Nurse-led psychological interventions to improve diabetes control: Assessing competencies

doi:10.1016/j.pec.2010.07.036

Patient Education and Counseling

Volume 84, Issue 2, August 2011, Pages e37-e43

https://doi.org/10.1016/j.pec.2010.07.036 Get rights and content

Abstract

Objective

To assess whether medical nurses can deliver motivational enhancement therapy (MET) and cognitive behavioural therapy (CBT) to a competent level and whether treatment fidelity is maintained.

Methods

Training consisted of classroom teaching, written materials, a training caseload, and audio-visual feedback. We used the Motivational Interviewing Treatment Integrity (MITI), the Revised 12-item Cognitive Therapy Scale (CTS-R), and components of the Motivational Interviewing Skill Code (MISC) to assess competency and treatment fidelity. Two independent clinical psychologists who were blind to the allocation rated a random selection of 40 sessions.

Results

Six nurses were trained in both interventions. For the MET the mean (SD) scores for empathy and spirit on the MITI scale were 5.1 (0.7) and 4.6 (1.0) respectively and for CBT the total mean (SD) CTS-R score was 52.1 (7.5), which was acceptable competency in both treatments. The two interventions were distinguishable.

Conclusion

Results suggest that nurses can be trained to deliver diabetes-specific MET and CBT competently and maintain treatment fidelity.

Practice implications

Findings of this study provide preliminary evidence to suggest that nurse-led psychological interventions could be incorporated into the traditional diabetes setting.

Introduction

Sub-optimal glycaemic control (SOGC) in type 1 diabetes is common despite the effectiveness of intensive insulin therapies, continuous subcutaneous insulin infusion pumps and structured education programs [1], [2], [3]. Factors which can contribute to sub-optimal glycaemic control are diverse and include biological factors such as subcutaneous insulin absorption, liver function and autonomic arousal, psychological barriers such as diabetes-related anxieties around hypoglycaemia, complications, self-injecting and glucose self-testing, weight gain and low mood [4], [5], [6], [7], [8]. National guidelines increasingly emphasise the need for diabetes teams to offer psychological care to empower and encourage patients towards healthier behaviour change, lifestyle modifications and effective self-care.

Current medical and structured educational models of diabetes management are based on conventional doctor/clinician–patient relationships and learning theories in which the patient is given instructions, information and advice. Psychological interventions differ from the above models of care, in that the relationship between the therapist/clinician and the patient is based on a therapeutic alliance in which they are collaborating as equal partners to identify unhelpful thoughts, feelings and behaviours, conscious and/or unconscious, with the aim of replacing these with more helpful psychological processes.

There is emerging evidence of the effectiveness of psychological treatments in improving glycaemic control in adults with type 1 diabetes [9]. Expert mental health providers such as psychologists are a costly and scarce resource and they may not always be best placed to deliver psychological care to most people with type 1 diabetes as the psychologist often needs a good working knowledge of diabetes. On the other hand, diabetes professionals are more readily accessible to people with diabetes and adding psychological treatments to their skills may be a more effective and convenient intervention to help patients improve self-care.

A recent review in type 2 diabetes suggests that brief psychological treatments delivered by general clinicians was as effective at improving glycaemic control at a clinically significant level as expert mental health providers. These promising findings need to be interpreted cautiously as the studies were mostly underpowered and older studies seemed to be more effective than recent ones. An additional dilemma for the diabetes clinician and patient is that strict or tight glycaemic control may be associated with increased cardiovascular and mortality risks [10]. In a systematic review of 13 RCTs of the effectiveness of psychological treatments in improving glycaemic control in type 1 diabetes, only one study had trained diabetes nurses to deliver the intervention [11]. The results from this study showed that the intervention resulted in better psychological outcomes but as glycaemic control was on average within the recommended range there were no observed improvements in this.

