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Nursing and You
Volume 1, No. 6, Dec. 1999 - Diabetes Care
Diabetes at the Doorstep: Keeping the Epidemic at Bay
With 60,000 more Canadians being diagnosed every year, diabetes can very truthfully be called the "epidemic of the millennium". And for nurses with the Peel Region VON (Victorian Order of Nurses) the evidence of that epidemic is all around them.
The Peel VON make about 180,000 visits a year in the region just west of metro Toronto, and fully 40% of these clients have been diagnosed with diabetes (even more people may have it but not know it – see stats below). Many of them have developed major complications from the disease, such as blindness or foot infections.
The Peel VON’s certified diabetes educator, Registered Nurse Linda Fraser, points out that the agency’s clients are only a small proportion of Peel’s diabetes-afflicted population.
"Generally, we see three types of people with the disease," she says. "There are those who can’t or won’t go to a regular hospital-based diabetes clinic; they may have transportation or communication problems, or other health problems that keep them at home. Others have mental or physical problems which prevent them from managing their own blood testing or insulin injections. And there are those who have severe complications from the disease, severe enough to keep them from getting out, and who require regular home nursing care."
"Specialists take care of the foot problems associated with diabetes, but along with everything else we do – IV, catheters, injections, wound dressing, and palliative care (i.e. care for a dying patient) – home care nurses are responsible for most other aspects of diabetes education and care."
"There is such a demand for diabetes care," says Linda, "that I developed a 30-hour course on the subject, and over 20 VON nurses have taken it. Now I get so many referrals from other nurses that I rarely do anything but diabetes care. I can only spread myself so thin, though. I’ll only get involved once a diagnosis has been confirmed, and even then, I have to do a lot of the work over the phone. The case load is immense."
Home care nurses specializing in diabetes care must also be prepared to work at all hours of the day and night, because with aging or infirm clients, minor lapses in diabetes management can result in major crises.
"It’s very demanding work, and also frustrating, because stabilization is the best you can do. Diabetes stays forever," she says. "The nurse’s role is to help people help themselves to keep it under control."
What is Diabetes?
Diabetes is an incurable condition in which your body cannot properly use and store the sugar you take in from the foods you eat. The pancreas, a gland in the abdomen, is supposed to take care of this by producing insulin, a hormone that helps the body to distribute sugar to the right places.
But diabetes results if either the production of insulin stops altogether (Type 1), or if the insulin produced doesn’t do its job effectively (Type 2).
Gestational diabetes, which occurs during pregnancy, is a temporary condition, although 40% of those afflicted are likely to develop Type 2 diabetes later in life. With Type 1, regular testing of blood sugar levels and regular injections of artificial insulin are necessary. With Type 2, a careful diet, monitoring of weight, and regular exercise are often sufficient to control the disease, but some medication, in the form of pills or insulin injections, may be required.
Editorial: Nurses as Part of a Team
Whenever hockey or football players are interviewed after the game and praised for their performance, they are usually eager to give much of the credit to their team-mates, or to say that their individual performance mattered little, because the team lost.
These sentiments are true in many areas of life. Certainly in this sense, nurses are much like quarterbacks or goalies, because health care in any setting is definitely a team sport. Each position is as important as any of the others. We win as a team, and we lose as a team.
All the articles in this issue of Nursing and You illustrate this concept very well. At the Thunder Bay Health Unit, nurses work alongside dentists, dieticians and health inspectors to try to preserve the wellness of their community. In North Bay, Registered Practical Nurse Christiane Fillion and her colleagues help each other in the quest of life-long learning, with strong support from their employer.
And perhaps like no other story in health care, the struggle to control diabetes dramatically illustrates the necessity of all members of the care team working harmoniously toward the same goal.
In some health care situations, although the patient has a strong voice in his care, he may not have an active role in delivering it. He trustingly gives the ball to the rest of the team.
