Screening for diabetes distress with standardized tools can help health care providers assess how a patient is coping psychologically with diabetes and prepare to respond to their needs.
People with diabetes (PWD) often need to make multiple lifestyle changes to help manage their blood glucose levels. These changes may include adjusting what foods they eat, increasing how physically active they are, avoiding risky habits like tobacco use, monitoring blood glucose levels, and administering several types of medications multiple times per day.
These complexities and the need for patientcentered care to address them are increasingly a focus in annual updates of the Standards of Care in Diabetes, which also highlights the challenges of adopting new lifestyle behaviors and of the daily, time-consuming work of managing diabetes. PWD already living with comorbidities (eg, cardiovascular disease) and food and housing insecurity (ie, social determinants of health) are particularly vulnerable to these challenges.
The challenges of psychosocial adjustment and the negative emotional experience resulting from the demands of living with diabetes, which PWD often describe as a sense of “burnout,” were first described as “diabetes distress” by Polonsky and colleagues in 1995. Distinct from depression, diabetes distress is a response to the stressors and emotional burdens that accumulate in response to diabetes self-care requirements and their impact on other areas of life. Research by Fisher et al (2012) and Schmitt et al (2018) indicates that reducing diabetes distress is important for improving quality of life, A1C values, and health outcomes.
Screening for diabetes distress with standardized tools can help health care providers assess how a patient is coping psychologically with diabetes and prepare to respond to their needs. In a 2012 article, Fisher and colleagues recommend using the 2-question Diabetes Distress Scale-2 (DDS2) and the 17-question Diabetes Distress Scale-17 (DDS17).
The DDS2 is an initial screening tool to assess to what extent diabetes is a problem for the patient on a 6-point Likert-like scale, where 1 is “not a problem at all” and 6 is “a very serious problem” (Table 1). Patients with an average score of 3 or greater on the DDS2 are asked to complete the more comprehensive DDS17, which assesses 4 distress-related domains: emotional burden, physician-related distress, regimen-related distress, and interpersonal distress (Table 2). Studies by Fisher and Polonsky have standardized assessment of the results for each of the domains, with subscores categorized as little or no distress (mean score <2), moderate distress (mean score 2.0-2.9), and high distress (mean score ≥3). These results help providers identify the domains where a patient needs more support and individualized care.
Interprofessional collaboration at the PATH Clinic is guided by a behavioral health integration model in which the primary care and behavioral health teams collaborate to address patients’ diabetes-related physical health and their mental health.
The Providing Access to Healthcare (PATH) Clinic, previously described by Shirey and colleagues in 2021, is a nurse-led clinic in an urban setting in Alabama that is connected to an academic medical center. PATH provides free health care to uninsured adults with uncontrolled diabetes, defined as a A1C >9%.
Clinic providers work collaboratively among professionals and trainees from medicine, nursing, optometry, physical therapy, psychiatry, and social work to provide care to approximately 300 unique patients per year. The goals of the clinic are to provide comprehensive support for patients as they manage their diabetes, help patients achieve optimal glycemic management, and prevent unnecessary emergency visits or hospitalizations.
Interprofessional collaboration at the PATH Clinic is guided by a behavioral health integration model in which the primary care and behavioral health teams collaborate to address patients’ diabetes-related physical health and their mental health. Addressing comprehensive needs among uninsured patients is especially important because underresourced individuals can often struggle with social determinants of health. These social determinants may include challenges such as low income, inability to find employment, or lower than average rates of health literacy, which can precipitate high levels of stress and anxiety and can present added self-management challenges.
Behavioral health screening tools are given to patients at each visit, and providers use evidence-based protocols to evaluate the results and determine if referrals are needed (Figure 1). On average at the PATH Clinic, 53% of patients are referred to the behavioral health team, 51% of whom have diabetes distress. When each provider sees their patients, they review the diabetes distress scores. If the overall score is elevated, the provider talks with the patient about the specific domains where they indicated the highest levels of distress. The provider and patient work together to troubleshoot solutions to distress-related challenges.
The importance of employing tools and strategies to manage diabetes distress as part of comprehensive diabetes care is supported by the results of Patel and colleagues’ observational study of PATH Clinic patients from 2020 to 2022. Findings indicated a potential direct correlation between trends in diabetes distress scores and A1C values over time and provided further evidence supporting the health benefits of addressing diabetes distress.
