Meeting the challenges posed by an escalating diabetes healthcare burden: A mixed methods study.

Background: The ongoing escalation in the incidence of diabetes is contributing to a growing burden on health services because patients with diabetes as a co-morbidity are now spread throughout the hospital (rather than being located in specific areas). Thus, there is a need for expertise in diabetes care throughout services to ensure optimal care and reduce threats to patient safety.Aims and objectives: To identify new strategies to maintain optimal care for patients with diabetes while in hospital.Design: Mixed methods underpinned by Appreciative Inquiry.Methods: The Diabetes Knowledge Questionnaire Survey (DKQS) (n = 173); focus group interviews with nurses and midwives (n = 40), and individual interviews with recently discharged hospital patients (n = 6). Quantitative data were analysed using descriptive statistics and qualitative data by thematic analysis.Results: Highlight a need to enhance knowledge and confidence of diabetes management among nursing, midwifery, medical and ancillary staff through the introduction of focused education strategies. This, together with improved communication and team work, is required to relieve the burdens on frontline nursing staff and patients caused by delays in prescribing and reviewing insulin requirements and in accessing needed food for people with diabetes.Conclusions: In seeking solutions to the challenges in caring for hospitalised patients with diabetes there is a need to work across the entire hospital workforce and to develop effective and efficient methods for ensuring appropriate skills and knowledge of diabetes management for staff across complex and rapidly changing hospital systems.Relevance to clinical practice: The introduction and implementation of innovative educational and organisational strategies are needed to assist in meeting the challenges posed by an escalating diabetes healthcare burden. The safety of patients with diabetes can be optimised with the timely availability of appropriate meals and snacks, and enhanced coordination and communication between and within multidisciplinary teams.

An integrative review of the psychosocial facilitators and challenges of continuous subcutaneous insulin infusion therapy in type 1 diabetes.

AIM: To use systematic methods to explore the psychosocial facilitators and challenges of insulin pump therapy among people with type 1 diabetes. BACKGROUND: Insulin pump therapy is now widely accepted in the management of type 1 diabetes. Given the increasing use of insulin pumps, it is timely to review the evidence relating to the psychosocial impacts of this therapy which have not been addressed in previous reviews. DESIGN: An integrative review of the literature (January 2005-February 2017). DATA SOURCES: A systematic search of electronic databases: CINAHL, Cochrane, Medline, PsycINFO and Scopus. REVIEW METHODS: Empirical literature reporting psychosocial facilitators and challenges of insulin pump therapy were eligible for inclusion. A constant comparative method was used to guide the review. Quality appraisal was performed using the Mixed Methods Appraisal Tool Version 2011. RESULTS: Thirty-five potential articles identified from titles and abstracts were reviewed. Of these, 13 articles were included in the final review. Psychosocial facilitators of insulin pump therapy included the flexibility and freedom it provided for living with diabetes, enhancing social situations and daily management. In contrast, challenges included the demands of pump therapy, self-consciousness in wearing the pump and fear of hypoglycaemia and pump failure. CONCLUSION: Findings can be used by health professionals to inform people embarking on insulin pump therapy and prepare them with regard to expectations of the treatment. Further research is required to explore the role of diabetes health professional in providing psychosocial support to people with type 1 diabetes on insulin pump therapy.

Islet Transplantation Provides Superior Glycemic Control With Less Hypoglycemia Compared With Continuous Subcutaneous Insulin Infusion or Multiple Daily Insulin Injections.

BACKGROUND: The aim was to compare efficacy of multiple daily injections (MDI), continuous subcutaneous insulin infusion (CSII) and islet transplantation to reduce hypoglycemia and glycemic variability in type 1 diabetes subjects with severe hypoglycemia. METHODS: This was a within-subject, paired comparison of MDI and CSII and CSII with 12 months postislet transplantation in 10 type 1 diabetes subjects referred with severe hypoglycemia, suitable for islet transplantation. Individuals were assessed with HbA1c, Edmonton Hypoglycemia Score (HYPOscore), continuous glucose monitoring (CGM) and in 8 subjects measurements of glucose variability using standard deviation of glucose (SD glucose) from CGM and continuous overlapping net glycemic action using a 4 hour interval (CONGA4). RESULTS: After changing from MDI to CSII before transplantation, 10 subjects reduced median HYPOscore from 2028 to 1085 (P < 0.05) and hypoglycemia events from 24 to 8 per patient-year (P < 0.05). While HbA1c, mean glucose and median percent time hypoglycemic on CGM were unchanged with CSII, SD glucose and CONGA4 reduced significantly (P < 0.05). At 12 months posttransplant 9 of 10 were C-peptide positive, (5 insulin independent). Twelve months postislet transplantation, there were significant reductions in all baseline parameters versus CSII, respectively, HbA1c (6.4% cf 8.2%), median HYPOscore (0 cf 1085), mean glucose (7.1 cf 8.6 mmol L), SD glucose (1.7 cf 3.2 mmol/L), and CONGA4 (1.6 cf 3.0). CONCLUSIONS: In subjects with severe hypoglycemia suitable for islet transplantation, CSII decreased hypoglycemia frequency and glycemic variability compared with MDI whereas islet transplantation resolved hypoglycemia and further improved glycemic variability regardless of insulin independence.

How clinical nurse and midwifery consultants optimise patient care in a tertiary referral hospital.

AIMS AND OBJECTIVES: To develop new insights into the phenomenon of clinical nurse/midwifery consultant clinical effectiveness in a tertiary referral hospital. BACKGROUND: International studies identify the pivotal role clinical nurse/midwifery consultants play in patient outcomes. There remains, however, a significant deficit in our knowledge of how these, or other advanced practice nurses and midwives, apply their extensive experience, ontological understandings and tacit knowledge to the enhancement of patient outcomes in complex healthcare environments. DESIGN: This study was underpinned by the principles of Heideggerian hermeneutic phenomenology. METHODS: Recruitment involved expressions of interest distributed hospital-wide to clinical nurse/midwifery consultants. Inclusion criteria specified a minimum of three years' experience. Fifteen clinical nurse/midwifery consultants, representing a broad range of specialties, were interviewed. Preliminary descriptive analysis of transcribed data was followed by in-depth hermeneutic analysis. RESULTS: The findings comprise four themes: walking beside the patient, anticipating the unexpected, pushing through barriers and leading within a complex system. These themes highlight how clinical nurse/midwifery consultants significantly influence pre-existing trajectories of patient care delivery through context-appropriate strategies. CONCLUSION: This study introduces new insights into the meanings advanced practice nurses and midwives develop from their engagements with patients and how these meanings inform clinical decisions. The paper accomplishes this by drawing on Heideggerian philosophical concepts such as ontological understandings, authenticity and care. It also casts light on the participants' shared understandings of how to synergise expectations within the team. RELEVANCE TO CLINICAL PRACTICE: The significance of this paper lies in the uncovering of ontological understandings and tacit knowledge of how consultant nurses and midwives optimise patient care delivery in challenging situations. The findings indicate, however, that the value of these internationally established roles is yet to be fully realised. The paper concludes by recommending strategies to assist newly appointed clinical nurse/midwifery consultants transition into these demanding autonomous roles.