With diabetes, however, the patient is very much a vital participant in the treatment. Self-care is the guiding principle of diabetes management, but the support group for each and every person with the disease is very large indeed, extending from an endocrinologist in a lab to a sociologist developing a computer program to help him cope better with the changes in his life.
The simple but eloquent words of Shauna Adeland in our "Reflections" story express it very well: we need to share our ideas and experiences, "hear each other’s stories", in order to give ourselves a chance to win the game. It’s something that nurses seem instinctively to know.
Mary MacLeod, RN
Council President, College of Nurses of Ontario
Margaret Risk, RN
Executive Director, College of Nurses of Ontario
Changing Behaviour: Research to Help Manage Diabetes
Of all common diseases in Canada, diabetes is probably the one for which the individual has the most control over his or her own fate. Through monitoring of blood sugar, through proper administration of medication, healthy diet and a regular exercise program, a person with diabetes can reduce or avoid the complications that lead to major health problems or even death.
Nevertheless, many people with diabetes, particularly those newly diagnosed with the disease, have trouble adjusting to the lifestyle changes that it can demand: a routine of blood testing and medication, a healthier diet, or quitting smoking, just to name a few. It is to help these people that a research project, co-directed by a nurse, is being undertaken at Toronto’s Mount Sinai Hospital.
The Diabetes: Stages of Change study has been ongoing for almost two years now, under the leadership of Helen Jones, RN, a clinical nurse specialist and manager of Mount Sinai’s Diabetes Clinical Research Unit, with Dr. Bernard Zinman of the University of Toronto.
"We have several hundred volunteers, each of whom had been diagnosed with diabetes at least a year before they became involved in the study," says Helen. "Some were on insulin, some just on diabetes pills. Half of them were randomly selected to continue with their usual management regime; this is what researchers call the "control" group. The others took part in a new treatment program called "Pathways to Change." Over 12 months, their behaviour is monitored and compared, and we hope to see that the treatment program has made a difference."
"Pathways to Change", which involves an interactive computer program, newsletters, personal reports by the participant and regular phone counselling by a nurse, was developed by a group at the University of Rhode Island, which has been studying behaviour change in the context of health care for almost 20 years. The diabetes-specific program was developed in 1997, and the Mount Sinai study is its first clinical trial.
"What the program does," says Helen, "is to try to educate and influence the person with diabetes in three fundamental areas which can effect how well they cope with the disease: blood testing, healthy eating and smoking. It gradually acclimatizes the person with diabetes to some of the personal changes that will be necessary to continue enjoying a healthy and happy life."
Nurses at Mount Sinai play a significant role in the study, introducing patients to how it works, counselling them during the year they participate, and analysing the results as they emerge. More importantly, though, if the program is shown to be effective in making self-management of diabetes easier to handle, the study will be of great benefit to nurses and their clients across Ontario.
"Nurses have always been on the front lines in diabetes care," says Helen, "helping people cope with the disease and live fairly normal lives in spite of it. ‘Pathways to Change’ could be a very powerful tool to help them do that job."
Who's Who In Public Health
In this instalment of our series designed to help the public identify the various care providers in different health care settings, we visit a thriving health unit serving a large part of northern Ontario.
The Thunder Bay District Health Unit, established in 1968 when Fort William and Port Arthur amalgamated to form a new municipality, is one of the largest in Ontario; its boundaries, in fact, take in almost 28% of the province’s total land area. The Unit has five branch offices in addition to its headquarters in Thunder Bay.
Within that area, stretching from the U.S. border to Hudson Bay, about 200,000 people live. The Health Unit provides education and preventative services in the following areas:
- chronic diseases;
- early detection of cancer;
- injury prevention;
- substance abuse;
- sexual health;
- reproductive health (such as neo-natal clinics);
- child health (including dental health and speech and hearing assessment);
- infectious disease control;
- food safety;
- safe water;
- sexually transmitted diseases, including HIV;
- tuberculosis control; and
- vaccine-preventable diseases.