Motivational interviewing is a tool providers use to effectively address patients’ elevated diabetes distress domains and consider other stressors influencing diabetes self-management. Learning what motivates each patient and how prepared they are to make behavioral changes is more effective than a provider-driven, one-size-fits-all approach. Motivational interviewing is an easily adaptable communication technique to guide conversations with patients when addressing consistency or challenges in meeting treatment goals.
The goal of motivational interviewing is listening to understand, rather than listening to respond, a basic human tendency that sometimes emerges in efforts to help patients move toward achieving provider-identified treatment goals. By listening to patients’ struggles, providers can better understand the sources behind their diabetes distress and more effectively troubleshoot patient-centered ways to support them in reducing that distress. Working with patients to reduce barriers to self-care enables providers to more effectively help patients achieve their health-focused goals.
The basic outline of a motivational interviewing session can be captured with the acronym OARS: open-ended questions, affirmations, reflective listening, and summarizing, as taught by motivational interviewing founders, Miller and Rollnick (Figure 2).
By asking questions that cannot be answered with a simple “yes” or “no,” providers introduce less bias into the questions and are more likely to get accurate answers rather than what the patient thinks the provider wants to hear. For instance, it would be better to ask a patient, “Tell me how you are checking your blood glucose,” rather than “Are you checking your blood glucose each day?”
Motivational interviewing is a tool providers use to effectively address patients’ elevated diabetes distress domains and consider other stressors influencing diabetes self-management.
Knowing that the goal is improved glucose control, patients often overreport their positive behaviors, such as regularly checking blood glucose levels, and underreport their negative behaviors, such as eating multiple servings of dessert. However, understanding the patient’s actual behaviors is the first step in supporting them to make improvements.
After using an open-ended question or statement to better understand patient behavior, a provider’s next inclination may be to transition to “teaching mode” and correct any behaviors they perceive to be incorrect. Instead, the next step in motivational interviewing is to affirm positive patient responses. Providers may only be able to identify a small improvement, but even these can be important and show effort on the patient’s part.
Although it can feel discouraging that the patient is checking their blood glucose only once per week, providers may be able to affirm the patient by saying, “At our last visit, you had not been checking your blood glucose at all, and I am happy to hear you have found a way to check it weekly. That gives us important information that can support you.” That affirmation can be followed up with another open-ended statement like, “Tell me more about how you were able to start checking your blood glucose more often.” Insights into how they made even small steps in the right direction provide a greater understanding of their remaining barriers.
Before moving to a new topic, reflecting can be helpful and allow the patient to think even more about their behaviors and elicit insight into why they do what they do. The provider may opt for a basic content-level reflection or a reflection that assigns an emotion to how they think a patient feels, which would allow the patient to clarify as needed.
For instance, the provider may say, “It sounds like you are discouraged that despite all your work, your blood glucose readings are still high.” At this point, the patient may clarify, “I’m not discouraged, I’m angry that my partner keeps bringing junk food into our house, and I have to watch everyone else eat it when I am supposed to be eating those boring, healthy foods.” Evoking reflection gives the providers more perspective into a patient’s life so that when it is time to move toward education, they are prepared to tailor the education to the patient’s actual needs and preferences rather than relying on assumptions.
In summarizing, the provider puts the first 3 steps together for a quick review. This can be done after each part of the conversation, or it can be used at the end of the visit to summarize several different topics discussed.
One example may be:
You have been checking your blood glucose once a week and are getting ready to start checking several mornings per week now that you are less afraid of needles. You like the feedback it gives about how you did the day before with eating and physical activity. You have been frustrated that no one else in your house seems ready to support you in your journey to better health, and you are going to consider talking openly with your partner about how that makes you feel and asking if they would like to come with you to one of our diabetes management classes.
Moving through the OARS acronym, the goal is to elicit the patient’s perspective on changing behaviors. Getting patients talking about what they want to change and why is more effective than telling them why they should change. Additionally, it has the advantage of engaging the patient in the important work of discerning problems and identifying possible solutions.
Adopting a motivational interviewing approach ensures the patient is the center of the interprofessional health care team.