The present study examines whether nurses could be trained to competently deliver two brief psychological treatments in the context of a randomised controlled trial (RCT) [12]. The aim of this 3-arm parallel RCT was to test the effectiveness of motivational enhancement therapy (MET) and MET with cognitive behavioural therapy (CBT) compared to usual diabetes care. MET is a brief focused (usually 1–4 sessions) counseling method for enhancing motivation to change problematic health behaviours by exploring and resolving the ambivalence about change [13]. MET is the treatment of choice for alcohol misuse and smoking and there is emerging evidence of its effectiveness in diabetes [9], [14]. A recent survey of psychological needs for people with diabetes suggested that MET was probably one of the first choices for interventions to support people with mild difficulties in trying to improve glycaemic control, especially in those without formal or clinical psychiatric disorders such depressive disorders, eating disorders, addictions or personality disturbance [15]. CBT is a longer therapy (usually a 6–18 sessions) that aims to enable the patient to identify, challenge and substitute unhelpful cognitions and behaviours with more constructive ones [16]. There have been several trials suggesting that CBT can be an effective intervention for the treatment of depression in diabetes [14] but less evidence that it is effective in improving glycaemic control in type 1 diabetes [9].

Section snippets

The training programme

In the UK there is no integrated training programme on psychotherapeutic skills for diabetes professionals. We developed a curriculum that would be easy to translate into the clinical setting. The curriculum in this study had two components; the nurses were educated in specific psychotherapy skills and then tested as to whether they had acquired these skills in other words: were they now trained in them. The principles underlying the curriculum were as follows: the training and the intervention

Nurse recruitment and training

Six nurses were recruited between May 2003 and February 2006 in two rotations of 3. They were all female and had at least 3 years post-qualification experience in the field of diabetes to varying degrees; there were 3 diabetes specialist nurses, two general nurses and one mental health nurse with experience of delivering CBT in diabetes.

Therapy session attendance and selection for rating

From the participants allocated to the MET group (n = 117), 88.9% (n = 104) attended the third session. From the participants allocated to the MET with CBT group (n =

Discussion

This paper describes a training programme for the delivery of a nurse-led therapy as part of a multi-centre RCT for adults with type 1 diabetes and persistent sub-optimal glycaemic control. We recruited nurses from a variety of backgrounds and expertise and adapted their training and supervision to their needs and competency levels. We found that the nurses developed satisfactory to high levels of competency in the behaviour change techniques and psychological skills used in these treatments.

Acknowledgments

The authors thank the funders who supported this study, the Health Technology Assessment Programme; the diabetes physicians who gave their permission and enduring support, the nurse therapists who delivered the treatments and the clinical raters who devoted their time and energy in order to ensure a rigorous analysis.

Grant support: By the United Kingdom Department of Health's Health Technology Assessment Programme (project no. 01/17/05).

References (45)

E.D. Mollema et al.
Insulin-treated diabetes patients with fear of self-injecting or fear of self-testing: psychological co-morbidity and general well-being
J Psychosom Res
(2001)
K. Ismail et al.
Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes
Lancet
(2004)
F.J. Moncher et al.
Treatment fidelity in outcome studies
Clin Psych Rev
(1991)
J.W. Pennebaker
Confession, inhibition, and disease
Adv Exp Soc Psychol
(1989)
J. DeVries et al.
Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem
Diabetic Med
(2004)
M. Davies
The reality of glycaemic control in insulin treated diabetes: defining the clinical challenges
Int J Obes
(2004)
Diabetes Control and Complications Trial Research Group
Lifetime benefits and costs of tight control therapy as practised in the diabetes control and complications trial
J Amer Med Assoc
(1996)
R.A.M. Wredling et al.
Psychosocial state of patients with IDDM prone to recurrent episodes of severe hypoglycaemia
Diabetes Care
(1992)
B. Karlsen et al.
Self-reported psychological well-being and disease-related strains among adults with diabetes
Psychol Health
(2002)
A.C. Rydall et al.
Disordered eating behaviour and microvascular complications in young women with insulin-dependent diabetes mellitus
N Engl J Med
(1997)

P. Ciechanowski et al.

Depression and diabetes: impact of depressive symptoms on adherence, function, and costs

Arch Intern Med

(2000)

K. Winkley et al.

Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials

Brit Med J

(2006)

H.C. Gerstein et al.

Effects of intensive glucose lowering in type 2 diabetes

N Engl J Med

(2008)

F. Pouwer et al.

Monitoring of psychological well-being in outpatients with diabetes. Effects on mood, HbA_1c and the patient's evaluation of the quality of diabetes care: a randomized controlled trial

Diabetes Care

(2001)

K. Ismail et al.

Motivational enhancement therapy with and without cognitive behavioural therapy to treat type 1 diabetes: a randomised control trial

Ann Intern Med

(2008)

W. Miller et al.

Motivational interviewing: preparing people to change addictive behaviour

(2002)

T. Nicholson et al.

National guidelines for psychological care in diabetes: how mindful have we been?