To do all these things, the Thunder Bay Health Unit has a staff of 110, including 45 nurses. At their head is a physician, the Medical Officer of Health, who in turn answers to the Board of Health, a 12-member group appointed by the various municipalities in the District, which provide 50% of the Health Unit’s operating budget (the other half coming directly from provincial coffers). The Health Unit is divided into five departments:
Administrative Resources
This section provides mostly clerical, financial and technical support to the rest of the Unit. The Librarian, however, also coordinates the many community volunteers who assist with such programs as needle exchange, immunization and dietary education.
Communicable Disease / Environment & Enforcement
This group includes the Public Health Inspectors who ensure that drinking water and restaurants are safe for the public. There are several Public Health Nurses who provide education and consultation on communicable diseases, such as tuberculosis.
Clinical and Specialty Services
This group includes the dental professionals, audiologists and speech language pathologists who mostly serve pre-school and school-age children. Among the nurses are those conducting HIV testing, immunization and sexual health clinics.
Population Health Resources & Communications
This is the public communications wing of the Health Unit. It also includes the epidemiologist (in charge of immunization programs), the nutritionist and dieticians, and one nurse, coordinator of the heart health program.
Community Health Nursing
Most of the front-line nurses – visiting new moms at home, teaching pre-natal classes, speaking to the local seniors’ group or your child’s grade eight class – are based in this department, as are the nurses located in the various branch offices.
Of the Unit’s 45 nurses, 37 use the designation Public Health Nurse (PHN); all either have degrees in nursing or diplomas in public health. They are all Registered Nurses (RNs), and there are six other RNs without the PHN designation. There are also two Registered Practical Nurses (RPNs); they support the physicians and PHNs in the sexual health and immunization clinical programs.
Although Thunder Bay and the province’s other Health Units do provide some treatment, mostly in the realm of infectious diseases, the overwhelming emphasis is on the prevention of injury and disease, primarily through education and health promotion. Nurses’ special skills are essential to this effort, and key to a healthy population.
Thanks to Darlene Binette, RN, Clinical Coordinator with the Thunder Bay District Health Unit, for her help with this article.
How Nurses Regulate Themselves: Continuing Learning
Nursing is probably among the least static professions. With rapid changes in technology, with great strides in research, not to mention the radical structural changes in Ontario’s health care system, nurses have to work hard to stay current.
As Registered Practical Nurse (RPN) Christiane Fillion of North Bay says, "There is always new information, new treatments. You have to keep up on things."
Ongoing learning is a basic principle of the Quality Assurance Program of nursing’s regulatory body, the College of Nurses of Ontario. Our primary job is to protect the public interest, and helping nurses maintain competence is an important part of that job.
Acquiring a basic nursing education, writing the national exam, becoming registered with the College – these are really just the beginnings of a nurse’s life-long learning. And Christiane, although she’s been a practising nurse for less than a decade, is already a prime example.
Let’s go back to the beginning. Growing up in Elliot Lake, about halfway between Sault Ste. Marie and Sudbury, young Christiane was certain she wanted to do something exciting with her life. But what? Maybe the law, she thought, so after high school, she enrolled in a law clerk program, and quickly discovered the excitement wasn’t there. An office job was not for her.
She decided to change direction to health care, and was soon accepted at North Bay’s Canadore College for both the Dental Hygienist course and the program to become a Registered Nursing Assistant (fore-runner to the RPN – see "What is Nursing?").
"Not long before that," she recalls, "I spent a lot of time with my grandmother in Sudbury. She was very sick, and I watched what the nurses did for her. I decided that kind of hands-on care was what I wanted to do."
After taking a refresher course in chemistry over the summer, Christiane enrolled at Canadore, graduating in practical nursing in May of 1990. Although she’d taken her clinical placement (on-the-job experience) at North Bay Psychiatric Hospital, her first paying nursing job took her to a nursing home in Callander, south of North Bay. And long-term care is where she’s been ever since.
Although to her delight she was given a lot of responsibility on her first job, she only stayed a year in Callander; the lure of more money, and being closer to home, brought her back to North Bay, to Casselholme Home for the Aged. She’s been at Casselholme for eight years, but hasn’t had time to get stuck in a routine. She’s been too busy experiencing new things and learning.
