COVID-19, type 2 diabetes and the role of generalist primary care nurses

It is unrealistic to expect that every patient with type 2 diabetes will be managed by a specialist nurse, so it is vital that everyone in the nursing team has a good understanding of the condition, especially given the impact of the pandemic

The COVID-19 pandemic has affected almost everyone in different ways, but it was clear very early on that those from lower socio-economic groups were experiencing more severe complications and ultimately, deaths as a direct result of the virus.¹ As well as this, the lockdown measures that were put into place to protect us all and suppress the spread of the virus may have more of an adverse effect on those same people in terms of jobs and family support.²

But as well as this, COVID-19 has also led to an increased number of deaths and morbidity in people with underlying health conditions. Among those with severe COVID-19 and those who died, there is a high prevalence of concomitant conditions including diabetes, cardiovascular disease, hypertension and obesity.³ Type 2 diabetes (T2D) was high up on the list.

T2D can affect anyone from any background, but according to Diabetes UK, the most deprived people in the UK are 1.5 times more likely to have T2D than those who are the least deprived.⁴

People with better control of their diabetes are less likely to require hospitalisation from a diabetes related illness or COVID-19.^3-6 With this in mind, it has never been more important to ensure people with diabetes have access to the best possible health advice and care for their condition and much of this will come from primary care. Changes due to the way we deliver care during a pandemic means some of this will be being done remotely as the safety of both patient and staff are prioritised, but routine care such as routine bloods, foot and eye care will need face to face appointments.

WHY DOES T2D CAUSE WORSE OUTCOMES IN PEOPLE WITH COVID-19?

Although data show both type 1 and type 2 diabetes are risk factors for developing severe COVID-19 symptoms,⁷ this article will focus on T2D.

In T2D, people have become resistant to the insulin they are making, or do not make enough insulin, and many have a combination of the two: either way they are less able to absorb glucose into the cells where it is converted to energy as well as they should. Poorly controlled T2D has long been known to be associated with a higher risk of infections.⁸ In fact, recurrent skin, urine or fungal infections can often alert us to a potential diagnosis of T2D. This is because not only does high blood glucose allow for more favourable environments for bacteria to thrive, but also it impairs the body’s immune response so it does not respond to infections as efficiently, known as immunosuppression. Chronic high blood glucose affects vital parts of our immune systems: it can deregulate white blood cells (neutrophils), which are needed in an immune system to attack a foreign invader and it also reduces the overall production of another type of white blood cell, phagocytes, which help ingest and destroy pathogens. As well as this, high blood glucose can lead to acidosis, which creates a difficult environment in which the immune system has to work.⁸

Sadly, for those with T2D there is more. T2D is often associated with obesity, especially central obesity. Although the exact mechanism of action is not fully understood, the combination of high levels of fat cells and insulin resistance can cause a low level of chronic inflammation in patients. In particular, levels of certain inflammatory cells called cytokines are higher in people with diabetes when compared with those without.^9,10

The combination of being immunocompromised and having chronic inflammation has been shown to be a risk factor for developing more severe symptoms of COVID-19 in patients with T2D.¹⁰

T2D does not appear to increase a person’s risk of catching the coronavirus, but it does increase the risk of them developing severe symptoms and needing hospitalisation.^6,11 A study done in the UK found people with T2D were more than twice as likely to die from COVID-19 than those who did not have T2D,⁷ after adjusting for potentially relevant risk factors such as social deprivation, ethnicity, cardiovascular disease and other comorbidities.

Even before COVID-19, having T2D increased the risk of hospitalisation, mostly due to the complications of diabetes.⁵ Furthermore, national data in the UK confirms that on average a patient with diabetes spends longer in hospital than a patient without diabetes despite being admitted for the same procedure or condition other than diabetes.¹²

Ethnicity continues to be a relevant topic during the COVID-19 pandemic. Patients from ethnic minority groups are disproportionately affected by COVID-19. In the UK, there is some evidence that people who are Black African or Black Caribbean are more likely to test positive for COVID-19 than white individuals, and that those in Black, Asian and Minority Ethnic (BAME) groups are at increased risk of mortality due to COVID-19.¹³ Being of Black and South Asian heritage also increases the risk of T2D. Among minority ethnic communities, T2D prevalence is approximately three to five times higher than in the white British population. The onset of T2D also occurs at a younger age, on average 10-12 years earlier, with a significant proportion of cases being diagnosed before the age of 40.¹⁴ It is therefore important that healthcare professionals adjust their approach for those from minority ethnic backgrounds and do not make assumptions that were built on Caucasian averages and lifestyles.

With T2D proving to be a risk factor for increased mortality and morbidity from COVID-19, it is vital we support our patients with T2D in ensuring their blood glucose is as well controlled as possible.

THE ROLE OF THE PRIMARY CARE TEAM IN DIABETES CARE

Good long term condition management should be the focus of community care, ensuring people have the tools to manage their own health and help reduce their risk of hospital admission.

General practice nurses have a key role in managing people with T2D. Although we have seen the number of community-based diabetes nurse specialist posts increase, in truth with the rise in people with T2D and the frequency with which they present to primary care, most clinical staff will come into contact with a person who has T2D.

