Improving insulin adherence in diabetes care

Despite the benefits of insulin therapy, many people with diabetes don’t adhere to treatment. Some avoid insulin therapy or refuse to start it. A recent study found more than a third of the roughly 25 million Americans with diabetes don’t take insulin as prescribed and 20% intentionally skip some doses, which can lead to serious health risks.

A study of nurses and physicians found nurses can play a more important role in improving insulin adherence. As nurses, we’re well positioned to help patients improve adherence because we play a key part in patient education, spend proportionately more time with patients than do other healthcare providers, and may be more familiar with a patient’s health history. Although time constraints may pose a challenge for nurses, if we ask the right questions during outpatient visits and hospital stays and address patient concerns, we can help motivate patients to take control of diabetes and adhere to insulin therapy over the long term.

Using the strategies described in this article, you can help patients better understand and address the challenges of insulin therapy. Patients who receive more comprehensive information about their care are better able to monitor and manage their condition at home.

Tailor the treatment plan

When talking with patients, ask about their lifestyle and concerns about treatment. Then work with the healthcare provider who manages their insulin to develop a treatment plan custom­ized to each patient’s needs and abilities. Communication is especially crucial before and during initiation of insulin therapy. But you also should continue to communicate with patients after treatment begins or when it’s modified. In many cases, patients don’t ask for help or discuss concerns related to self-care while in the hospital, unless their admission is diabetes related. But a hospital stay is a good opportunity to ask about treatment challenges or elicit the patient’s questions.

You may want to consider using a motivational interview to encourage patients to identify and resolve concerns about their insulin regimen. The question-and-answer format of the motivational interview helps patients identify, discuss, and address challenges. For example, ask patients to describe insulin benefits and drawbacks and which factors typically cause them to change their injection behavior. Then offer positive reinforcement. Based on their answers, collaborate with the healthcare pro­vider who manages the patient’s insulin to make appropriate changes to the treatment plan.

Barriers to adherence

Many patients find insulin therapy complicated, inconvenient, and painful. Some skip insulin doses or stop taking insulin altogether because of a mental barrier, such as fear of needles. To empower them and help them overcome their fears, provide targeted information. For example, various strategies can ease the fear of injection. To teach the proper technique, use an injection pad; have the patient practice inserting the needle without injecting medication. (See Six weeks in their patients’ shoes by clicking the PDF icon above.)


Comforting language can ease patient anxiety, too. When providing injection instructions, avoid such words as “shooting,” “spearing,” and “stabbing”; these may increase anxiety. Also, inform patients that certain techniques can reduce injection pain. (See How to reduce pain from insulin injection by clicking the PDF icon above.)

Choosing the proper needle for the patient can reduce both anxiety and injection-site discomfort. Researchers have developed a shorter 4-mm pen needle with a narrow gauge (32G) that has been shown to reduce injection pain and anxiety in insulin delivery, especially in children. These smaller needles are less intimidating and less likely to reach muscle tissue in leaner patients. (In contrast, traditional longer needles commonly are injected into muscle tissue, which increases insulin absorption, negatively affecting both pain and blood glucose control.) Insulin pen needles are available in 4-mm (32G), 5-mm (31G), 8-mm (31G), and 12.7-mm (29G) sizes. Insulin syringes are available in 6-mm (31G), 8-mm (31G), and 12.7-mm (31G) sizes.

Although some studies indicate patients can reuse needles, this practice could increase injection pain. (See Don’t reuse insulin needles or pen needles by clicking the PDF icon above.)

Dosing using pen needles makes injections easier for some patients, and studies report greater patient satisfaction with prefilled disposable insulin pens. In a randomized trial of 121 patients with type 1 or 2 diabetes, 74% preferred a prefilled insulin pen device over vials and syringes. In a crossover study of 60 patients older than age 60, 54 (90%) found the functioning of a prefilled insulin pen easy to understand and preferred it.

Needed: A renewed focus on patient education

Despite widespread insulin use, several studies show patient education on many aspects of diabetes care (including drug-delivery options) is inadequate for many patients. For education to be effective, they should receive comprehensive information on the following:

  • review and “teach back” of the insulin regimen
  • options regarding different needle lengths
  • availability of insulin pens with shorter needles
  • injection-site selection, rotation, and care
  • proper insulin administration technique
  • how to identify and avoid injection-site complications
  • safe disposal of used sharps.

Besides talking through these issues with a nurse, patients should have this information available for reference at home.

Take advantage of teachable moments

With the right educational resources, you can take advantage of many teachable moments during patient interactions. In the hospital, insulin is given four times each day; this creates four teachable moments.

