ORIGINAL RESEARCH
Self-monitoring of blood glucose experiences of adults with type 2 diabetes Lucie B. Dlugasch, PhD, APRN (Assistant Clinical Professor)1 & Doris N. Ugarriza, PhD, APRN (Professor)2 1 2
College of Nursing and Health Sciences, Florida International University, Miami, Florida School of Nursing and Health Sciences, University of Miami, Coral Gables, Florida
Keywords Type 2 diabetes mellitus; diabetes mellitus; self-monitoring of blood glucose; self-monitoring of blood glucose experiences. Correspondence Lucie B. Dlugasch, PhD, APRN, College of Nursing and Health Sciences, Florida International University, 11200 SW 8 st, AHC 3, Room 227, Miami, Florida 33199. Tel: 305-348-0367; Fax: 305-348-7051; E-mail: lucie.dlugasch@fiu.edu Received: August 2011; accepted: January 2012 doi: 10.1002/2327-6924.12042
Abstract Purpose: The purpose of this study was to analyze the experiences of selfmonitoring of blood glucose (SMBG) usage of adults with type 2 diabetes mellitus (T2DM) who are not using insulin. Data sources: Nineteen adults were asked to describe their experiences with self-monitoring. Data were analyzed using the grounded theory method. Conclusions: The theory of “SMBG as a Cue in T2DM Self-Care” emerged from the data and is composed of four categories: (a) Engaging, (b) Checking, (c) Responding, and (d) Establishing a Pattern. Engaging marks the beginning. Frequent monitoring characterizes this stage. Checking involves evaluating and validating the blood glucose level. The most common item evaluated or validated was the effect of foods. Responding involves taking action or experiencing emotion. Actions taken centered on dietary changes. Emotions felt were dependent on the level and ranged from blame to happiness. Participants established a pattern and used SMBG regularly or sporadically. Frequency was based on obtaining “normal” patterns, the absence of symptoms, provider disinterest, and fingertip pain. Implications for practice: Participants described many benefits and struggles when incorporating SMBG into their self-care. Information from this study could be used to develop effective guidelines for the use of SMBG in T2DM.
Introduction Self-monitoring of blood glucose (SMBG) was introduced approximately 30 years ago as part of a treatment plan to provide individuals with diabetes mellitus (DM) “real-time” blood glucose levels (Sonksen, Judd, & Lowy, 1978; Walford, Fale, Allison, & Tatersall, 1978). By knowing their blood glucose levels, individuals with DM can make lifestyle or pharmacologic changes to achieve blood glucose control. Blood glucose control is a fundamental outcome of a successful DM management plan and has been associated with a reduction in complications of DM (Gerich, 2005; The ACCORD Group, 2008; The ADVANCE Group, 2008; The DCCT Research Group, 1993; UKPDS Group, 1998). Despite the years of SMBG use, the efficacy of SMBG for individuals with type 2 diabetes mellitus (T2DM) who are not on insulin is questionable and controversial (ADA, 2011; Coster, Gulliford, Seed, Powrie, & Swaminathan, 2000; McAndrew, Schneider, Burns, & Leventhal, 2007; McGeoch, Derry, & Moore,
2007; Sarol, Nicodemus, Tan, & Grava, 2005; Welschen et al., 2005). Researchers have failed to explain how and why some individuals change their behaviors with SMBG use and others do not (McAndrew et al., 2007). The purpose of this study was to describe and analyze the experiences of SMBG usage of adults with T2DM who are not using insulin and to develop a theory of SMBG. With a better understanding of how individuals use SMBG values, nurse practitioners (NPs) may be able to guide their patients in the effective use of SMBG and develop better practice guidelines.
