Fears and worries associated with hypoglycaemia and diabetes complications: perceptions and experience of Hong Kong Chinese clients
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- ISSUES AND INNOVATIONS IN NURSING PRACTICE Fears and worries associated with hypoglycaemia and diabetes complications: perceptions and experience of Hong Kong Chinese clients Ann Tak-Ying Shiu MSc MSc RM RN HV Associate Professor, The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong, China and Rebecca Yee-Man Wong MSc RN Nurse Specialist (Diabetes Care), Prince of Wales Hospital, Hong Kong, China Submitted for publication 31 July 2001 Accepted for publication 16 April 2002 � 2002 Blackwell Science Ltd 155 Correspondence: Ann Tak-Ying Shiu, The Nethersole School of Nursing, Rm. 830, Esther Lee Building, The Chinese University of Hong Kong, Shatin, Hong Kong, China. E-mail: email@example.com SHIU A.T. -Y & WONG R Y.-M. (2002)SHIU A.T. -Y. & WONG R.Y. -M. (2002) Journal of Advanced Nursing 39(2), 155–163 Fears and worries associated with hypoglycaemia and diabetes complications: perceptions and experience of Hong Kong Chinese clients Aim. This paper reports the second phase of a study that explored the perceptions and experience of Hong Kong Chinese insulin-treated clients who demonstrated fear of hypoglycaemia and worry about diabetes complications. Background. The first phase of the study, a descriptive survey (n ¼ 120), identified 15% of respondents as simultaneously sustaining fears and worries associated with hypoglycaemia and diabetes complications. Although a small percentage, given the increasing number of clients using insulin treatment, this finding suggests a pocket of clients suffering from undesirable emotional health. However, a search of the lit- erature identified few studies exploring Chinese clients’ perceptions and experience in this area. Design. The second phase of the study employed a purposive sampling method and semi-structured interviews to collect data from 13 participants experiencing these fears and worries. Findings. Two researchers independently used content analysis to code and categ- orize data. Six categories identified were: the influence of perceptions of glycaemic control on emotion, hypo- and hyperglycaemia as a constant threat, keeping optimal glycaemic control or maintaining a working life, financial and psychological burden of blood glucose self-monitoring, being alone with the threat and finally distancing as the coping method. An overriding issue, a sense of losing control, emerged from the findings that described participants’ perceptions and experience. This issue and two major health needs, developing self-efficacy and emotional support from nurses, were drawn from the findings for discussion. It is suggested that self-efficacy theory can be adopted as a conceptual framework to guide nursing practice for enhancing clients’ capacity to exercise control over diabetes self-management. Conclusions. Findings obtained from the second phase of the study illuminated those from the first phase. Implications for nursing practice were identified, inclu- ding facilitating both technical and psychosocial self-efficacy, assessing clients’ total life situation, strengthening competence in counselling skills and forming alliances with clients.
