About 25.8 million Americans are diagnosed with diabetes and 90-95% of cases are type 2 or non-insulin dependent (CDC, 2012). Diabetes mellitus is a very complex illness brought about by the interplay of genetics and unhealthy lifestyles and affecting multiple organ systems (Strayer & Schub, 2012). It is one of the leading etiologies of stroke and cardiovascular disease and thus remains a significant cause of morbidity. A complex etiology requires equally complex management focusing on better lifestyles, adherence to medications and self-monitoring one’s health status. Patient education is then an indispensable component of care and must be supported by research evidence which guarantees the achievement of optimal health outcomes.
Evidence-based practice means being conscientious and judicious in using the best evidence when making patient care decisions (The EBP process, 2010). Nurses need to utilize their clinical expertise in appraising and applying best evidence to specific patient situations. Adherence to EBP reflects strong accountability in the rendering of nursing care, an underlying value in today’s health care system reforms. EBP allows nurses to provide high-quality, safe and cost-effective care. For instance, limited time and resources make the group setting a more practical way of rendering adult patient education services compared to the traditional one-on-one interaction. This begs the question as to the evidence base supporting group-based patient education among type 2 diabetes patients.
A search in the Cochrane Library yields an intervention review by Deakin et al. (2009) which provides a comprehensive EBP perspective on group-based education applicable to the chosen population. The review entailed a literature search, retrieval and selection of 11 randomized controlled trials (RCTs) as well as controlled clinical trials (CCTs) based on selection criteria. The aim of the review was to determine the clinical (diabetes control, blood pressure, weight, triglyceride level), psychosocial (empowerment, quality of life, satisfaction with treatment) and lifestyle (knowledge of diabetes, self-management skills) outcomes among participants in these trials in comparison with either a control group, routine treatment or no intervention (Deakin et al., 2009).
The selected studies had a minimum of 6 adult participants, inclusive or exclusive of patients’ friends and family. The total number of participants involved in the review was 1,532 representing populations in European countries and the U.S. Majority were Caucasians and a small proportion was composed of South Asians and Mexican Americans (Deakin et al., 2009). The programs were based on patient-centered education models or concepts such as patient activation, therapeutic patient education and empowerment. Hence, their aim was to develop self-management skills, self-empowerment or self-efficacy. The interventions were administered by trained nurses, physicians, physician assistants, dieticians and lay health personnel. Follow-ups of outcomes were done at least 6 months following patients’ attendance to a session.
Results of the review’s meta-analysis showed that participation in group-based education was associated with improved glycated hemoglobin and fasting blood glucose, laboratory values indicative of better diabetes control (Deakin et al., 2009). The group approach was shown to be more effective in this regard than intensive one-on-one. This is a highly significant outcome considering that a reduction in glycated hemoglobin by just 1% can translate to a 21% reduction in the risk for secondary complications such as cardiovascular disease (Syed & Khan, 2011). Group-based education was also found to improve patient knowledge about diabetes in the short and long-term. Patient knowledge was measured using validated questionnaires. In both of the above outcomes, more than one yearly session resulted in longer-term outcomes lasting 2-4 years (Deakin et al., 2009).
Though the evidence is not as strong, group-based education was also found to reduce patients’ needs for drug therapy. It is projected that out of every five patients, one will successfully attain this outcome (Deakin et al., 2009). The intervention review further revealed some evidence that group-based education for type 2 diabetic adults can potentially lead to small decreases in body weight and short-term reductions in blood pressure as well as triglyceride levels. The meta-analysis also generated some evidence that group-based education as an intervention can enhance patient quality of life, self-management skills, empowerment and patient satisfaction with care (Deakin et al., 2009). However, more studies are needed to validate these findings.
The guiding principles of the National Standards for Diabetes Self-Management Education underscores the above study findings when it stated that there is no best approach to educating patients but that the effectiveness of group education is already accepted based on a growing body of evidence (Funnell et al., 2010). While the traditional one-on-one approach consumes a lot of time and resources in a period when type 2 diabetes has reached epidemic proportions, the method of delivery also presents a barrier in improving self-management and resulting outcomes (Steinsbekk et al., 2012). Traditional diabetes education is mainly delivered through lectures and often fails to address patients’ psychological, social, cultural and emotional concerns with self-management.
On the other hand, the findings of the intervention review discussed shows that group-based education, especially when it utilizes a patient-centered framework, promotes the participation of friends and family allowing them to serve as effective patient support systems. Programs within this framework also incorporate cultural sensitivity in the design and meet client needs for social interaction with patients having the same chronic illness. Coupled with effective facilitation that targets behavior change, group-based education promotes learning that is empowering and motivating which can translate to improved and sustained self-management knowledge and skills. This, in turn, contributes to better clinical outcomes and possibly lifestyle and other psychosocial outcomes as well.
References
Center for Disease Control and Prevention (2012, Sept. 6). Basics about diabetes. Retrieved from http://www.cdc.gov/diabetes/consumer/learn.htm
Deakin, T.A., McShane, C.E., Cade, J.E., & Williams, R. (2009). Group based training for self-management strategies in people with type 2 diabetes mellitus (review). Cochrane Database of Systematic Reviews, 2009(1), 1-91.
Funnell, M.M., Brown, T.L., Childs, B.P., Haas, L.B., Hosey, G.M., Jensen, B., Weiss, M.A. (2010). National standards for diabetes self-management education. Diabetes Care, 33(Supplement 1), S89-S96.
Steinsbekk, A., Rygg, L., Lisulo, M., Rise, M.B., & Fretheim, A. (2012). Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus: A systematic review with meta-analysis. BMC Health Services Research 2012, 12(213), 1-19.
Strayer, D.A., & Schub, T. (2012). Diabetes mellitus, type 2. California, CA: CINAHL Information Systems.
Syed, I.A., & Khan, W.A. (2011). Glycated haemoglobin - a marker and predictor of cardiovascular disease. Journal of the Pakistan Medical Association, 61(7), 690-695.
The EBP process (2010). Retrieved from http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm
