Nursing people with diabetes: where is the evidence?

Evidence-based practice is being heavily promoted at the moment. However, despite strong evidence to support the medical treatment of diabetes, such as the recently published UKPDS results (UKPDS Group, 1998), there is a relatively small amount of evidence to support diabetes nursing practice.

One example of this relates to issues surrounding perceptions of best practice when commencing insulin therapy. Some DSNs start insulin in the home setting and continue to visit, often for several days, until they are sure that the individual is both confident and competent with regard to injections. Others commence insulin in an outpatient setting or a diabetes centre, and follow up the patient by telephone. In other cases, district or practice nurses commence insulin therapy. Although the outcomes may be the same in each of these situations, in relation to the individual being able to safely self-inject, there are other factors to consider.

One of these is the patient’s perspective. It is not known, for example, whether people with diabetes prefer the home environment to a hospital or surgery setting for insulin commencement. Nurses might assume that the former would be preferable, but people with diabetes could perceive that other aspects, such as time to discuss their worries about insulin or to improve their relationship with their nurses, are more relevant; the psychological ‘environment’ may be more important than the physical one.

How do we move forward?
This is, of course, only one example of diabetes nursing practice about which there are many unanswered questions. It is surely imperative that diabetes nurses try to answer these questions, particularly in the climate of evidence-based practice, and with the increased emphasis on the quality of health services (DoH, 1998).

So how do we go about doing this? Perhaps we should start with sharing more information about how and what we practise. Very often the ‘ordinary’ things we do are assumed to be done by others as well. However, my experience is that this is often not the case. 

We must also challenge our own thinking and ask ourselves if we really are doing the right things at the right time and in the right place. Undertaking an activity in a particular fashion because it has always been done like that does not necessarily make it the best or most cost-effective way to practise. Disseminating information about ‘ordinary’ practice, and the results of our reflections on that practice, is vital to ensure that all of us can potentially benefit from new insights. Of course, this sharing of clinical expertise does not by itself constitute an evidence base for practice. However, in conjunction with research evidence and patient preferences it does contribute to evidence-based decision making (Mulhall, 1998).

Paucity of research evidence in diabetes nursing practice
This raises the issue of the paucity of research evidence in relation to diabetes nursing practice. As far as I am aware there are no randomised clinical trials or systematic reviews evaluating the effectiveness of diabetes nursing interventions (but I would enjoy being proved wrong about this). Despite the existence of some qualitative work on patients’ experiences and preferences, it is questionable how many nurses caring for people with diabetes are aware of such work. Given that there may be a variety of reasons, e.g. a lack of time, for why individual practitioners often have difficulties accessing literature, e.g. a lack of time, it surely behoves at least some of us to review what is available and publish the findings in journals that are moreeasily accessible to diabetes nurses, in particular the Journal of Diabetes Nursing. This may help to spread key messages more effectively.

Of course, in an ideal world diabetes nurses would be undertaking large-scale randomised clinical trials. This may be a goal for the future, as I imagine there are few practising diabetes nurses who, at present, have the supportive infrastructure necessary to undertake such activity. However, if we work collaboratively, pooling our intellectual and physical resources, and supporting each other, the undertaking of such studies may be a reality sooner rather than later.

If we are to achieve the delivery of a first class nursing service to people with diabetes, which is appropriate, efficient and cost effective (DoH, 1998), we must take our research role seriously and begin the process of collecting the evidence to support our practice.