- Introduction The prevalence of diabetes in Hong Kong was estimated to be 7% (500 000 clients) in 2000 (Chan 2000). Over 90% of clients have Type 2 diabetes (Chan et al. 1996) and half of them with a 10 years history require insulin treatment for optimal glycaemic control to curb and delay the onset of diabetic complications [Chan et al. 1998, United Kingdom Prospective Diabetes Study Group (UKPDS) 1998]. Although insulin treatment helps achieve better glycaemic control, it brings about more frequent hypoglycaemic episodes (Diabetes Control and Complications Trial Research Group 1991, UKPDS 1998) with some clients displaying high levels of fear of hypoglycaemia (Irvine et al. 1992, Polonsky et al. 1992, Richmond 1993). We conducted a two-phase descriptive study with a convenience sample of 120 insulin-treated Hong Kong Chinese outpatients, aiming to investigate the extent and experience of fear of hypoglycaemia. Phase one was a survey assessing the extent of the fear and its effects on self- management behaviour (Shiu & Wong 2000). The findings identified 18 respondents (15%) who sustained above average levels of fear. Of particular concern was that these respondents simultaneously had worries about diabetes complications. The survey adopted a small nonprobability sample and therefore its findings cannot be generalized to the whole diabetes population in Hong Kong. However, given the increasing number of clients who require insulin treatment, the 15% of respondents suffering from both fears and worries is clinically significant. This finding suggests a group of clients sustaining high threat and needs addressing. In self-efficacy theory, perception of threat is not a fixed outcome of stressful situations; individuals who believe that they can exercise control over potential threats do not experience high anxiety (Bandura 1997). Chronic illness research demonstrate that clients with higher self-efficacy have better self-management, more effective coping and fewer hospital admissions (Edwards et al. 2001, Scherer & Bruce 2001). Similar evidence is demonstrated in diabetes research (Wang et al. 1998, Bernal et al. 2000, Senecal et al. 2000). Some studies have also reported the positive effects of diabetes self-efficacy on clients’ emotional wellbeing (Rubin et al. 1993, Anderson et al. 1995, Feste & Anderson 1995). Phase one of our study demonstrated that respondents with above average levels of fear of hypoglycaemia, despite their worries of diabetes complications, tended to raise glycaemic levels at times by eating more or injecting less insulin (Shiu & Wong 2000). Such findings are consistent with those from the West (Irvine et al. 1992, Richmond 1993, 1996). Richmond (1993) speculated that individual clients might run high glycaemic levels to obviate the threat of hypoglycaemia. With such attempts clients also suffered the tension of developing diabetes complications, thus resulting in a �catch 22� phe- nomenon (p. 1685). This phenomenon, however, was not explored further by Richmond (1996) and a search of the literature identified few published studies investigating it. In addition, research demonstrates that clients who have a high fear of hypoglycaemia, contrary to expectations, do not practise regular blood glucose self-monitoring (BGSM) (Irvine et al. 1992, Hernandez 1995), which can provide instant feedback on glycaemic levels allowing remedial action if necessary. In phase one of our study, 42Æ5% of the total sample reported regular BGSM. Interestingly, amongst the 18 respondents with high fear eight reported that they performed this self-management practice regularly. Although this finding may not be reliable due to self-report bias, it is important to examine this issue from a clients perspective. China is second in the �Top 10� countries of the world in terms of the number of people with diabetes (King et al. 1998). However, no published study describing Chinese clients’ perceptions and experiences with hypo- and/or hyperglycaemia could be found. Inadequate understanding of clients’ emotional world can pose a barrier to facilitating effective holistic care (Gruninger 1995, Benson & Latter 1998). The aim of the second phase of the study was therefore to investigate the perceptions and experience of insulin-treated Hong Kong Chinese clients who simulta- neously demonstrated high fear of hypoglycaemia and worry about diabetes complications. The study Method Design and sample This paper focuses on the second phase of the study. Detailed discussion of phase one has been published elsewhere (Shiu & Wong 2000). To attain the aim of the second phase a qualitative design was undertaken. We adopted purposive Keywords: control, empowerment, self-efficacy, emotional support, counselling skills, diabetes nursing, glycaemic control, blood glucose self-monitoring A.T.-Y. Shiu and R.Y.-M. Wong 156 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(2), 155–163