Background SMBG levels represent the frequent variations in daily blood glucose levels that reflect the degree of blood glucose level stability. Five studies were found in the literature that describe how individuals use SMBG levels and what role and value SMBG plays in a T2DM
C 2013 The Author(s) Journal of the American Association of Nurse Practitioners 26 (2014) 323–329
C 2013 American Association of Nurse Practitioners
323
Self-monitoring of blood glucose experiences of adults
self-management plan (Bjorness, Krezowski, McDowall, Butcher, Helgerson, & Gohdes, 2003; Hjelm, Nyberg, & Apelqvist, 2001; Peel, Douglas, & Lawton, 2007; Peel, Parry, Douglas, & Lawton, 2004; Stewart et al., 2004). Four of the five studies took place outside the United States: one in Sweden (Hjelm et al., 2001), one in the United Kingdom (Stewart et al., 2004), and two in Scotland (Peel et al., 2004, 2007). In four of the five studies, the sample included participants using insulin (Bjorness et al., 2003; Hjelm et al., 2001; Peel et al., 2007; Stewart et al., 2004). The inclusion of participants with T2DM who are on insulin limits the interpretation of the role of SMBG for individuals with T2DM who are not using insulin. All of the studies were inadequate because of various methodological limitations or flaws. Peel and colleagues (2004) had participants who were diagnosed with T2DM for less than 6 months thereby limiting the understanding of experiences over time. Three studies did not include questions to evaluate patients’ views, attitudes, or reasons underlying their behavior as it pertains to SMBG use (Bjorness et al., 2003; Hjelm et al., 2001; Stewart et al., 2004). Stewart et al., 2004, did not identify how their open-ended questions were analyzed. Peel and colleagues (2004) used grounded theory methods but the analytical techniques were not consistent with grounded theory. A different approach and re-evaluation of SMBG use in a U.S. population with individuals with T2DM who were not on insulin was considered necessary.
Methods A grounded theory design was used for the study (Corbin & Strauss, 2008). The emphasis in grounded theory on analyzing structure and process was considered the most appropriate method for analyzing experiences and capturing the dynamic, evolving, and complex nature of the health behavior of SMBG from the patient’s point of view.
Sample The study participants were recruited from South Florida using purposive and network sampling techniques during 2008. The participants were self-identified English speaking, Caucasian American adults over the age of 18 who had a diagnosis of T2DM for longer than 6 months. Caucasian Americans account for 14.9 million of all non-Hispanic Whites over 20 years old who are diagnosed with DM, a substantial group (Centers for Disease Control and Prevention, 2007). All participants were on
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dietary therapy only or dietary therapy in combination with oral medications and/or a noninsulin injectable such as Byetta. To ensure variability and to avoid premature sampling closure, the sample consisted of men and women of varying age groups who monitored their own blood glucose with different frequencies within a week. Redundancy, adequate variability, and saturation were reached after 14 participants were interviewed. Five additional participants were interviewed to assure that categories and patterns were stable.
Procedure The study was approved by the institutional review board at the University of Miami. Face-to-face or phone interviews were conducted in a semistructured manner incorporating open-ended questions. The interviewer started by asking the broad question, “What are your experiences with self-monitoring of blood glucose?” The interviews were immediately transcribed and analyzed and used as a basis for guiding and refining questions for each interview. The interviews lasted between 15 min and 21 s to 40 min and 56 s.
Analysis A qualitative software program MAXQDA was used to code, store, sort, and retrieve data from the interviews. The first analytical coding technique used was open coding. Properties (characteristics) and dimensions (variation of a property along a range) of codes were identified and codes were placed into categories and subcategories (Corbin & Strauss, 2008). The second analytic technique used was axial coding which is the process of relating categories and subcategories by analyzing their properties and dimensions. The number of identified categories was reduced and several categories were collapsed into a larger category. The last analytic technique used was the process of integrating and refining the theory. A central (core) category was identified (Corbin & Strauss, 2008; Glaser & Strauss, 1967).
