By Diane O’Grady
It is Friday morning and my co-worker has just called in sick. Efforts to replace her on such short notice fail. The pre-diabetes class is scheduled to start in 30 minutes and clients are already beginning to arrive. The afternoon is fully booked with individual assessment appointments. I have seven telephone messages to return, and I have been asked to see the family of a two-year-old boy who was admitted during the night.
So what do I do now?
A diabetes educator faces many challenges in helping individuals achieve glycemic control at all stages of life. To demonstrate what I mean, I will relate some of what I experience in my day to day working life in a busy diabetes education centre.
Increasing number of referrals
Diabetes clinics are flooded by a rising tide of individuals with pre-diabetes and new-onset type 2 diabetes. And there is no end in sight, as children are the fastest-growing population of obese individuals in North America. Twenty-five per cent of Canadian children are either obese or overweight.(1) This means an even greater increase in diabetes cases for years to come unless the epidemic of childhood obesity is reversed.
In the 10 years that I have worked here, our staff has doubled but the numbers of clients and new programs have more than doubled. Some of this is due to an increased focus on diabetes prevention, an excellent strategy for saving lives, preventing disability and saving the health care system millions of dollars. However, initiatives for people with pre-diabetes and diabetes emergencies, as well as residents in extended care facilities, have taken their toll on pre-existing programs. It is still possible for clients with pre-diabetes or new-onset diabetes to get an appointment at our multidisciplinary diabetes education centre within one to four weeks of referral. However, our regular follow-up program has gone from semi-annually to yearly and then to every three years (dependent on A1C), and is now in danger of further scaling down. This despite the fact that studies clearly demonstrate the effectiveness of follow-up in helping individuals maintain glycemic control over the long term.(2)
Referrals are prioritized as wait times grow. In addition, we are always looking for larger spaces to educate larger and larger groups. Where are the staff, time, money and facilities to run these worthwhile programs?
Lack of qualified diabetes educators
The insufficient number of qualified diabetes educators and the huge workloads are creating stress, resulting in increased illness and burnout. This makes it very difficult to attract, train and retain qualified educators. There is stiff competition for a dwindling number of professionals from other areas of health care as well.
Finding diabetes educators to fill casual positions is also difficult, as they may not work enough hours to keep themselves up to date. Add to that the large number who are reaching retirement age and leaving the workforce. In fact, I know of several “retired” educators who are still going in to work months and years after their official retirement simply because no replacement has been found.
Shortage of physicians
A young woman with type 1 diabetes who just moved here from another province can’t find a family physician. She was able to get a referral to the diabetes education centre through the walk-in clinic but does not have a physician with whom we can collaborate. Our medical director calls a colleague to ask if she can take her on. Success . . . this time!
The same factors that are leading to a shortage of diabetes educators apply to all health care professionals, including physicians. The ones that are left tend to be overworked and do not always have the time to screen for complications.
Progressive nature of diabetes
Mr. K. was last seen in the diabetes education centre three years ago. At that time his A1C was 6.7%. He is coming back for a follow-up visit today with an A1C of 10%.
This is a not an uncommon story; I see cases like this every day. I don’t believe the problem would have escalated the way it has if Mr. K. had received ongoing education. At this point the damage to his blood vessels may be irreversible. We must now try to prevent further damage, or at least slow the rate of progression.
As diabetes is not an episodic condition, diabetes education should not be considered complete after delivery at diagnosis. This chronic, progressive condition necessitates self- care education over the long-term.
Greater urgency to achieve glycemic targets
Mr. J., who has type 2 diabetes, calls to tell you that he was sent to the pharmacy to buy insulin and syringes. He has not been told what to do or how much insulin to take.
Mrs. R.’s insulin pre-mix has been discontinued by the pharmaceutical company. Her physician has called to ask if we can help her transfer to a new analogue pre-mix instead. He also wants us to show her how to use a rapid-acting insulin analogue to correct any above target blood glucose results.