- sampling to recruit participants from the total sample of the first phase. Selection criteria were: clients who obtained an above average level of fear of hypoglycaemia from the Worry Scale (Cox et al. 1987) and simultaneously denoted worry about diabetes complications. Of the 18 who fulfilled the criteria, three subsequently attended other clinics due to moving home and one was hospitalized. Another was an Indonesian Chinese, who although speaking Cantonese, demonstrated difficulties dur- ing the in-depth interview in expressing her feelings fluently. This interview was therefore excluded from the data analysis, leaving a total of 13 participants. Table 1 shows the demographic and clinical data of the 13 participants. Their ages ranged from 22 to 56 years, six were full-time workers, five had Type 2 diabetes and eight had Type 1. Three participants had developed diabetic complica- tions and another three were in poor glycaemic control as shown by their glycosylated haemoglobin (HbA1C) levels at the time of the interview (World Health Organization 1985). Methods Semi-structured interviews were adopted as the data collec- tion method. Results from phase one of the study informed the development of the interview guide. A panel of 10 experts including diabetes health professionals and insulin-treated clients reviewed and determined the face validity of the guide. The interview guide examined participants’ perceptions and experience with two major areas: factors contributing to fears and worries and coping methods. A sample of blood was routinely taken for HbA1c on the day of the medical follow- up to review the average glycaemic concentration over the preceding three months. The reading was obtained from the patient record. The first author conducted all interviews after verbal consent was obtained. The interviews were conducted in Cantonese and audiotaped. Each interview lasted for approximately an hour. All interviews took place in an interview room when participants attended for medical follow-up. Ethical considerations Ethical approval and access to clients were obtained from the university and hospital concerned. All participants were informed of the confidentiality of personal data gained from the study. They were assured of their right to withdraw at anytime without any negative impact on the health care provided at the hospital. The independence of the interviewer from the administration of the hospital was highlighted to all participants before the interview to minimize any bias arising from social desirability of participation. Because of the nature of the experience to be explored in the second phase of the study, it was recognized that participants might recall or express experience causing emotional disturbance. In the event of this, the interviewer would refer participants to an appropriate source for care. The interviewer, who was also a counsellor with a nongovernment organization, was profes- sionally competent to pick up such cues. Data analysis All interviews were transcribed verbatim. Data analysis was undertaken in Chinese and therefore the influence of the quality of translated transcripts on the validity and reliability of the analysis was not an issue in this study (Twinn 1997). Latent content analysis was applied to code and categorize data (Fox 1982, Morse & Field 1995). Codes were used to identify the content in each interview and category labels, Table 1 Demographic and clinical data of the 13 participants Code/ gender Age (years) Marital status Education Employment status Type Year since diagnosed Year since insulin-treated Complication HbA1c%* 1. F 56 Married Secondary Housewife 2 13 2 – 9Æ7 2. F 52 Married Secondary Housewife 1 28 28 Blind 6Æ3 3. M 53 Married Secondary Full-time 2 16 12 – 7Æ6 4. F 26 Single Tertiary Full-time 1 12 12 – 6Æ3 5. M 47 Married Primary Full-time 2 9 5 – 7Æ6 6. F 42 Single Primary Unemployed 1 25 25 – 8Æ4 7. M 23 Single Tertiary Student 1 4 4 – 8Æ3 8. M 40 Single Secondary Full-time 1 30 30 – 7Æ9 9. F 22 Single Tertiary Full-time 1 5 5 – 10Æ4 10. M 25 Single Secondary Full-time 2 4 2 – 15Æ6 11. F 36 Married Secondary Housewife 1 13 13 Blind 7 12. F 37 Married Matriculated Part-time 1 18 17 – 6Æ8 13. F 32 Separated Secondary Part-time 2 11 3 Proteinuria 5Æ4 *Less than 7% as optimal control, 7–8Æ5% as borderline control, over 8Æ5% as undesirable control (World Health Organization 1985). Issues and innovations in nursing practice Fears and worries associated with hypoglycaemia � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(2), 155–163 157
