Nurse, Heal Thyself
Walking in the patient's shoes.
Maureen Anthony, MSN, RN, CS, CDE
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I became a patient not by fate or genetics, but by choice. As a diabetes educator, I'm frequently asked to counsel patients having difficulty with the changes in lifestyle necessary to achieve blood glucose control. All too often the referring physician or nurse warns that the patient is "noncompliant." I've pondered the meaning of that word for the past three decades.
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In my younger days, I thought noncompliant patients purposely ignored good advice while they blithely pursued lives of self-indulgence. Yet soon after starting work as a diabetes educator, I began to recognize the difficulty in changing lifestyles, even without the burden of insulin, glucose monitoring, and foot care. This understanding grew as I faced—and failed—my own comparatively minor challenges, such as how three pregnancies in less than four years left me with a few extra pounds to lose. I vowed "every day" to start "tomorrow," but even when tomorrow came, my attempts were fleeting—from hours to months.
Compassion began to replace my previous intolerance. I no longer saw noncompliant patients as disobedient hedonists, but as people struggling between hope and discouragement. And with this understanding came a new sense of responsibility. It didn't seem right to dish out advice without having lived the life I was advocating. I decided that for one month, I would live as though I had diabetes, complete with injections, blood glucose monitoring, meal planning, and foot care. I thought I knew what was involved; however, I soon learned that despite my years as a nurse, I really didn't have a clue.
The first time I plunged a needle into my abdomen was the only pleasant surprise of my tenure as a person with diabetes. Using a 30-gauge needle, my "insulin shots" (I used saline) were virtually painless. What I found painful was my constant vigilance surrounding my appetite. I could no longer eat what I wanted, when I wanted. I had to eat a half hour after each injection and again when the insulin peaked. I had to downsize my portions and decrease the amount of carbohydrates in my diet. I had to give up candy and potato chips, which took up too many of my carbohydrate choices. I'd always enjoyed food, but suddenly every meal was potentially fraught with guilt and shame, as I constantly struggled to make "good choices." I sorely missed my freedom with food.
What can I say about blood glucose monitoring? While it's a definite improvement since the days when patients had only vague symptoms and inexact urine dip sticks to guide them, it was one of the more challenging aspects of living with diabetes. It's more painful than insulin injections. It's also an intrusive and uncomfortable annoyance; one more reminder that life is no longer simple. Ordering, organizing, and toting supplies was a challenge. And I had the luxury of "adjusting to insulin" before I began monitoring. I can still only imagine the upheaval patients go through those first few weeks after they're sent home with a starter kit of insulin, syringes, lancets, strips, and lofty goals.
The first day, as I headed to lunch in the cafeteria, I realized that I had forgotten my meter in the office. I lost much of my break returning to retrieve my supplies. My original plan of testing four times a day was quickly replaced by a not-so-compliant once-daily schedule.
And then there was exercise. I love to walk, and when the weather is good, I normally walk up to an hour a day—but I never worry if I miss a day. But diabetes requires consistency, so I set a daily goal. Yet, every time I considered walking, I had to keep in mind my last insulin dose, when it was going to peak, and when I last ate. I had to remember to carry a source of carbohydrates in case I became hypo-glycemic. (I carried glucose tablets because I was afraid I would eat Lifesavers!) Again, the loss of spontaneity took the fun out of an activity I'd previously enjoyed.
As for foot care, I found I couldn't even remember not to walk in my bare feet, let alone check them every day. Those corns and calluses that threaten the limbs of those with diabetes remained just a minor annoyance to me. I was often tempted to quit. But living as I was recommending became a very important exercise—one that fueled my desire to eliminate the word "noncompliance" from the medical vocabulary. My month with diabetes is now a starting point in my discussions with patients, who seem to greatly appreciate my efforts. And, now, I can fully appreciate theirs.
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