With the regular release of new evidence-based clinical practice guidelines, physicians and clients are continually learning about new treatment targets.
Type 2 diabetes is a progressive disorder for which multiple antihyperglycemic therapies are ultimately required in order to maintain adequate glycemic control.(3) More and more people with type 2 diabetes are starting insulin therapy as endogenous insulin production decreases to a point where basal and/or bolus insulin is required.(4) Intensive diabetes treatment plans with multiple daily injections allow the client more flexibility and greater control of blood glucose; they also require intensive education and supported practice.
Pressures from the acute care system
A two-year-old child was admitted last night with new-onset type 1 diabetes. Nurses on the ward are requesting diabetes education for the parents—regular staff are unsure how to proceed.
Several telephone messages await me. One is from the ICU. Staff want me to see a post-MI patient who is being discharged today because of a lack of beds on the medical ward. He started insulin therapy four days ago and needs a review of insulin administration and help with adjustments over the weekend.
Mrs. M., a patient on the medical ward for the past week, was initially diagnosed with lupus and started on steroid therapy. She subsequently developed diabetes and her blood glucose shot up to over 20 mmol/L. She was taught insulin administration, and staff followed pre-printed orders for insulin adjustment in hospital. Now Mrs. M. needs an assessment and review of her self-care skills by the diabetes educator before going home.
There are too few diabetes educators in the acute care system, increasing the pressure on diabetes clinics. As well, acute care shortages lead to bed closures, overcrowding and “hallway nursing,” forcing patients to be discharged before receiving sufficient diabetes education. These people also swell the rising tide flooding diabetes education centres.
Carol, 32 weeks pregnant, was seen in the gestational clinic last week. She calls to tell me that her average fasting blood glucose over the past three days has been over 6 mmol/L and is rising. She does not have insulin at home.
A physician calls to say that his patient has blood sugar in the high 20s and requires insulin immediately. As he can’t be admitted to hospital because there are no beds, this person is on his way to the diabetes education centre.
Telephone calling time and emergency slots are now being booked into our daily schedules to alleviate the sheer volume of requests for our services and give us a chance to “put out the fires.”
Suzanne’s co-worker calls 911 because Suzanne has vomited several times and is complaining of nausea and abdominal pain. She also appears restless and confused. Her blood glucose is 30.0 mmol/L when paramedics arrive. When I visit her in the hospital, she tells me she thinks her last contact with our centre was in 2005.
When clients were followed up routinely, there were far fewer admissions to hospital. Now that follow-up services are being cut back, we are seeing more clients admitted to hospital with preventable diabetes emergencies. Mounting pressures from the acute care system cause even longer wait times for follow-up care . . . and the cycle continues!
New treatments and technology
Gillian, 24, has not attended a diabetes clinic for eight years and does not routinely see her physician. She wants to switch to insulin pump therapy but does not know how to count carbohydrates or assess her insulin sensitivity factor. She has never used an insulin analogue.
The principal at a local elementary school is concerned about a child in grade one. She is on an insulin pump and the parents are requesting that the aide administer correction boluses throughout the day. The principal wants a meeting with you and the parents to clarify each person’s role in the school setting.
There are three e-mail messages from clients who began insulin pump therapy on Monday. They have sent in their blood glucose data and wish to discuss adjustments to basal rates.
Donna, a retired nurse who owns a seniors’ residence, calls for instructions on helping a new resident use an insulin pen.
We welcome progress in blood glucose monitoring, oral antihyperglycemic agents, insulin analogues and insulin administration devices. Improvements in management tools such as carbohydrate counting, insulin sensitivity factors and computer-assisted decision making are also good news—but we need more educators to train clients to use them effectively.
Clients who receive specific, timely diabetes education are more likely to understand and adhere to treatment plans.(5) These are the people who will take full advantage of the new tools and therapies.