- descriptive names, were used for each group of codes. The two authors read the transcripts independently, coded the data, generated and then compared categories to minimize threats to the validity and reliability during data analysis (Morse & Field 1995). We discussed similarities and differ- ences in coding and compared categories to develop a pre- liminary category list. We again read the transcripts independently, searching for data in supporting or rejecting the preliminary categories. Another round of discussion and comparison resulted in an amended version of category list. We conducted this iterative process of categorization until consensus was reached. A note of caution is that a compar- ison of data between participants with Type 1 and Type 2 diabetes yielded no difference in categories, which could be a result of the small sample size and unsaturated data. Findings Analysis of the data identified six categories that describe participants’ experience and perceptions of worries arising from concerns with hypo- and hyperglycaemia. To maintain the verbatim nature of the interview data all quotations, although presented in English, have been literally translated from Cantonese and may in places appear as grammatically incorrect. Influence of perceptions of glycaemic control on emotion Participants verbalized that optimal glycaemic control was the only indicator of good self-management. They said this was knowledge gained from their encounters with diabetol- ogists and diabetes nurses. Interestingly, all participants’ subjective ratings of glycaemic control matched their HbA1C results at the time of interview. More importantly, all perceived maintaining stable and optimal glycaemic levels as very difficult. A total of five (three Type 1 and two Type 2) directly equated the difficulty as �standing in the middle of a spring balance�. One participant’s (Type 1) comment summed up their struggle: Insulin is very potent. Immediately after injection, it suppresses blood glucose, if it slips to low, it’s much lower than �optimal�…The best is, of course, to stand in the middle of a spring balance. But it’s impossible, isn’t it?…I’m anxious…worry about late complications …It’s like a cunning enemy…I fight with it everyday, with good blood glucose I’m happy, if poor then I’m worry. It appears that participants’ emotions were influenced by the ability to control and the fluctuation of glycaemic levels. Moreover, they unequivocally said they had �no solution� to the fluctuation of blood glucose because in part they �could not survive without insulin�. They went on to describe other difficulties arising from daily life in relation to maintaining optimal glycaemic control, which will be reported in the following categories. Hypo- and hyperglycaemia as a constant threat A total of seven participants (6 Type 1 and 1 Type 2) who had previous experience of severe hypoglycaemia verbalized higher worries towards hypoglycaemia than hyperglycaemia. They described the feelings during hypoglycaemic attacks as �dying� and �with empty brain�. One said that the experience was �difficult to tolerate which no outsiders could under- stand�. Hypoglycaemia attacked even when one was well prepared, giving rise to high insecurity. One participant with HbA1C at 10Æ4% at the time of the interview said: I went to a barbecue picnic. On the minibus [public transport] to the picnic site, I injected insulin and ate two pieces of biscuit. It turned out to be a long traffic jam lasting for 45 minute [should be a 15-minute ride]. I started feeling light-headed. When I got off the minibus, fortunately my friends were there and found me fainting; I lost consciousness there in their arms. If the traffic jam had lasted for 15 minutes more, I would have passed out in the minibus with no one knowing. Seven participants (4 Type 1 and 3 Type 2) said that they tended �not to suppress the blood glucose to avoid hypo� especially during working or school hours. Their HbA1C levels ranged from 7Æ6 to 15Æ6%. All participants described an ultimate future with diabetes complications. Although they said they were �emotionally prepared� for the complications, they still found the thought of the future caused �fearful and disturbed� feelings. Eight (4 Type 1 and 4 Type 2) said that the future with diabetes complications meant �dependence and a burden to family members�. One participant (Type 2) who had proteinuria said, �No future, except a future with renal dialysis, but I want to defer it as late as possible…I�m very sorry for myself’. She said she put great effort into maintaining optimal control. Her HbA1C level was 5Æ4%. It is important to note that although she worried more of the late complications, she also suffered high fear of hypoglycaemia. Two participants (Type 1) who were blind as a result of retinopathy, although verbalizing a higher degree of worry about hypoglycaemia than diabetes complications, regarded the latter as the inevitable end stage, that denoted a �slow and miserable process of dying�. Diabetic complications were perceived as �a silent invader�, �worse than cancer�, and �invading every important organ�. In an attempt to defer this A.T.-Y. Shiu and R.Y.-M. Wong 158 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(2), 155–163
