The dilemma of providing choice

I attended a session at the recent Diabetes UK Annual Professional Conference during which discussions about appropriate insulin regimens for people with diabetes occurred and, as one does, compared our practice with others’. One of the people close by said that about 95% of her patients used one particular device because it was easy for health professionals to teach patients to use it; by implication this saved time.

My initial reaction was one of surprise, mainly because I had assumed that most diabetes health professionals would ensure that people with diabetes had their insulin regimens and delivery devices determined by individual preferences and needs. However, this reaction led me to challenge my assumption and to reflect again on the issue of choice in the context of an ever-increasing workload and limited resources.

The importance of choice
Our unit, like others, is under increasing pressure to develop new services as well as new ways of delivering those that already exist. For example, we have recently started a ‘pump’ service and are exploring group education. While this is occurring the diabetes nursing team continue to provide an insulin conversion programme. Our philosophy has always been that individual choice in relation to the delivery device used is important, for various reasons.

However, it could be argued that making time to ensure the provision of choice is not efficient; more people could be started on insulin earlier if we could teach them how to use the device in groups, for instance. One consideration to be taken into account is the speed at which insulin conversion takes place, once the decision to do so has been reached. It can be difficult for people with diabetes to wait for relatively long periods of time for ‘the needle’ in a state of trepidation, and timely interventions are as much an aspect of quality care as choice.

Conflicting aspects of quality care
At this point my reflections have reached the stage of confusion! When should a philosophy of care, with passionately held beliefs, override practicality, for instance? Is it appropriate to prioritise one aspect of care rather than another?

We could turn to the notion of best practice to help us sort our dilemma of conflicting aspects of quality care. Best practice would be to use existing research to help answer this question; however, I’m not sure we know whether people with diabetes rate choice above timeliness or vice versa. Even if we had an answer to this question, individuals do not always hold the majority view – some may prefer to wait a little longer to ensure they have access to all possible choices and others would prefer to get things done quickly!

Thinking outside the box
One diabetes team has arrived at another solution for the dilemma of giving choice in relation to insulin delivery devices – in Portsmouth, people with diabetes are issued with a bag of pens and so forth and take it away to ‘play’ with, rather than being taught about them. They come back to continue the conversion process, having made their choice with no inadvertent influence from health professionals. This is an example of ‘thinking outside the box’ and the result is that neither stance – timeliness or choice – is compromised.

What I have gained from one small comment, and my subsequent reflections on it, is a confirmed view that sharing opinions and ideas can only be beneficial in stimulating ideas and alternative ways of viewing things. This can lead to an active seeking out of other information to help with decision making, and it may even lead to alternative ways of practicing!

However, surely the most important feature of my deliberations is that there is still much to do in involving people with diabetes in these processes, whether on an individual basis, or in a more formal way.