Diabetic Med

(2009)

A. Beck

Cognitive therapy and the emotional disorders

(1976)

C. Trepka et al.

Therapist competence and outcome of cognitive therapy for depression

Cognitive Ther Res

(2004)

G. Welch

The Accu-Check Interview software program

(2000)

L.A. King

The health benefits of writing about life goals

Pers Soc Psych Bull

(2001)

H. Markus et al.

Possible selves

Am Psychol

(1986)

Cited by (31)

Digital mental health interventions for people with epilepsy: A systematic review
2023, Seizure
Although mental health difficulties are common in people with epilepsy, their assessment and treatment are rarely incorporated into routine medical care, with detrimental effects on quality of life. Several barriers to access traditional face to face interventions have been identified, including travel restriction and shortage of appropriately trained mental health clinicians. Digital mental health interventions offer the potential to improve access to mental health treatment. The main aim of the present study is to systematically review the empirical literature to identify what digital mental health interventions for adults, children and young people with epilepsy are currently available, as well as exploring if these interventions are effective in improving mental health and wellbeing.
Searches were conducted using the MEDLINE, PsycINFO, Web of Science and Embase. The reference lists of papers collected were examined in order to identify any further relevant articles cited in peer-reviewed journals. A total of 1490 papers were identified; of these 11 were included in this review. The protocol was registered in the PROSPERO database (CRD42022318658) and the PRISMA 2020 statement was followed.
Seven digital interventions were identified. All interventions were based predominantly on CBT and mindfulness techniques and showed promising results in reducing symptoms of depression, with some studies also reporting encouraging results in reducing anxiety and improving satisfaction with life and the quality of life of adults and children and young people with epilepsy.
In summary, digital mental health interventions for people with epilepsy seem to be effective and have the potential to improve access to psychological interventions and reach underserved clinical populations. However, further well-powered and methodological rigorous studies are needed to confirm the effect of such interventions for people with epilepsy.
Feasibility of telephone-delivered therapy for common mental health difficulties embedded in pediatric epilepsy clinics
2021, Epilepsy and Behavior
Citation Excerpt :
Children with epilepsy and their families want a therapist that understands the daily challenges associated with medication, seizures, and learning difficulties [15] and frequently turn to their epilepsy nurse to discuss concerns regarding emotional and behavioral difficulties [16]. Research in other areas has demonstrated that evidence-based therapies delivered by nurses working in physical health settings can be both effective and highly acceptable to patients [17–19]. This paper reports on the second phase of a five-year research program to develop and trial telephone-delivered therapy for common mental health difficulties integrated within pediatric epilepsy clinics and delivered by healthcare professionals (HCPs) who do not have significant prior formal experience of psychological therapy.
Mental and physical health treatment should be delivered together for children and young people with epilepsy. Training healthcare professionals (HCPs) in epilepsy services to deliver mental health interventions is an important way to facilitate integrated care.
To determine the feasibility of remotely delivered assessment and psychological treatment for mental health difficulties delivered by HCPs in pediatric epilepsy clinics with limited formal training in psychological interventions. We hypothesized that it would be (i) feasible to train HCPs to deliver the psychological intervention and (ii) that participants receiving the psychological therapy would report reductions in symptoms of mental health difficulties including anxiety, depression, and behavior difficulties and improve quality of life.
Thirty-four children and young people with epilepsy who had impairing symptoms of a common mental health difficulty (anxiety, depression, disruptive behavior, and/or trauma) were allocated to receive 6 months of a modular cognitive behavioral intervention delivered by a HCP with limited formal psychological therapy experience. Thirteen HCPs were trained in delivery of the intervention. Healthcare professional competence was assessed in a two-stage process. Parent-reported measures of mental health symptoms and quality of life were completed at baseline and following the intervention. Paired t-tests were used to analyze changes in symptoms over time.
All thirteen HCPs who participated in the training were considered competent in therapeutic delivery by the end of the training period. Twenty-three patients completed pre- and post-intervention measures and were included in the analysis. There were statistically significant improvements in: symptoms of mental health problems (p = 0.01; Cohen’s d = 0.62), total impact of mental health problems (p = 0.03; Cohen’s d = 0.52), anxiety and depression symptoms (p = 0.02; Cohen’s d = 0.57) and quality of life (p = 0.01; Cohen’s d = 0.57).
A modular cognitive behavioral treatment delivered over the telephone by HCPs with limited experience of psychological therapy was feasible and effective in treating mental health problems in children and young people with epilepsy. Health-related Quality of Life also improved over the duration of treatment. A randomized controlled trial (RCT) is needed to demonstrate efficacy of the intervention.
Effect of locally-contextualized nurse-led diabetes self-management education on psychosocial health and quality of life: A controlled before-after study
2021, International Journal of Africa Nursing Sciences
Our study evaluated the potential of nurse-led, locally contextualized diabetes self-management education (DSME) to modify psychosocial symptoms and health-related quality of life (HRQoL) in a resource-limited setting. Thus, a controlled, two-group, before-after study was conducted among people with type 2 diabetes mellitus (T2DM). At the baseline, 116 participants were randomly assigned to the intervention, and 104 to the comparison group. The intervention consisted of six interactive DSME sessions administered by nurses for six months.