Findings Table 1 is a description of the sample. The core category that emerged in this study is “SMBG: A Cue in T2DM Self-Care.” The experience of SMBG is composed of four categories that evolve over time and except for the first category, may be repeated more than once. These categories are (a) Engaging, (b) Checking, (c) Responding, and (d) Establishing a Pattern. A schematic description of
Self-monitoring of blood glucose experiences of adults
L. B. Dlugasch & D. N. Ugarriza
Table 1 Demographic characteristics of participants
Male Female Age (year) 30–39 40–49 50–59 60–69 70–79 Highest level of education Less than high school High school Some college Bachelors degree Postgraduate degree Annual household income $100,000 Duration of diagnosis 6 month to
Self-monitoring of blood glucose experiences of adults with type 2 diabetes Lucie B. Dlugasch, PhD, APRN (Assistant Clinical Professor)1 & Doris N. Ugarriza, PhD, APRN (Professor)2 1 2
College of Nursing and Health Sciences, Florida International University, Miami, Florida School of Nursing and Health Sciences, University of Miami, Coral Gables, Florida
Keywords Type 2 diabetes mellitus; diabetes mellitus; self-monitoring of blood glucose; self-monitoring of blood glucose experiences. Correspondence Lucie B. Dlugasch, PhD, APRN, College of Nursing and Health Sciences, Florida International University, 11200 SW 8 st, AHC 3, Room 227, Miami, Florida 33199. Tel: 305-348-0367; Fax: 305-348-7051; E-mail: lucie.dlugasch@fiu.edu Received: August 2011; accepted: January 2012 doi: 10.1002/2327-6924.12042
Abstract Purpose: The purpose of this study was to analyze the experiences of selfmonitoring of blood glucose (SMBG) usage of adults with type 2 diabetes mellitus (T2DM) who are not using insulin. Data sources: Nineteen adults were asked to describe their experiences with self-monitoring. Data were analyzed using the grounded theory method. Conclusions: The theory of “SMBG as a Cue in T2DM Self-Care” emerged from the data and is composed of four categories: (a) Engaging, (b) Checking, (c) Responding, and (d) Establishing a Pattern. Engaging marks the beginning. Frequent monitoring characterizes this stage. Checking involves evaluating and validating the blood glucose level. The most common item evaluated or validated was the effect of foods. Responding involves taking action or experiencing emotion. Actions taken centered on dietary changes. Emotions felt were dependent on the level and ranged from blame to happiness. Participants established a pattern and used SMBG regularly or sporadically. Frequency was based on obtaining “normal” patterns, the absence of symptoms, provider disinterest, and fingertip pain. Implications for practice: Participants described many benefits and struggles when incorporating SMBG into their self-care. Information from this study could be used to develop effective guidelines for the use of SMBG in T2DM.
Introduction Self-monitoring of blood glucose (SMBG) was introduced approximately 30 years ago as part of a treatment plan to provide individuals with diabetes mellitus (DM) “real-time” blood glucose levels (Sonksen, Judd, & Lowy, 1978; Walford, Fale, Allison, & Tatersall, 1978). By knowing their blood glucose levels, individuals with DM can make lifestyle or pharmacologic changes to achieve blood glucose control. Blood glucose control is a fundamental outcome of a successful DM management plan and has been associated with a reduction in complications of DM (Gerich, 2005; The ACCORD Group, 2008; The ADVANCE Group, 2008; The DCCT Research Group, 1993; UKPDS Group, 1998). Despite the years of SMBG use, the efficacy of SMBG for individuals with type 2 diabetes mellitus (T2DM) who are not on insulin is questionable and controversial (ADA, 2011; Coster, Gulliford, Seed, Powrie, & Swaminathan, 2000; McAndrew, Schneider, Burns, & Leventhal, 2007; McGeoch, Derry, & Moore,
2007; Sarol, Nicodemus, Tan, & Grava, 2005; Welschen et al., 2005). Researchers have failed to explain how and why some individuals change their behaviors with SMBG use and others do not (McAndrew et al., 2007). The purpose of this study was to describe and analyze the experiences of SMBG usage of adults with T2DM who are not using insulin and to develop a theory of SMBG. With a better understanding of how individuals use SMBG values, nurse practitioners (NPs) may be able to guide their patients in the effective use of SMBG and develop better practice guidelines.