The list of refresher or supplementary courses Christiane’s taken over her years in practice is a long one: medication administration, catheterization, venipuncture, human anatomy, wound management, pain management, and many others, about a dozen since she started at Casselholme. Some have been in-services, offered right in the facility. For other courses, she has travelled many miles to other cities. All have been supported by her employer.
"Casselholme’s been very encouraging. They know that everything I learn helps them. But all these courses have been baby steps, really. I’d like to go back to school full-time, maybe to become a Registered Nurse, and perhaps I’ll do it someday. I know I have the capability, but right now, I can’t afford it. And it would be very hard work. It’s something to think about."
In the meantime, Christiane "broadens her horizons", as she puts it, with a course here, an in-service there, and with Reflective Practice, the component of the QA Program that requires every Ontario nurse to have a learning plan as part of her ongoing practice.
"This year, I want to improve my charting skills. I took an in-service on it, and on my night shifts, I got other nurses to help me with it. I think Reflective Practice is very valuable."
"Nursing," she says, "can get monotonous, no matter how it looks on T.V. You have to take every chance you can to better yourself, test your abilities, stretch your limits."
It’s all part of the excitement that Christiane dreamed of, when she decided to become a nurse.
Nurses in the News: Leading the Fight Against Diabetes
Despite the continuing absence of a cure for diabetes, we can still keep fighting against the disease with the weapons at our disposal. The best weapons right now are public and professional education and scientific research. The person with chief custody of those weapons for the Canadian Diabetes Association (CDA) is a nurse.
Registered Nurse Donna Lillie is Director of National Research and Professional Education for CDA. Not only is she in charge of the innovative scientists, many of them nurses, attacking diabetes on all fronts (at a cost of about $5 million this year), she is also at the head of the national network of diabetes educators (the majority of whom are nurses), who are key to the management of the disease.
"The diabetes team is a very large one, of course," she says, "and at the centre is the client, so very responsible for her or his own care. But the nurse educator is often the prime motivator and coordinator, the one who makes sure they are all moving in sync, in the same direction."
As for her own position, Donna says that being a nurse, with a background in patient education as well as hospital administration, gives her experience with the entire spectrum of diabetes care, and allows her to see a problem or solution from several different perspectives.
What are CDA’s principal goals at this stage of the fight? "Our ultimate goal, of course, is the elimination of diabetes; it’s hard to say how close we are to that. In the meantime, we need to make the quality of life of the person with diabetes the best it can possibly be. That means heightening the public’s awareness, catching the disease early so complications don’t arise, making sure that those already diagnosed know how much they can do, and have the skills to manage the disease."
"In research," says Donna, " there are new drug therapies on the horizon, new ideas in nutrition, as well as exciting projects looking at the causes of Type 2, and trying to get the pancreas working again. The best research, I think, comes from brilliant ideas, and we’re fortunate to have some truly brilliant people working on our behalf."
Coordinating the efforts of those brilliant minds, as well as the hundreds of educators trying to keep the "epidemic" of diabetes under control, is a mammoth task. In nurse Donna Lillie, Canadians with diabetes have a very strong weapon indeed.
Diabetes: Symptoms and Risk Factors
The following symptoms will occur suddenly and dramatically with Type 1 diabetes, more slowly (or perhaps not at all) with Type 2:
- unusual thirst or change of appetite;
- unusual weight loss;
- frequent urination;
- extreme fatigue;
- irritability;
- blurred vision;
- vomiting or nausea;
- slow-healing cuts or bruises; or
- tingling or numbness in the extremities.
You may be more at risk for developing diabetes if you:
- have a family history of diabetes;
- are over 45 years old;
- are severely overweight;
- have given birth to a large baby (over four kilograms);
- are inactive; or
- are of Hispanic, African or Aboriginal descent.
