Quality assessment of practice nurse communication with type 2 diabetes patients

Highlights

• We evaluate to what extent practice nurses apply self-management support elements.

• Quality criteria are used to assess how self-management support is delivered.

• Practice nurses do not apply several key elements of self-management support.

• Specific recommendations for training practice nurses in counseling are discussed.

Abstract

Objective

Nurse self-management support for type 2 diabetes patients may benefit from applying theory-based behavior change counseling. The 5As model was used to assess if, and how, nurses applied the five key elements of self-management support in standard care.

Methods

Seven practice nurses audio-recorded consultations with 66 patients. An existing instrument for assessing counseling quality was used to determine if the 5As were applied. Applied As were compared with quality criteria, to provide an in-depth assessment.

Results

In almost every consultation, nurses assessed health behaviors, and arranged a follow-up meeting. However, nurses advised behavior change in less than half of the consultations, while setting goals and assisting patients to overcome barriers were used even less. Comparing applied As with quality criteria revealed several issues that could be improved.

Conclusion

Nurses consistently discussed health behaviors with patients, but important elements of self-management support were not applied.

Practice implications

Self-management support may benefit from training nurses in performing assessments that form the base for specific advice, setting goals, and addressing barriers to behavior change. Nurses also have to learn how to combine being medical expert and behavioral counselor. Clarifying both roles to patients may facilitate communication and establishing a collaborative relationship.

Introduction

Patients with type 2 diabetes mellitus (T2DM) need to control their blood glucose level, blood pressure and lipid levels in order to minimize their increased risk for heart disease and other complications [1]. However, less than 20% of T2DM patients reach all three clinical targets [2], and more than one third of patients do not reach glycemic control [3], [4]. Besides adhering to medical prescriptions, self-managing clinical risk factors require patients to (simultaneously) change to a healthier diet and be more physically active, ideally leading to weight loss [5], [6]. Diabetes self-management through changing health behaviors is often challenging for patients, because it is their habitual unhealthy lifestyle that has contributed to the development of T2DM [7], [8], [9].

With T2DM mainly being treated in primary care, the practice nurse or diabetes specialist nurse is the main caregiver providing self-management support and health behavior change counseling to T2DM patients [10], [11], [12]. Even though diabetes care is equally effective when it is transferred from physicians to nurses [13], nurses often struggle with health behavior change counseling because of several communication barriers, and a lack of effective communication skills training [14].

In The Netherlands, T2DM patients commonly visit their practice nurse every three months to discuss, among other topics, their wellbeing, glycemic control and lifestyle change. Nurse consultations generally consist of a physical examination, during which blood glucose, blood pressure, lipid levels, and/or weight (BMI) are measured, providing clinical outcomes that are taken into account when discussing past and future health behaviors [15]. The physical examination may set the stage for a biomedical approach, where central communications methods comprise advise giving and communicating risks of non-adherence to recommendations [16], [17]. Self-management support, however, requires a patient-centered approach from a biopsychosocial perspective, which entails being responsive to patient preferences, needs, and values [18], [19]. Unfortunately, nurses may feel non-confident and experience conflict between their role as a medical expert and patient-centered counselor [20]. Training nurses in patient-centered communication does not seem effective in overcoming these issues [14].

Besides taking a patient-centered approach, effectiveness of behavior change counseling may benefit when based on behavioral theory and evidence [14]. Originally developed for smoking cessation counseling [21], the 5As model is an example of an evidence-based counseling model, suitable for application in busy health service environments, and not requiring sophisticated skills or experience [22]. The 5As refer to Assess current risk behaviors, Advise behavior change, Agree upon clear goals for behavior, Assist in addressing barriers and securing social support, and Arrange follow-up contact [23]. Across diverse populations and health behaviors, use of the 5As is associated with change in health behaviors and determinants thereof [24], [25], [26]. Because the 5As model covers the key elements of self-management support, it presents a unifying conceptual framework for evaluating and implementing behavioral change counseling interventions in primary care [27], including diabetes care [23], [28]. Our purpose is to use the 5As model as a tool for evaluating the quality of practice nurse communication.

Often, nurses have received training in behavior change counseling, and therefore it is expected that standard counseling practices reflect, to varying extent, the 5As. However, to our knowledge, no studies have assessed nurses’ use of the 5As in counseling T2DM patients, which is therefore the focus of the current study.

It not only matters if the 5As are applied, but also how they are applied. Specifically, it is recommended that the 5As are used as an integrated sequence, and in collaboration with the patient. A second aim is, therefore, to analyze how the 5As are used, based on criteria that have been formulated for the application of each A [23], [24].