At the endline, data from 78 (67%) intervention and 64 (62%) comparison group participants were included in the final analysis. Statistically, no significant differences were observed in depressive symptoms, stress, and HRQoL. Even though statistically not significant the proportion of participants who had eye examination at the endline was slightly greater in the intervention group, which is clinically significant in reducing the risk of diabetes retinopathy complication. Moreover, intervention group participants reported the DSME sessions to be helpful for the management of stress and depressive symptoms. We discuss different reasons that may explain the non-significant findings, most specifically, gaps in the adaptation of the education materials for a resource-limited setting, and modifications for low-literacy. Despite the non-significant findings in this part of our study, our overall project paved a way to design and test contextualized DSME programs in resource-limited settings of Africa.
This clinical trial was retrospectively registered on ClinicalTrials.gov (Identifier: NCT03185689) on June 14, 2017. https://clinicaltrials.gov/ct2/show/NCT03185689
Assessing competence in health professionals’ use of motivational interviewing: A systematic review of training and supervision tools
2020, Patient Education and Counseling
To conduct a systematic review of instruments for assessing the competency of therapists in motivational interviewing (MI) for training purposes.
A search of Medline, Emcare, CINAHL, Scopus, Proquest, and Web of Science databases yielded 20,313 articles, of which 105 were included in the review. Data were summarised in terms of the instruments’ development, adherence to MI principles, administration characteristics, psychometric properties, advantages, and disadvantages.
Twelve instruments were identified. Tools tended to be better at covering simpler MI techniques. Differences in administration burden allow users to choose between briefer but cheaper and more detailed yet costly tools. Psychometric testing was often limited, and even if more extensive, the quality was often inconsistent. Although each tool tended to have relatively unique advantages (e.g. use of client ratings), they shared common disadvantages (e.g. lack of psychometric testing).
A number of tools can be used to assess MI competency, each with their own strengths but notable weaknesses that should be considered by potential users.
There is a need to further test existing tools before creating new ones, due to the repetition of the same limitations. Standardised guidelines should also be created to ensure each tool meets the same quality standards.
A protocol for a pilot randomized controlled trial to assess the feasibility and effect of a cognitive behavioral intervention on quality of life for patients on hemodialysis
2018, Contemporary Clinical Trials
Poor health-related quality of life (HrQOL) is highly prevalent in patients on hemodialysis (HD), and is associated with increased hospitalizations and mortality. Cognitive behavioral (CB) techniques have improved HrQOL in HD patients but have not been routinely translated into clinical practice. The investigators present the rationale, study design and protocol of a randomized controlled trial to pilot the feasibility and effect of a translatable, behavioral-education intervention using CB techniques to improve poor HrQOL and self-management in hemodialysis patients.
Forty-eight HD patients will be randomly assigned to either the study intervention which includes 8–12 behavioral-education sessions with incorporated CB techniques delivered over 12 weeks or a control group of dialysis education without incorporated CB techniques. Subjects will be followed for 16 weeks and the primary outcome, change in kidney disease quality of life (KDQOL)-36 scores, will be measured at 0, 8, and 16 weeks. The study will have 85% power to detect an 8-point change in KDQOL-36 scores. At the end of the study, qualitative data will be gathered through end-of-study focus groups, and semi-structured interviews. These data will be used to refine the intervention and help translate it into clinical practice.
There is promising evidence in support of CB-based interventions to improve HrQOL for patients on HD. Despite this, these interventions have not been routinely incorporated into clinical practice. The proposed intervention has the potential to improve both HrQOL and self-management, while also being easily translatable to other HD units.
Psychological skills training to support diabetes self-management: Qualitative assessment of nurses’ experiences
2016, Primary Care Diabetes
Citation Excerpt :
The results of this study will be reported elsewhere. This evaluation is deliberately being conducted before the main quantitative results are known to minimise researcher bias in the interviews and interpretation of the data [13]. MI is a brief (usually 1–4 sessions) counselling method for enhancing motivation to change and problematic health behaviours by exploring and resolving ambivalence about change [14].
Evidence for the efficacy of psychological skills training as a method of supporting patients’ self-management is growing, but there is a shortage of mental health providers with specialist diabetes knowledge to deliver them. Primary care nurses are now increasingly expected to learn and use these techniques. This study explores nurse experience of training in six psychological skills to support patients’ self-management of type 2 diabetes.
Semi-structured interviews elicited themes relating to nurses’ experiences of participating in a trial of a psychological intervention, the Diabetes-6 study (D-6). Nurses were employed in GP surgeries in 5 South London boroughs. Thematic framework analysis was used to compare and contrast themes across participants. Nine nurses delivering the intervention (n = 11), and 7 from the control intervention (n = 12, no psychological element) were interviewed.
Three key themes were identified: (i) positive and negative impact of D6 on nurses’ practice: positives included patient empowerment; negatives included patients’ capacity to engage; (ii) professional boundaries including concerns about over-stepping role as a nurse and (iii) concerns about degree of support from physicians at participating practices in integrating psychological and diabetes care.
Primary care nurses report that psychological skills training can have a positive impact on patient care. Significant role adjustment is required, which may be aided by additional support from the practice team. Qualitative evaluation of effectiveness of psychological interventions may reveal processes that hinder or contribute to efficacy and translation. Appropriate support is necessary for primary care nurses to deliver psychological therapies with confidence.