Background SMBG levels represent the frequent variations in daily blood glucose levels that reflect the degree of blood glucose level stability. Five studies were found in the literature that describe how individuals use SMBG levels and what role and value SMBG plays in a T2DM
C 2013 The Author(s) Journal of the American Association of Nurse Practitioners 26 (2014) 323–329
C 2013 American Association of Nurse Practitioners
323
Self-monitoring of blood glucose experiences of adults
self-management plan (Bjorness, Krezowski, McDowall, Butcher, Helgerson, & Gohdes, 2003; Hjelm, Nyberg, & Apelqvist, 2001; Peel, Douglas, & Lawton, 2007; Peel, Parry, Douglas, & Lawton, 2004; Stewart et al., 2004). Four of the five studies took place outside the United States: one in Sweden (Hjelm et al., 2001), one in the United Kingdom (Stewart et al., 2004), and two in Scotland (Peel et al., 2004, 2007). In four of the five studies, the sample included participants using insulin (Bjorness et al., 2003; Hjelm et al., 2001; Peel et al., 2007; Stewart et al., 2004). The inclusion of participants with T2DM who are on insulin limits the interpretation of the role of SMBG for individuals with T2DM who are not using insulin. All of the studies were inadequate because of various methodological limitations or flaws. Peel and colleagues (2004) had participants who were diagnosed with T2DM for less than 6 months thereby limiting the understanding of experiences over time. Three studies did not include questions to evaluate patients’ views, attitudes, or reasons underlying their behavior as it pertains to SMBG use (Bjorness et al., 2003; Hjelm et al., 2001; Stewart et al., 2004). Stewart et al., 2004, did not identify how their open-ended questions were analyzed. Peel and colleagues (2004) used grounded theory methods but the analytical techniques were not consistent with grounded theory. A different approach and re-evaluation of SMBG use in a U.S. population with individuals with T2DM who were not on insulin was considered necessary.
Methods A grounded theory design was used for the study (Corbin & Strauss, 2008). The emphasis in grounded theory on analyzing structure and process was considered the most appropriate method for analyzing experiences and capturing the dynamic, evolving, and complex nature of the health behavior of SMBG from the patient’s point of view.
Sample The study participants were recruited from South Florida using purposive and network sampling techniques during 2008. The participants were self-identified English speaking, Caucasian American adults over the age of 18 who had a diagnosis of T2DM for longer than 6 months. Caucasian Americans account for 14.9 million of all non-Hispanic Whites over 20 years old who are diagnosed with DM, a substantial group (Centers for Disease Control and Prevention, 2007). All participants were on
324
L. B. Dlugasch & D. N. Ugarriza
dietary therapy only or dietary therapy in combination with oral medications and/or a noninsulin injectable such as Byetta. To ensure variability and to avoid premature sampling closure, the sample consisted of men and women of varying age groups who monitored their own blood glucose with different frequencies within a week. Redundancy, adequate variability, and saturation were reached after 14 participants were interviewed. Five additional participants were interviewed to assure that categories and patterns were stable.
Procedure The study was approved by the institutional review board at the University of Miami. Face-to-face or phone interviews were conducted in a semistructured manner incorporating open-ended questions. The interviewer started by asking the broad question, “What are your experiences with self-monitoring of blood glucose?” The interviews were immediately transcribed and analyzed and used as a basis for guiding and refining questions for each interview. The interviews lasted between 15 min and 21 s to 40 min and 56 s.
Analysis A qualitative software program MAXQDA was used to code, store, sort, and retrieve data from the interviews. The first analytical coding technique used was open coding. Properties (characteristics) and dimensions (variation of a property along a range) of codes were identified and codes were placed into categories and subcategories (Corbin & Strauss, 2008). The second analytic technique used was axial coding which is the process of relating categories and subcategories by analyzing their properties and dimensions. The number of identified categories was reduced and several categories were collapsed into a larger category. The last analytic technique used was the process of integrating and refining the theory. A central (core) category was identified (Corbin & Strauss, 2008; Glaser & Strauss, 1967).
Findings Table 1 is a description of the sample. The core category that emerged in this study is “SMBG: A Cue in T2DM Self-Care.” The experience of SMBG is composed of four categories that evolve over time and except for the first category, may be repeated more than once. These categories are (a) Engaging, (b) Checking, (c) Responding, and (d) Establishing a Pattern. A schematic description of
Self-monitoring of blood glucose experiences of adults
L. B. Dlugasch & D. N. Ugarriza
Table 1 Demographic characteristics of participants
Male Female Age (year) 30–39 40–49 50–59 60–69 70–79 Highest level of education Less than high school High school Some college Bachelors degree Postgraduate degree Annual household income $100,000 Duration of diagnosis 6 month to