Diabetes is a leading cause of death by disease in Canada, and if improperly managed can lead to blindness, amputations, heart disease, kidney disease or impotence. If diagnosed early and well managed, diabetes need not result in any of these complications.
What Is Nursing?
(with a short history of the Registered Practical Nurse)
The goal of nursing is to restore, maintain and advance the health of individuals, groups or entire communities. It is both a "science" and an "art". The science is the application of nursing knowledge and the technical aspects of the practice. The art is the establishment of a caring relationship through which the nurse applies nursing knowledge and uses judgement in a compassionate manner. Both focus on the whole person, not just a particular health problem.
Nurses can play many different roles – clinical practitioner, administrator, teacher, researcher – in many different settings: hospitals, long-term care facilities, patients’ homes, clinics, industry, or classrooms, to name just a few. They care for patients at all stages of the life cycle and in all states of health, from normal functioning to crisis.
In Ontario, the nursing profession is comprised of two groups: Registered Nurses (RNs) and Registered Practical Nurses (RPNs); they are the only health care providers entitled to call themselves "nurses". The two categories are subject to the same regulatory requirements; the general standards of practice, the complaints and discipline process, the registration process, all are the same. The major areas of difference are in educational preparation, and consequently in the depth and breadth of practice.
RNs have existed for more than a century. RPNs, however, had their genesis in World War II, as the demand for more nurses prompted a number of six-month training programs for "practical nurses" across Canada. After the war, the first training centres for "certified nursing assistants" were established in Ontario, and in 1953 the length of the education program expanded to 10 months.
The first professional association for "nursing assistants" was founded in 1958, and its name changed over the years as its members changed to "registered nursing assistants" and then, in 1993, "registered practical nurses". The Registered Practical Nurses Association of Ontario now provides a variety of practice support programs, and advocates for the over 33,000 RPNs across the province. In 30 colleges and secondary schools, the current length of the RPN educational program is three semesters. At present, new program standards are being developed for RPN basic education, based on expanded expectations that the College of Nurses has set for RPNs entering the profession in 2005.
Reflections: The Impact of Type 1 Diabetes on a Young University Student
In 1985, when she was only five years old, Shauna Adeland of London was diagnosed with diabetes. It changed her life, and that of her parents, who had to dedicate a lot of time to helping their daughter manage her disease. Her parents became very involved in diabetes education and research through the Canadian Diabetes Association, and as she got older, Shauna followed their example. With time, she also became much more independent in her self-care. This past fall, Shauna began her first year at the University of Western Ontario, aiming toward a career in social work. Although she still lives at home, the university routine presents new challenges to Shauna in controlling her diabetes. And the age of 19 is always an important watershed for those with diabetes; paediatric care is left behind, and a high degree of self-management assumed. These are some of Shauna’s thoughts on living with the disease.
As soon as I wake up in the morning, the first thing I always do is test my blood, to give me an idea of what kind of blood sugar I'm dealing with and to help me adjust my insulin accordingly. I used to be on two shots of insulin a day, but switched over to three for better control.
I'm a vegetarian, and my diet is very healthy. I eat three meals a day, with occasional snacks. Before Humalog (a fast-acting type of insulin) it was important to eat snacks between all your meals, but now you don't have to. Humalog is a great product and helps a lot of young people living with diabetes to lead more active and spontaneous life styles. You have a lot more freedom in the times you have to eat, when you have to get up, etc...
I always carry a blood glucose monitor to school with me, in case I feel low in blood sugar or just want to test my blood. I also carry a Humalog pen with me, in case I don't make it home for dinner. And I always carry a little bit of food to up my sugar levels, just in case. If the bus breaks down and I end up walking for 20 minutes, I need to be ready to compensate.
I take my third shot of insulin at night before bed. I also like to test before going to bed, and judge if I need a snack or not, depending on my blood sugar.
I've had diabetes since the age of five, so I don't really remember what life was like "before diabetes". When I was small, even my dolls had diabetes. It’s so routine that I don't even think about it.