View all citing articles on Scopus

View full text

InterventionNurse-led psychological interventions to improve diabetes control: Assessing competencies

Abstract

Objective

Methods

Results

Conclusion

Practice implications

Introduction

Section snippets

The training programme

Nurse recruitment and training

Therapy session attendance and selection for rating

Discussion

Acknowledgments

J Psychosom Res

Lancet

Clin Psych Rev

Adv Exp Soc Psychol

Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem

Diabetic Med

The reality of glycaemic control in insulin treated diabetes: defining the clinical challenges

Int J Obes

Lifetime benefits and costs of tight control therapy as practised in the diabetes control and complications trial

J Amer Med Assoc

Psychosocial state of patients with IDDM prone to recurrent episodes of severe hypoglycaemia

Diabetes Care

Self-reported psychological well-being and disease-related strains among adults with diabetes

Psychol Health

Disordered eating behaviour and microvascular complications in young women with insulin-dependent diabetes mellitus

N Engl J Med

Depression and diabetes: impact of depressive symptoms on adherence, function, and costs

Arch Intern Med

Psychological interventions to improve glycaemic control in patients with type 1 diabetes: systematic review and meta-analysis of randomised controlled trials

Brit Med J

Effects of intensive glucose lowering in type 2 diabetes

N Engl J Med

Monitoring of psychological well-being in outpatients with diabetes. Effects on mood, HbA1c and the patient's evaluation of the quality of diabetes care: a randomized controlled trial

Diabetes Care

Motivational enhancement therapy with and without cognitive behavioural therapy to treat type 1 diabetes: a randomised control trial

Ann Intern Med

Motivational interviewing: preparing people to change addictive behaviour

National guidelines for psychological care in diabetes: how mindful have we been?

Diabetic Med

Cognitive therapy and the emotional disorders

Therapist competence and outcome of cognitive therapy for depression

Cognitive Ther Res

The Accu-Check Interview software program

The health benefits of writing about life goals

Pers Soc Psych Bull

Possible selves

Am Psychol

Intervention
Nurse-led psychological interventions to improve diabetes control: Assessing competencies

Monitoring of psychological well-being in outpatients with diabetes. Effects on mood, HbA_1c and the patient's evaluation of the quality of diabetes care: a randomized controlled trial