Type 1 Diabetes Mellitus (T1DM) self management in hospital; is it possible?: a literature review

Rebecca Munt
Lecturer in Nursing, School of Nursing and Midwifery, Flinders University, Adelaide SA

Alison Hutton
School of Nursing and Midwifery, Flinders University, Adelaide SA

PP: 179 - 193

Abstract

Aim: To review research evidence on the adults with Type I Diabetes Mellitus's ability to continue self management in the hospital setting.

Background: A person with Type 1 Diabetes Mellitus requires a daily management routine to control glycaemia levels known as self management. On admission to hospital anecdotal evidence suggests people with Type 1 Diabetes Mellitus are  managed by health professionals and self management is difficult. A review of the literature is required to explore the anecdotal evidence.

Design: A literature review of available primary peer reviewed research on self management of Type 1 Diabetes Mellitus in hospital.

Method: A systematic search of the literature published between 1998 - 2008 was undertaken to identify research available on self management of Type 1 Diabetes Mellitus in hospital. The mixed methods review was conducted using critique tools for randomised control trials, qualitative and quantitative studies. Four main themes were identified; Glycaemic control, development of self management, the expert patient and T1DM management in hospital.

Results: Sixteen related publications were identified. In the context of their daily life adults with Type 1 Diabetes Mellitus perceive their ability to self manage as important and view  themselves as 'experts' in their self management . However, there is a recognised conflict about Type 1 Diabetes Mellitus management between the 'expert' and health professional. Furthermore, management of Type 1 Diabetes Mellitus by health professionals in the hospital setting has been identified as having a biomedical focus and being poorly managed.

Conclusion: People with Type 1 Diabetes Mellitus have knowledge and skills to self manage. Whilst there is support for adults to actively self manage their illness to maintain glycaemic control, there is no support in the literature regarding a continuation of self management in the hospital setting.

Keywords

Type 1 Diabetes Mellitus; self management; hospital; patients’ perspective; chronic disease management

Article Text

Type 1 Diabetes Mellitus (T1DM) is a chronic condition for which there is currently no cure. T1DM is an autoimmune disorder that destroys the pancreas cells ability to produce insulin leading to high plasma glucose levels (Drury & Gatling 2005).  In 2011 the NDSS register recorded that over 129,000 Australians have T1DM (NDSS 2011). In order for people with T1DM to maintain normal blood glucose levels (normoglycaemia) and reduce the potential microvascular, macrovascular and neurologic complications that are associated with poor glycaemic control, a daily management routine is required (The Diabetes Control and Complications Trial Research 1993). This daily management routine includes blood glucose monitoring (BGM), insulin administration, controlling dietary intake and partaking in physical activity (Due - Christensen, Borrild & Larsen 2006, Germain & Nemchik 1988, Toljamo & Hentinen 2001).  The intricate complex daily management routine also incorporates timing of all management tasks, decision making around those tasks and implementing treatment in response to alterations of blood glucose levels (BGLs) (Paterson & Thorne 2000b). This routine which encompasses complex daily management performed by the individual is known as self management.  For the purpose of this review the term self management 'makes reference to the activities people undertake to create order, discipline and control in their lives' (Kralik et al. 2004, p. 260).

While adults with T1DM self manage in their daily environment there is a dearth of literature on whether they can continue their self management regime in the hospital setting. It is recognised that people with T1DM will develop complications overtime (Colagiuri et al 2009: DCCT 1993; Dunning 2003). As a consequence of microvascular and macrovasular complications developing, an individual will be admitted to the hospital setting with a variety of primary admission diagnosis, other than unstable glycaemia control (Colagiuri et al. 2009). In 2004/05 a total of 531, 069 people admitted to hospital in Australia (8% of all recorded hospital admissions) had diabetes as a principle or additional diagnosis with 22% of those identified as having T1DM (AIHW 2008). Regardless of this primary admission diagnosis these adults will require their daily T1DM management to continue. However Dunning (2003) suggests, through clinical observation and patient's stories, inpatients are stripped of their normal self management regime by health professionals leaving them feeling incompetent. Cohen et al. (2007) also suggests the person with T1DM in hospital is often required to alter or relinquish their daily self management responsibility. In addition, inpatients express fear for the treatment they receive from health professionals for their T1DM, especially linked to medication and hypoglycaemia management (Dunning 2003). Furthermore patients' express being labelled as poor self managers and non compliant if their BGLs are elevated especially if consuming foods containing sugar (Dunning 2003).Therefore an understanding of  what self management means to the person with T1DM is needed in order for health professionals to provide support and plan collaborative care in the hospital setting.

Aim

The aim is to review the published health literature on self management of T1DM in hospital and to analyse and critically appraise the findings. In particular the focus of this review is on adults who were admitted for a primary admission diagnosis other than T1DM. The inclusion criteria were studies that focused only on adults in relation to Type 1 Diabetes management, self management, the person with T1DMs perspective or management of the T1DM in the hospital environment. Articles were excluded if the research focus was on outcomes of community led self management support groups or health professional management of uncontrolled BGL in hospital. Articles on patients admitted to hospital with diabetic ketoacidosis (DKA) or admitted to an intensive care unit were excluded as these topics were not the focus of the review as these factors may impact on the adults ability to continue to self manage.

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