My parents have always told me I can do anything I want to, and it’s true. I just can’t go crazy about it, like eat a whole bag of licorice. But even now, some people stare if they see me eat a chocolate chip cookie. You really can do anything, as long as you’re prepared to make the proper adjustments. I’ve never really encountered any discrimination because of the disease. People just don’t know what it means to have this disease.
I feel comfortable doing my insulin or testing wherever I am. I don't feel the need to hide it or be embarrassed about living with diabetes. I like it when it starts conversations, because it’s a great informal way to educate people.
Providing a voice
When I was diagnosed with Juvenile Diabetes, now called Type 1, my parents, like probably all parents whose child has been diagnosed with a chronic disease, wanted to quit their jobs and go out and find a cure for me. They made me a deal. They would do everything in their power to raise funds on behalf of the Canadian Diabetes Association (CDA). In turn, when it was time for me to pitch in and become involved, I would do that.
As a young child, every March (now November is Diabetes Month) meant canvassing door-to-door with my family. Volunteering became infectious. The more involved I became, the more involved I wanted to be. The idea of organizing a support group for teens grew from a thought to a reality. Now, it’s my hope that the London Teen Group can serve as a model for teens with diabetes in other communities. Also, I now sit on the Board of the London and District Branch of CDA, providing another way for young people with diabetes to be heard.
From age 8, I’ve attended Camp Huronda (a residential camp for children with diabetes, on Lake Waseosa near Huntsville), for many years as a camper, more recently as a counsellor, and the last two years as a section head in charge of arts and crafts. There, many of the young counsellors provided me with a positive role model. Now, as a staff member, I have the chance to return the favour.
Over the years, I have been a part of many exciting programs that have brought young people with diabetes together. We need to meet each other and hear each other’s stories, no matter how old or young we are. The support that we bring to each other is so important.
Sure, if I’d had the choice, I would not have chosen to have diabetes. Now that I have it, however, it is important to live my life positively, and to provide a voice for those who cannot be heard.
Encounters with Nurses
Since I was quite young, I’ve tried to take the responsibility for controlling my diabetes. I’ve gotten pretty good at it; even when I don’t feel like making the effort, my brain and my heart force me to take the time to do the right thing. If I ever make a mistake, though, I know there will be lots of people there to catch me. My parents would be first in line, and a nurse would be right behind them.
In the last several years, I’ve seen nurses in connection with my diabetes in two main places. One is the hospital, when I make my regular trips to the diabetes clinics (now that I’m an adult, these happen only twice a year instead of four times). Nurses welcome me, make me comfortable, do the initial assessment of my physicial condition. Then, in addition to seeing the endocrinologist and the dietician, I spend quite a while with the diabetes educator, an RN, who talks to me about changes in my lifestyle, and what they mean to my diabetes. I know I can call her whenever I have a problem.
Also, at Camp Huronda, CDA’s camp for kids, nurses were always there, teaching and supporting. I’m a staff member now, and many of the nurses have become good friends.
So much of taking charge of your diabetes is being confident, trusting yourself and those who are helping you. Nurses have done a lot to build that trust as I was growing up; now I know I’ll never lose it.
What is the College of Nurses of Ontario?
The College of Nurses (CNO) is the regulatory body for nursing in this
province. Established by, but at arm’s length from, the provincial
government, CNO derives its revenues from annual membership fees; it receives
no funding from the province. The College decides the criteria for becoming
a nurse in Ontario, and the standards of practice to be met to maintain
that designation and privilege. No one can practice as a nurse in Ontario,
or use the titles "nurse", "registered nurse", or
"registered practical nurse", without a valid certificate of
registration from the College.
Contact Us
For further information about any aspect of nursing regulation in Ontario, including how to express a concern about a nurse's conduct or practice, please contact:
College of Nurses of Ontario
101 Davenport Road
Toronto, Ontario, M5R 3P1
cno@cnomail.org
Telephone: 416-928-0900 or Toll Free 1-800-387-5526
Fax: 416-928-9841
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