Diabetes Management for New Nurse Practitioners
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Show notes:
Diabetes management is the bread and butter of primary care. Why is it so hard to get a handle on blood sugar levels that are out of range?
First, there’s the meds. SO many meds.
Speaking of which, we cover all the medications and updated guidelines inside the Managing Diabetes, Hypertension and CKD Review Course. Hop on the waitlist to hear about the next time it's opening.
Second, there are so many facets of this illness that make it challenging for patients to manage.
Managing Diabetes in Primary Care
In this video, you’ll learn:
The first question to start your diabetes visits with
The two camps of patients, and how to think about & help each
Strategies to help bring high A1Cs down
**Important note** A Real World NP audience member was kind enough to point out to me that referring to A1C goals out of range as "uncontrolled" is not a very patient-centered term, and encouraged me to talk about diabetes as a chronic "management" instead of something that one "controls." So I've updated the text here, but I still use the "uncontrolled" language in the video.
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Well, hey there. It's Liz Roar from Real
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World NP. And you're watching NP
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Practice Made Simple, the weekly videos
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to help save you time, frustration, and
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help you learn faster so you can take
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the best care of your patients. So, in
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this week's video, I'm going to be
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talking about uncontrolled diabetes. And
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just right off the bat, there's kind of
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two pathways. One has to do with all the
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medications, how to um titrate them,
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which ones to choose, basically where to
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go after Metformin. And I actually have
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my first live two-hour workshop coming
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up on July 30th to go over all of those
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things. It's really just too much to
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pack into one video or even a set of
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videos. So if you want to join us for
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that, go head over to
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realorldnp.comdiabetes.
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And then the other path is what I really
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want to talk about today is the all of
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the kind of factors that contribute to
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uncontrolled diabetes.
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So for me, and I'm just going to speak
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from my own experience. Um, I've been a
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nurse practitioner for almost 5 years.
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And when it comes to diabetes, um,
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especially when it's uncontrolled, so
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controlled meaning, um, 6.5, uh, 6.9 or
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less or depending on the goal depends
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obviously on, um, the patient that
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you're dealing with because of age and
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risk factors and all that kind of stuff.
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But whatever the goal is for your
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patient, if it's not in that range,
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that's what I'm talking about. And it
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can be really frustrating um, both for
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patients and for for providers, for
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nurse practitioners. So, I wanted to
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talk about a couple of things that I do
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that I find helpful to kind of help with
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um those situations, especially over
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time when they are continuing to not get
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better. So, especially as you add more
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and more medication. So, I think the
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very first thing that I want to say is
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that as a new nurse practitioner, I
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found myself feeling this way all the
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time, and I definitely see it for other
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nurse practitioners, new nurse
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practitioners now in my communities. um
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that which is that there's a desire uh
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to fix everything all at once and this
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kind of pressure we put on ourselves to
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fix everything and to address everything
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at every single visit because there's
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this urgency of like if we don't do it
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now it's just not going to get under
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control and it's going to keep spiraling
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keep spiraling and the truth of it is
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yes that's true but at the same time I
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think one of the things that um I want
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to stress to you if you're a newer nurse
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practitioner is that this if you can
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kind of zoom out of your role of like
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looking at the numbers
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um of how things are controlled or not
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controlled. Like think about it in terms
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of this patient's life. And maybe this
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is a little bit of a touchyfey type of
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video, but this is the stuff that
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actually works because when the patient
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walks into the room, you're going to
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talk about the medical management,
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right? But when they leave, they're
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going to go back to their regular life.
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And this is a lifelong illness. And it's
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very patient specific. And I think
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that's one of the hard parts about it is
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that there are medications that are
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helpful, but like if we don't have the
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other components involved, it's not
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going to get better. So, one of the
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things just first off the bat, it's all
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in my experience, it's all about
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developing rapport with patients. So, I
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am a very chill person and I try to make
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things really um comfortable for
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patients. I put everything in their
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court, their decisions, all that stuff.
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Um, but even though I try to be as
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unintimidating as possible, it is still
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intimidating to be a patient. And you
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just keeping that in mind as a provider,
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like I think that will be really helpful
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for you going forward and get less
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frustrated because if you expect the
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patients to feel intimidated when they
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go into their office visit with you, um,
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it'll kind of frame your perspective a
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little bit better because I think one of
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the things that that happens because of
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that is that patients don't necessarily
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disclose information. And I feel like
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that for me is my biggest focus is
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getting a relationship on board so that
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they can tell me very honestly what
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they're doing and they're not doing
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because if they're not going to be
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honest and you tell patients, you know,
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advise them of what you recommend that
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they do to get their diabetes under
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control. If you don't have that rapport,
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you might find yourself getting stuck.