- end stage, the two participants meticulously maintained a tight glycaemic control. Their effort was reflected in their HbA1C readings, 6Æ3 and 6Æ8%. Paradoxically, they felt threatened by hypoglycaemia. No matter which approach they used the maintenance of glycaemic levels, participants were fully aware of potential risks of hypo- and hyperglycaemia, and described this experience as �living with a constant shadow of dilemma�. One women (Type 1) with HbA1C at 10Æ4% described her experience: I worry both of them. When high, often I don’t know if I’m lazy and not checking constantly. If I always have high, I’d have late complications. My life will be very miserable…When I have low, I can’t work nor concentrate, with shaky hands and sweating.…Low can happen very suddenly. I eat to full but can still have it if too much insulin. Then I need to eat again. It’s terrible. Eating should be enjoyable but is like being sentenced to punishment, very miserable. Therefore I’m afraid of both. Keeping optimal glycaemic control or maintaining a working life The six participants (3 Type 1 and 3 Type 2) who worked full-time described keeping optimal glycaemic control while maintaining a working life as �at odds to each other�. A man (Type 2) who worked on a construction site and required strenuous physical output said that with the prescribed diet and insulin regime, he would �go into hypo anytime�. Because of the risk of causing fatal accidents to himself and colleagues, he did not inject insulin and ate more than recommended while at work. Interestingly, his HbA1C was 7Æ6%. Although running higher glycaemic levels allowed partic- ipants to carry on with their working life, they were well aware of the threat of diabetic complications. It is important to note that these six participants perceived �no solution� for this threat. One used a Chinese saying to illustrate the situation: �a needle can�t be pointed at both ends’. This means that one has to live with both the benefits and shortcomings of a decision. Another participant said: If I could stay at home and stop working, so that I don’t need to eat out and could follow doctors’ and nurses’ advice to do appropriate amount of exercise, I believe I could better control my blood glucose. The trouble is I work eight to 10 hours a day. I eat in restaurants or fast food centres. How could I follow their advice? A participant (Type 1) who had been a saleswoman disclosed that: I couldn’t walk away from my work and eat, therefore I ate more while I was at work…I had long working hours with irregular meal times, therefore I injected only after work…I lost my eyesight because of poor control. Four interviewees (two Type 1 and two Type 2) said they had changed to a less demanding or a part-time job and another three had involuntarily stopped working. Financial and psychological burden of blood glucose self- monitoring BGSM was not always perceived as a helpful mechanism to gauge glycaemic control. Eight participants (three Type 1 and five Type 2) said that the test strips were too expensive and they preferred irregular testing unless it was indicative, for example, when having a dizzy spell. Ten participants (five Type 1 and five Type 2) described a psychological burden which involved anticipatory anxiety as well as a sense of failure with undesirable readings. They avoided BGSM at all or at times. Of particular concern was that five participants (two Type 1 and three Type 2) admitted that they sometimes falsified good readings for doctors and nurses’ review during follow-up appointments. Two (Type 1) asserted that BGSM was essential and they did not skip it. However, they had described a sense of fatigue. One said that: I’m fed up,…after hiking, my friends sleep through the night, I can’t, I have to check blood glucose, inject and eat snack before I can take a rest,…need to struggle, mentally studying the consequences if I don’t do these…very painful,…I’m not free. Being alone with the threat The �dilemma� of the constant threat of hypo- and hypergly- caemia was �mixed and complex� and 10 participants (six Type 1 and four Type 2) described themselves facing it alone, saying that one’s family, close friends and health profession- als could not fully comprehend the intensity of the suffering. One woman (Type 1) described how, although her relation- ship with her husband was like that of �skin and flesh�, her husband could not comprehend her suffering. Another (Type 2) recalled how her ex-husband could not tolerate her constant suffering and opted for a divorce. Participants generally described diabetes nurses as very knowledgeable and up-to-date with technical aspects of self- management, and found them competent information givers. This information was described as one of the reasons for regular attendance to the diabetes centre. Issues and innovations in nursing practice Fears and worries associated with hypoglycaemia � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(2), 155–163 159
