18-20.
Data Protection Act (1998) [Online] Availanle: http://www.legislation.gov.uk/ukpga/1998/29/
contents [Accessed: 4 March 2013].
De Kleijn, A. (2008) Health Improvement through dietary management of type 2 diabetes. British Journal of Community Nursing. Vol. 13 (8), pp. 378-383.
6
Department of Health (2006) Our Health, Our Care, Our Say: a New Direction for Community Services. London, HMSO.
Driscoll, J. (1994) Reflective practice for practise – a framework of structured reflection for clinical areas. Senior Nurse. Vol. 14 (1), pp. 47-50.
Eggenberger, S., Meiers, S., Krumwiede, N., Bliesmer, M. and Earle, P. (2011) Reintegration within families in the context of chronic illness: a family health promoting process. Journal of Nursing and Healthcare of Chronic Diseases. Vol. 3 (3), pp. 283-292.
Escudero-Carretero, M., Prieto-Rodrigues, M., Fernandez-Fernandez, I. and March-Cerda, J. (2007) Expectations held by type 1 and type 2 diabetes mellitus patients and their relatives: the importance of facilitating the health-care process. Health Expectations. Vol. 10 (14), pp. 337-349.
Ferrand, C., Perrin, C. and Nasarre, S. (2008) Motives for regular physical activity in women and men: a qualitative study in French adults with type 2 diabetes, belonging to a patients' association. Health and Social Care in the Community. Vol. 16 (5), pp. 511-520.
Hill. J. (2011) Diabetes monitoring: risk factors, complications and management. Nurse Prescribing. Vol. 9 (3), pp. 122-130.
Jasper, M (2003) Beginning Reflective Practice. Cheltenham: Nelson Thornes Ltd.
Lambe, B., Connoly, C. and McEvoy, R. (2008) The determinants of lifestyle counselling among practice nurses in Ireland. International Journal of Health Promotion and Education. Vol. 46 (3), pp. 94-99.
Madden, S., Loeb, S. and Smith, C. (2008) An integrative literature review of lifestyle interventions for the prevention of type 2 diabetes mellitus. Journal of Clinical Nursing. Vol.17 (17), pp. 2243-2256.
Miles, L. (2007) Physical activity and health. Nutrition Bulletin. Vol. 32 (), pp. 314-363.
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National Institute for Health and Clinical Excellence (2011) Preventing Type 2 Diabetes: Population and Community Interventions. London: NICE. [Online] Available: http://guidance.nice.org.uk/PH35 [Accessed: 19 April 2013].
Nursing and Midwifery Council (2008) The NMC Code of Professional Conduct: Standards for Conduct, Performance and Ethics. London: NMC.
Oftedal, B., Karlsen, B. and Bru, E. (2010) Perceived support from healthcare practitioners among adults with type 2 diabetes. Journal of Advanced Nursing. Vol. 66 (7), pp. 1500-1509.
Persson, M. and Friberg, F. (2010) The dramatic encounter: experiences of taking part in a health conversation. Journal of Clinical Nursing. Vol. 18 (4), pp. 520-528.
Plotnikoff, R., Lippke, S., Courneya, K., Birkett, N. and Sigal, R. (2010) Physical activity and diabetes: An application of the theory of planned behviour to explain physical activity for type 1 and type 2 diabetes in an adult population sample. Psychology and Health. Vol. 25 (1), pp. 7-23.
Redman, B. (2008) When is patient education unethical? Nursing Ethics. Vol. 15 (6), pp. 813-820.
Russel-Jones, D. and Khan, R. (2007) Insulin-associated weight gain in diabetes – causes, effects and strategies. Diabetes Obesity Methabolism. Vol. 9 (6), pp. 799-812.
Scottish Intercollegiate Guidelines Network (2010) Management of diabetes. A National Clinical Guideline (116). Edinburgh: SIGN.
Scottish Government (2008) Healthy Eating, Active Living. An Action Plan to Improve Diet, Increase Physical Activity and Tackle Obesity. Edinburgh: The Scottish Government.
Scottish Government (2010) The Healthcare Quality Strategy For NHS Scotland. Edinburgh: The Scottish Government.
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Thornton, H. (2009) Type 1 diabetes, part one: An introduction. British Journal of School Nursing. Vol. 4 (5), pp. 223-227.
Watts, S., O'Hara, L. and Trigg, R. (2010) Living with type 1 diabetes: A by-person qualitative exploration. Psychology and Health. Vol. 25 (4), pp. 491-506.
World Health Organisation (2010) Global Recommendations on Physical Activity for Health. Geneva: WHO.