There is strong evidence that nurses can have a major effect when counselling patients on self-management of their disease, particularly when combined with the proactive care management model and decision-making support.¹⁵

Nurses and healthcare assistants (HCAs) have a particularly vital role as they are often the people who carry out essential checks and reviews for people with diabetes, including:

• Foot checks
• Routine bloods
• Blood pressure monitoring
• Advice about diabetes, exercise and promoting health and wellbeing
• Screening for T2D in high risk individuals
• Asking about mental health in particular relation to chronic disease
• Blood glucose monitoring
• Urinalysis
• Advice about oral hypoglycaemics
• Advice about injectable therapies
• Advice about hypoglycaemia and hyperglycaemia

With the pandemic, fewer patient contacts have been face to face, but research has shown us that even virtual consultations may reduce social isolation and prove beneficial in helping with T2D self-management.¹⁶

Roles within primary care are changing. The workforce is becoming more diverse, and where once there were clear lines of roles and responsibilities there are now large overlapping areas with shared care divided amongst a multidisciplinary team. Diabetic Specialist Nurses (DSNs) are a vital part of the community diabetic team, but the sheer number of people with diabetes means they tend to only see the most at-risk or most vulnerable people with T2D, and once stable, their care is transferred back to the primary care team. Practice nurses and HCAs are doing the bulk of management for those people with T2D, particularly for those on oral hypoglycaemic agents.

But to think that those practice nurses who have experience or a qualification in managing people with diabetes are the only ones doing this work does a great disservice to all the other members of the team involved in their care. As much as we would like them to, patients do not attend our clinics with single illnesses, they often have a myriad of complex physical and psychological health issues and when they attend for their asthma review or for a review of their wound, they may also mention their diabetic related neuropathy or skin infection. And, with mounting pressure on the NHS, issues that were previously dealt with in a secondary care setting or by a specialist are now becoming not only necessary, but urgent for generalists to manage.

In my experience, many patients prefer their care to be closer to home, they find primary care more accessible and are familiar with the clinicians who provide their care for them. I have also heard many patients with long term conditions and comorbidities express that, in some cases, the rapid expansion of specialisation has led to disjointed care, and they would prefer access to someone who understands their medical history and who can coordinate the delivery of holistic care. This allows patients to build up a relationship with someone able to pick up on problems that may go unnoticed by clinicians who are treating only a part of the patient's many and varied conditions.

This vital role often falls to primary care, either nurses or GPs who are involved in the ongoing care of the patient. Therefore, it is important that each nurse or clinician the people with T2D come into contact with can offer something beneficial to their overall health outcomes.

MOTIVATIONAL INTERVIEWING

It is not my suggestion that every primary care nurse or clinician should be trained up to become a diabetes specialist. Working within our capabilities and knowing when to refer onwards is key to being a good clinician. But it is worth us all having some universally applicable weapons in our arsenal that we can pull out and use, when patients need it.

Motivational interviewing (MI) has been used increasingly in healthcare settings to guide and influence change in patients’ behaviour for the overall benefit of their health. It has been defined as person-centred method of guiding to elicit and strengthen personal motivation for change. Core clinical strategies include, for example, reflective listening and eliciting change talk. MI encourages individuals to work through their ambivalence about behaviour change and to explore discrepancies between their current behaviour and broader life goals and values.¹⁷ MI is a teachable, evidence-based approach to behaviour change counselling.

In my experience, people struggling with managing their T2D, a condition that requires adherence to complex daily regimens, appear to be only weakly motivated by other people's suggestions as to what lifestyle and self-management issues they should address and how these improvements should be achieved. MI focuses on providing opportunities to help patients assess for themselves what might be important or possible and how change might be achieved.¹⁸ This is the key; every person with T2D has individual circumstances, and applying broad strokes to get them to make unachievable lifestyle changes may lead to a sense of failure in that person. Listening to them, and getting them to suggest small but achievable changes to their daily routine and rituals, may be far more likely to improve their T2D in the long term.

As part of the Novo Nordisk Make Type 2 Diabetes Different campaign, we have formulated a quick reference guide for healthcare professionals on applying motivational interviewing techniques during consultations with people with T2D, to help establish a partnership that empowers people living with T2D to take further ownership of managing their condition, (available to download from novonordisk.co.uk/MakeT2DdifferentHCPs). This approach is patient-centred and allows healthcare professionals supporting people with T2D to:

1. Help the person to explore their values and motivations, and connect these to health behaviours

2. Listen to people with T2D, because people are often more likely to change by hearing themselves speak about their challenges

3. Empower the person to take ownership of their condition and help them feel more confident of change, by looking for opportunities to highlight their strengths and inviting them to reflect on times in their life when they have successfully changed, even if just in a small way.

This is a technique we can all use in varying degrees during our time with our patients. Although this is a relatively brief motivational conversations guide, healthcare professionals do need time for training and development in order to use these skills proficiently and it is important that organisations and employers support them to do this – for the benefit of their employees and their patients.

SUMMARY

People living with T2D are at increased risk of hospitalisation when compared with those living without T2D.³ The global coronavirus pandemic has highlighted this further as people with T2D are at higher risk of severe COVID-19 and hospital treatment. T2D affects those from poorer backgrounds and certain minority ethnic groups disproportionately, and these same risk factors contribute to the increased risk of COVID-19 complications.⁷

Having good diabetic control could help reduce your patient’s risk of hospitalisation from diabetes-related illnesses.⁵ Much of T2D management is done in the community rather than by secondary care, with a host of healthcare professionals involved. Although each healthcare professional will have an individual part to play in the management of people living with diabetes, there are some parts that overlap. General practice nurses play a pivotal role in helping to manage people with T2D. Every patient contact should serve as a high-quality opportunity to encourage and enable patients to make achievable changes to their individual lifestyles to help improve their health and T2D.

Motivational interviewing has been shown to empower change in those living with T2D for the better. By using these skills in varying degrees in every opportunity we have with our patients, we could help them better control their T2D.

REFERENCES

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