- However, eight participants (four Type 1 and four Type 2) described both diabetologists and nurses as preoccupied with heavy patient-loads and not able to spare adequate time to understand the �dilemma� as well as environmental con- straints that impact on self-management. Some advice was regarded as �general� or �an ideal that one could not adjust to it�. For example, one participant (Type 1) said, �Diet, injection, exercise, these could be different day by day. …They could talk, I could talk too.� Participants were asked to list something that, if present, might help reduce their fears and worries. Seven (five Type 1 and two Type 2) identified facilities such as �psychological counselling� and seeing �nurses and doctors who have diabetes themselves�. An exploration of the suggestions identified that participants requested �genuine concern� and �understanding� from health professionals. One (Type 1) said that, �Giving me medicine, you�re treating 30 per cent of my illness; if you could treat my heart, you could have treated 70 per cent’. Distancing as the coping method All participants repeatedly said that they had �no solution� but to accept the �dilemma� as part of life. They also said that no matter how hard they struggled, �The dilemma still exists, the threat is still there�. All admitted that they could not survive if they constantly faced the �dilemma�. One said: You have to let go the negative feelings because low and high happen everyday; otherwise you’ll be a nervous wreck. Interviewees deliberately distanced themselves from the threat at least for some of the time. They described methods such as �I focus on the present moment�, �I put my thought on other areas�, �I think of the day with an invention of a miracle cure�, �I cycle for a couple of hours� and �I keep a dog and take care of him�. Four participants (1 Type 1 and 3 Type 2) revealed that they sometimes avoided diabetes health professionals and did not perform BGSM to allow for an escape from the threat. One participant whose HbA1C was 9Æ7% made this comment, I don’t have any particular coping method. Sometimes I avoid the contact, for example, those health talks, I try my very best not to attend. I’ve bought many books of that kind. The more I read the higher the fear,…therefore, I use the negative method and put them away. I put the books somewhere so that I won’t be bothered. Discussion The findings obtained from the second phase of the study, while illuminating those from the first phase, also provide insight into the experience and perceptions of Hong Kong Chinese clients who simultaneously suffer from fear of hypoglycaemia and worry about diabetic complications. The overriding issue of a sense of losing control emerged and described participants’ perceptions and experiences. This issue and two major health needs, developing self-efficacy and emotional support from nurses, were drawn from the findings for discussion. A sense of losing control Participants were caught between fear of hypoglycaemia and worry about diabetic complications. Their emotions appeared to fluctuate with the glycaemic levels. They described the experience as �living with a constant shadow of dilemma�, echoing Richmond’s speculation of a �Catch 22� phenomenon (Richmond 1993) as well as demonstrating a heightened awareness of their vulnerability as a result of undesirable glycaemic control (Weiss & Hutchinson 2000). Perceiving optimal glycaemic control as the primary indicator of good self-management is a finding congruent with previous studies (Callaghan & Williams 1994, Richmond 1996, Paterson et al. 1998). Concurring with previous findings, maintaining stable and desirable glycaemic control was experienced as �standing in the middle of a spring balance� (Polonsky et al. 1992, Paterson et al. 1998). For participants who had been achieving desirable glycaemic control this perception posed a constant tension. Worse still, for those who deviated from desirable levels this perception might create a sense of failure and appears to contribute to a sense of losing control. Maintaining a job is an important function of adulthood. Participants described maintaining a job and desirable glycaemic control as �at odds to each other�. While echoing previous findings (Ratner & Whitehouse 1989, Callaghan & Williams 1994, Hernandez 1995), this perhaps exacerbated their perceptions of losing control. Their descriptions of sustaining higher glycaemic levels while at work fitted with the current argument on �constructive� use of nonadherence in relation to the requirements of daily living (Thorne 1990). It is interesting to note that only 2 out of 13 reported regular BGSM. Participants experienced either or both psychological and financial burdens created by BGSM. Nonadherence with this practice, while a consistent piece of evidence in previous research (Callaghan & Williams 1994, Hernandez 1995, Hunt et al. 1998), highlights the con- straints arising from one’s psychosocial environment. Again psychosocial constraints might intensify a sense of losing control over the self-management practice. A.T.-Y. Shiu and R.Y.-M. Wong 160 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(2), 155–163