Increased awareness/searching for answers
Diabetes education centre staff are asked to set up and man a display at an upcoming health fair. A seniors’ group requests a diabetes educator to speak to their group about prevention strategies. Community nursing and extended care facility staff require in-services on diabetes care. Organizers of an annual pharmacists’ conference want to hear about diabetes education. Where are the educators to take advantage of these great opportunities?
Mrs. P., who has gestational diabetes, started insulin last week. She calls to inform me that she has stopped taking it on the advice of a relative who has been doing her own “research” on diabetes. This person has convinced her that her blood glucose targets are too low and that she will suffer hypoglycemia if she continues on insulin therapy.
Individuals with diabetes will find answers wherever they can. And if they cannot access credible sources, I worry that they will access the myths and misconceptions, many of them harmful, that abound in some of the public media.
Expanding body of knowledge
As knowledge of diabetes education and care expands, we must continually maintain and expand our own knowledge base. There are many opportunities to keep abreast of recent developments, including the annual diabetes educator conference and teleconferences. However, we often need to take advantage of educational opportunities on our own time; there is simply no way to do so during the work day. We also have to find ways to share information about the most current and beneficial therapies with clients and allied health professionals.
New approaches to diabetes education
We are challenged to find new and innovative ways to provide education and follow-up care for those individuals with diabetes who can no longer be seen routinely in traditional diabetes education centres. Several pilot projects are tying diabetes education into the Chronic Disease Management model of care so that health care resources can be pooled. Newsletters, books, public forums and seminars also play a part in educating the public, as well as health care professionals in all work settings, about diabetes prevention and care.
Staffing levels and funding remain stagnant in the face of major increases in diabetes cases in centres across the country. Other centres suffer from a reduction in funding and some are even closing altogether! To stay within existing budgets and with no increase in staffing levels, difficult decisions are being made every day regarding whom we can teach and for how long, and whom we cannot even see.
Collaboration between health care professionals such as diabetes nurse educators, dietitians, pharmacists, counselors and physicians may be the most important factor in improving disease management and long-term outcomes. We need an integrated, coordinated, multidisciplinary team approach to diabetes management that supports the client and team members across the health care system effectively and efficiently. So why do we continually suffer from inadequate funding to properly educate and care for ALL individuals with pre-diabetes and diabetes throughout their lives? I wish I knew the answer to this question!
Is it because governments do not yet realize that such an approach to diabetes education would save money, not to mention the incalculable personal costs of suffering and disability?(6) Diabetes and its complications cost the Canadian health care system an estimated $13.2 billion every year. This figure will rise to an estimated $15.6 billion a year by 2010 and to $19.2 billion by 2020.(7) Heart disease and stroke will continue to claim more and more victims as an estimated 80% of people with diabetes die as a result of these complications(7).
Challenges facing the diabetes educator are the ultimate good news, bad news scenario: dedicated educators shouldering huge and growing workloads but paying the price in stress and illness; rapid advances in medical treatment but too few educators to train clients to take advantage of them; increased awareness of the need for diabetes education but too few educators to deliver it; and urgency to meet glycemic targets but too little help for clients to achieve them.
Individually and collectively, how can we meet these challenges?
- Merrifield R. Healthy Weights for Healthy Kids. Report of the Standing Committee on Health. Ottawa, ON: Government of Canada Publishing. 2007;1-60.
- Welschen LM et al. Abstract, EASD 2007.
- Turner RC, Cull CA, Frighi V, et al. Glycemic control with diet, sulfonylurea, metformin, or insulin in patients with type 2 diabetes mellitus: (UKPDS) JSMS. 1999;281: 2005-2012.
- Canadian Diabetes. Toronto. ON: Canadian Diabetes Association. 2007:20:1.
- The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus N Engl J Med. 1993;329:977-986.
- Long-Term Cost-utility Analysis of a Multidisciplinary Primary Care Diabetes Management Program in Ontario. Canadian Journal of Diabetes. 2007; 31(3) 205-214.
- Canadian Diabetes Association Fact sheet., 2006.