A misconception exists that teaching a patient how to administer insulin takes more time than a nurse may have. But delivering teaching during scheduled insulin doses takes only 5 to 10 minutes. Over the course of a patient’s hospital stay, these 5 to 10 minutes per administration add up and can pay high dividends by enabling patients to self-administer insulin safely. This approach is much less stressful than teaching patients everything they need to know on discharge day.

In addition, healthcare settings should have a range of diabetes-care information material available to give to patients with questions or concerns. Materials should be written in language that’s easy to read and understand. For example, the BD Getting Started™ Take Home Kit contains an instruction book, glucose tablets, alcohol wipes, five pen needles or insulin syringes, and a personal diabetes care card.

Emphasize overall self-care

Diabetes self-management education is a collaborative process through which patients with diabetes gain the knowledge and skills they need to modify their behavior and self-manage their condition. According to the American Association of Diabetes Educators (AADE), when patients understand how best to manage their health, they can improve their health status and quality of life and reduce the need for costly health care. (See Self-care behaviors related to diabetes management by clicking the PDF icon above.) Also, suggest a family member or close friend become involved in the patient’s self-care. At-home support may help patients better adhere to treatment.

Take steps to make a difference

By addressing patient concerns both proactively and reactively, you can help patients continue insulin therapy successfully, with less pain and anxiety. Establishing a team of diabetes nurse champions dedicated to self-management education can make these goals a priority. A clearly defined diabetes-education model with policies and protocols helps ensure nurses are familiar with and can easily reference the important steps necessary to empower patients to self-manage their diabetes.

To take these steps, nurses need to have adequate training to understand challenges to patient acceptance and adherence, as well as ways to address them. Training also helps nurses expand their focus on education without enduring even greater time constraints on their patient interactions. Finally, communicating with peers about best practices in diabetes self-management education can help make your teaching more effective and help you recognize when a patient needs additional teaching.

Selected references

A look at the reuse of insulin needles. Becton Dickinson.com. 2006. www.bd.com/us/diabetes/download/Reuse_White_Paper.pdf. Accessed July 19, 2013.

American Association of Diabetes Educators. Measurable behavior change is the desired outcome of diabetes education. (n.d.)
www.diabeteseducator.org/ProfessionalResources/AADE7. Accessed July 16, 2013.

Frid A, Hirsch L, Gaspar R, et al.; Scientific Advisory Board for the Third Injection Technique Workshop. New injection recommendations for patients with diabetes. Diabetes Metab. 2010;36(suppl 2):S3-S18.

Gibney MA, Arce CH, Byron KJ, et al. Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections: implications for needle length recommendation. Curr Med Res Opin. 2010;
26(6):1519-30.

Hirsch LJ, Gibney MA, Albanese J, et al. Comparative glycemic control, safety and patient ratings for a new 4 mm X 32G insulin pen needle in adults with diabetes. Curr Med Res Opin. 2010;26(6):1531-41.

Institute for Safe Medication Practices. Ongoing concern about insulin pen reuse shows hospital need to consider transitioning away from them. February 7, 2013. www.ismp.org/newsletters/acutecare/showarticle.asp?id=41. Accessed July 19, 2013.

Meece J. Effect of insulin pen devices on the management of diabetes mellitus. Am J Health Syst Pharm. 2008;65(11):1076-82.

Peyrot M, Barnett AH, Meneghini LF, et al. Factors associated with injection omission/non-adherence in the Global Attitudes of Patients and Physicians in Insulin Therapy study. Diabetes Obes Metab. 2012;14(12):1081-7.

Peyrot M, Rubin RR, Kruger DF, et al. Correlates of insulin injection omission. Diabetes Care. 2010;33(2):240-45.

Rowe K, Weatherall R. Why do patients fail to follow long term treatment? Nurs Times. 2011;107(13):12-5.

Siminerio LM, Funnell MM, Peyrot M, et al. US nurses’ perceptions of their role in diabetes care: results of the cross-national Diabetes Attitudes Wishes and Needs (DAWN) Study. Diabetes Educ. 2007;33(1):152-62.

Siminerio L, Kulkarni K, Meece J, et al.; American Association of Diabetes Educators. Strategies for insulin injection therapy in diabetes self-management. 2011. www.diabeteseducator.org/export/sites/aade/_resources/pdf/research/AADE_MedEd.pdf. Accessed July 20, 2013.

Ulrich PA, Abner N. Diabetes under control: Meter, meds, meals, move, and more. Am J Nurs. 2010;110(7):62-5.

Kellie Antinori-Lent is a diabetes nurse specialist at the University of Pittsburgh Medical Center Shadyside in Pittsburgh, Pennsylvania.

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