- The coping method for the threat of hypo- and hypergly- caemia identified in this study is consistent with the coping pattern of �emotion-based action� demonstrated in Lundman and Norberg’s study (1993); these actions have been shown to be associated with feelings of incompetence, psychological disturbances and denial. This coping method is also similar to that used by people who perceive diabetes as a problem and a burden (Anderson et al. 1982). �No solution� was a term repeatedly used by participants, and highlight their percep- tions of powerlessness in resolving this constant �dilemma�. Need to develop self-efficacy To overcome feelings of losing control the literature suggests adopting an empowerment approach to care (Tones 1998). Such an approach involves the development of technical and psychosocial aspects of self-efficacy. The former involves development of the technical aspects of glycaemic control and solving clinical problems (Humphry et al. 1997), while the latter includes personal efficacy with the identification of realistic diabetes goals, obtaining social support and man- aging the stress of diabetes (Rubin et al. 1993, Anderson et al. 1995, Feste & Anderson 1995). These two aspects are not developed in isolation. Indeed, research indicates that clients with high technical aspects of self-efficacy demonstrate better social relationships and glycaemic control (Wang et al. 1998, Bernal et al. 2000). Similarly, interventions addressing psychosocial aspects result in improved self-management and glycaemic control (Rubin et al. 1993, Anderson et al. 1995). The four interrelated mechanisms of the self-efficacy theory suggested by Bandura (1997) provide a possible conceptual framework to guide diabetes patient education. These mechanisms are: (a) performance accomplishment, (b) vicarious experience, (c) verbal persuasion and (d) physiolo- gical states. Bandura (1997) suggests that performance accomplish- ment is the most effective vehicle for developing a sense of control, but performance failure undermines it. Participants in the current study described optimal glycaemic control as the only indicator of good self-management but described great difficulties in achieving it. Indeed, accomplishing tight glycaemia control for good physiological endpoints some time in the future is suggested as difficult for many clients (Wolpert & Anderson 2001). Bandura (2001, p.8) asserts that whether individuals are motivated to achieve a goal depends on its �specificity, level of challenge and temporal proximity�. Six participants of the current study said that maintaining a normal working life was important to fulfil familial roles. The literature suggests that nurses should develop collaborative relationships with clients (Hernandez 1995) to facilitate the identification and achievement of short-term realistic goals. Indeed, the achievement of a short- term goal, which is tailored to aptitude and life circum- stances, provides clients with a mastery experience and may motivate them for further endeavours (Rapley & Fruin 1999). Glycaemic levels, however, are not under exclusive control by clients’ self-management behaviours (Wolpert & Anderson 2001). When clients’ efforts appear unsuccessful, nurses need to show understanding and empathy. This highlights nurses’ role in providing emotional support, which is described below. Secondly, modelling self-management practice from an exemplar client who successfully overcomes psychosocial constraints and maintains a stabilized level of glycaemia can also strengthen self-efficacy. In order to make this vicarious experience work for individual clients, nurses should identify role models with demographic and clinical characteristics similar to those of the client. Thirdly, the mechanism of verbal persuasion is a further means of strengthening client’s self-efficacy. Findings of the current study demonstrate that participants had a high opinion of nurses’ professional knowledge. Self-efficacy research highlights that verbal encouragement from a cred- ible source works particularly well in strengthening personal efficacy (Ozer & Bandura 1990). Nurses should provide positive feedback to clients on their self-management performance, highlighting areas of achievement and effort no matter how small they are. The final mechanism is feedback from the clients’ physio- logical status. This status provides an indicator of compet- ence and can enhance self-efficacy. Unfortunately, for clients who lack confidence in avoiding hypo- and hyperglycaemia, their glycaemic levels may reinforce low perceived personal efficacy (Rapley & Fruin 1999). Perhaps a way forward is for nurses to alert clients to the change of physiological status before and after a given self-management task. An example can be drawn from an experiment undertaken by some diabetes nurses in Hong Kong, who accompanied a group of clients for a brisk walk for half an hour and asked them to compare their pre- and post-walking readings of BGSM. Those clients were amazed by the decrease in glycaemic levels. Physiological feedback such as this may enhance clients’ personal mastery. Need for emotional support from nurses The finding in this study highlighting that participants found themselves alone with their fears and worries is of particular concern, suggesting that they perceived themselves as receiv- ing inadequate emotional support from health professionals, Issues and innovations in nursing practice Fears and worries associated with hypoglycaemia � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(2), 155–163 161