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At least I have a number of times where
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um patients felt like they couldn't
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disclose to me that they weren't taking
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their medications, they weren't checking
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their blood sugars, things like that. Um
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and which brings me to my next point
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which is about like what is the very
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first thing that I talk about which is
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what are the barriers for you like what
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is your first of all what is your
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perspective on diabetes and what are the
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barriers for you because you have kind
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of two general camps one is that
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somebody doesn't see it as a problem
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because they feel fine or whatever
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reason that they have and then you have
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other people who are concerned about it
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however like if there are barriers in
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the way like they can't afford their
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medications they work all day they work
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uh multiple jobs they can't eat during
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the day and so they eat it all at night
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and they don't um take their meds during
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the day like that kind of thing. That'll
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kind of like shape this story for you
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about like what's actually going on here
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and will kind of help you recognize who
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is ready to make changes and who is not.
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And I think like one also thing to keep
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in mind is that there is a lot of guilt
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and a lot of shame and a lot of pressure
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on this topic in terms of provider to
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patient, patient to provider like it's
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just it's a little bit messy. Um, so I
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think if we can keep that in mind that
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there's intimidation, guilt, and shame
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in this entire conversation, it tends to
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make things a little bit easier to to
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talk about going forward. The other
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thing I want to say is that this is a
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lot to talk about in one visit. And so
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there you are allowed to make an
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appointment that is literally just about
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talking and counseling about diabetes
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where you don't have to quote fix
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something, you don't have to make an
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adjustment, you don't have to order
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something, you can literally just have a
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meeting. they come in and like all you
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do is talk. So, um, a lot of times
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that's what I have to do because my
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visits are so short. They're 15 maybe 20
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minutes max. And so, for for patients
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who are having a hard time controlling
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diabetes, I'll start with that first
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kind of question of like, what do you
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what are your thoughts about diabetes?
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How do you feel like it's going? And
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then you'll kind of feel and read
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between the lines what people are saying
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in terms of whether or not they see it
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as a problem or not. I'll kind of next
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ask like what if if they feel like it's
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a concern, um, what do you what do you
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feel like the barriers are for you? And
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then you can kind of hear from people is
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it something in the way like financial
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or time based or motivation based versus
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if they don't see it as a problem. The
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next kind of question you could ask
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there's a couple of different questions
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but I love scripts. I love relying on
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different scripts to help me. So um
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couple questions you could ask one what
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would need to happen for this to be a
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concern to you? Um another one is how
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does this fit into where you're see
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where you see yourself in the future?
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And then the other thing is what's most
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important to you in your life right now.
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So kind of using those again a little
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bit of a touchy Philly question, but you
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can ask those things to help better
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understand your patients and how this
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fits into their life. And I recognize
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that this can be challenging when you
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have language barriers, when you have
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cultural barriers between provider and
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patient. But rapport building is rapport
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building. And um that can still happen
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um in a variety of ways. And it doesn't
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have to be this kind of like rigid or
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strict. These are just kind of some
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suggestions to start with. So for the
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people who are motivated towards change,
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um, one of the things that can be really
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helpful is motivational interviewing.
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And I don't know about you if you
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learned about it in school. I certainly
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did a number of times. And I think it's
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just a little, it is a skill. And I
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think that's what's hard about it is
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that we just kind of have to practice.
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And I can actually make a separate video
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about that if you'd like. I just don't
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want to throw too much information at
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you with this one. But um basically what
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you're getting at is like what do they
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see as um an area that they're motivated
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to change or even ambivalent about
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change actually because what you're that
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like that is a normal part of the change
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process for any human being on the
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planet. And if we can kind of keep that
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in our mind about like everyone is going
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to be ambivalent about some decision,
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right? And so that we're kind of just
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focusing on like what what's catching
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them there and what are like the what
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are the little steps that they can
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commit to kind of going forward. So, one
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last thing aside from kind of like
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getting into the the touchyfey stuff for
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patients, um, is that we have a policy.
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It's a loose policy, but it's kind of a
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general guideline recommendation that
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anybody who has an A1C of greater than
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9% has monthly visits with the provider.
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Um, as well as the other resources that
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we have, community health workers,
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diabetes, uh, education through the
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nursing staff, um, things like that. But
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just kind of like again using that time.
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You don't necessarily have to make
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medication changes. You don't have to
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check their A1C every month, but you can
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just check in with them and just see how
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things are going. And I feel like the
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real change that happens for patients is
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when you have those real relationships,
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those real conversations that can be a
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little bit uncomfortable sometimes. So
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hopefully this was helpful. If you like
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this video, hit like and subscribe and
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share with your NP friends so together
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we can reach as many nurse practitioners
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as possible to help make their first
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years a little bit easier. Let me know
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if you have any questions and I would
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love to see you at the diabetes um
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medication workshop. Again, it's in July
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30th. It's going to be recorded if you
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can't make it live, but all the details
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are over at realorldnp.com/diabetes.
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Thank you so much for watching. Hang in
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there and I'll see you soon.
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