- including nurses. A previous study showed that clients tended to perceive a lack of understanding by both physicians and spouses of the emotional effect of hypoglycaemia (Ritholz & Jacobson 1998). In addition, these clients did not go to physicians for emotional care. It is noteworthy that participants in the current study expressed the need for emotional support from nurses and doctors, and tended to regard emotional aspects of care provided by health professionals as more important than that of physical care. This was illustrated in the comment on treating the �heart�. Chinese people use the concept �heart� to refer to the affective domain (Russell & Yik 1996). In part this may be explained by the value traditionally placed by Chinese people on health professionals’ caring attitude rather than professional knowledge (Shih 1996). Furthermore, given the heavy patient-load and the research evidence of good physiological endpoints with euglycaemia (DCCT 1991, UKPDS 1998), nurses may have put overt effort into achieving clients’ physiological wellbeing. The finding that participants gave tribute to nurses’ professional knowledge and competence in information-giving lends support to this suggestion. Research highlights the importance of professional support in the attainment of euglycaemia by including life contexts into client–provider interactions (Ritholz & Jacobson 1998, Weiss & Hutchinson 2000). Nurses should assess health needs in the light of clients’ total life situations, especially of those who do not attend for education activities or demon- strate nonadherence to treatment regimes. Findings of the current study suggest that the nonadherence may be in part the result of fears and worries as well as environmental constraints. It is important for nurses to strengthen their skills in facilitating acceptance of the restrictions caused by diabetes as well as the ability to accommodate negative emotions, of which empathy and unconditional positive regard are key elements (van Ryn & Heaney 1997, Benson & Latter 1998). Indeed the literature supports counselling skills as one important tool nurses should employ to build mutual understanding, facilitate learning and sustain self- management behaviour (Gruninger 1995, Benson & Latter 1998). The finding that some participants admitted falsifying BGSM results to satisfy health professionals including nurses suggests a lack of nurse-client collaboration, consistent with findings from the West (Callaghan & Williams 1994, Hernandez 1995). While supporting the need for emotional support and counselling skills from nurses, it also has implications for nurses in relating to clients as equal partners (Hernandez 1995, Hunt et al. 1997). Conclusion Readers are cautioned of the limitations of the study. Because Type 1 and Type 2 diabetes clients were included in the sample, it was difficult to achieve saturation of data with this sample size. The two forms of diabetes have a different aetiology and can influence perceptions and experiences. Although the categories captured perceptions and experience of both types, it is highly likely that a difference existed in experience and the intensity of the feelings. In our opinion, the findings reported in this paper illuminate the quantitative data obtained in phase one of the study and provide a starting point for further research on an understudied area. The overriding issue of a sense of losing control and two major health needs, development of self-efficacy and emo- tional support from nurses, provide some important insights from which implications could be drawn for nursing practice, in particular with clients who simultaneously sustain fear of hypoglycaemia and worries of diabetes complications. Impli- cations for practice include facilitating both technical and psychosocial efficacy, assessing clients’ total life situation, and strengthening competence in counselling skills. Acknowledgements The study was supported by the United Board for Christian Higher Education in Asia Faculty Research Grant of the Chinese University of Hong Kong. References Anderson R.M., Arnold M.S., Funnell M.M., Fitzgerald J.T., Bulter P.M. & Feste. C. (1995) Patient empowerment: results of a ran- domised controlled trial. Diabetes Care 18, 943–949. Anderson R.M., Genthner R.W. & Alogna M. (1982) Diabetic patient education: from philosophy to delivery. 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