Adopting a motivational interviewing approach ensures the patient is the center of the interprofessional health care team. From the time the patient first calls the PATH Clinic, the entire staff focuses on tailoring services to their needs, which is why ancillary staff, who are often the face of the clinic, were included in the training on motivational interviewing, as well as providers, who were already reviewing diabetes distress scores and targeting identified difficulties in their interactions with patients.
In the first educational session, staff were introduced to motivational interviewing constructs, including the OARS acronym. Based on staff feedback, a follow-up interactive workshop was offered at the following annual workday for all staff to allow staff a low-stress environment to practice the motivational interviewing constructs they had learned.
Before the workshop, the behavioral health team solicited examples from staff of real-life challenging patient situations or statements. These statements were incorporated throughout the workshop so that after a reminder of each aspect of the OARS acronym, staff were presented with an actual patient scenario or statement to consider. Staff members then partnered to practice responses to these challenging patient statements.
This workshop pair-and-share style allowed staff to practice motivational interviewing communication strategies in a way that could be easily applied to day-to-day patient interactions. The entire team also had the benefit of having peers from the behavioral health team present to guide them in implementing OARS strategies in challenging scenarios.
PATH Clinic administrators found that after educating staff on motivational interviewing approaches, many still had questions about how to implement strategies. Because of this, motivational interviewing practice sessions were added to annual staff retreats. Session leaders emphasized that in some cases, there may not be enough time or knowledge of the patient’s barriers to use the entire OARS approach but that implementing even 1 element of OARS, such as an open-ended question or reflection, can help patients feel more valued and empowered. This also allowed ancillary and licensed staff to give each other feedback about the effectiveness of their responses based on their unique vantage points of common patient experiences and concerns.
After the motivational interviewing workshop with PATH Clinic staff using the practice-session approach, posttraining surveys were conducted with staff, and analysis focused on assessing their comfort with and adoption of motivational interviewing techniques. When asked to respond to the prompt, “The information presented in this session will help me incorporate motivational interviewing approaches into my interactions with patients,” 100% (n = 8) of respondents selected “strongly agree.” When asked to list a motivational interviewing strategy they would implement in future interactions with patients, 87.5% (n = 7) listed a specific strategy they planned to incorporate.
Staff verbally reported increased confidence with using motivational interviewing techniques and that being able to practice using OARS in a low-risk, safe learning environment made them more likely to use OARS with patients, compared to only reading or hearing about these techniques in lecture format. Because OARS is such a simple tool, even the receptionist commented this was something she felt comfortable implementing in brief interactions in the waiting area or when patients call to reschedule an appointment.
As staff become increasingly proficient with using motivational interviewing techniques, the overall clinic culture shifts to be more patient-centered.
As staff become increasingly proficient with using motivational interviewing techniques, the overall clinic culture shifts to be more patientcentered. For example, instead of discussing patient noncompliance, staff discussion focuses on how the PATH Clinic can help address patients’ barriers and challenges related to diabetes management.
Integrating motivational interviewing to address factors that contribute to diabetes distress in a limited-resource population is a feasible approach that improves patient-centered care. Given the competing demands for clinicians’ time, routinely assessing for diabetes distress and addressing domains with higher distress using the OARS acronym can quickly enhance communication methods and boost clinician confidence.
Motivational interviewing conveys a commitment to empathy and a patient-centered solution to mitigate diabetes self-management stressors. Many stressors are beyond the clinic’s control, but offering time for the patients to reflect on the difficult aspects of their lives and coordinating a tailored approach to address their concerns may in itself be a helpful intervention. Training and focused practice with motivational interviewing is an important way to ensure improved communication techniques that center the interprofessional team’s focus on understanding and supporting each patient.
Katie Crawford Buys, DNP, MPH, FNP-BC, PMHNP-BC, Bela Patel, DNP, CRNP, NP-C, Alison Hernandez, PhD, RN, and Michele Talley, PhD, CRNP, ACNP-BC, FAANP, FNAP, FAAN, are with the University of Alabama at Birmingham School of Nursing in Birmingham, AL.
The authors declare having no professional or financial association or interest in any entity, product, or service related to the content or development of this article.
This study was partially supported by the Health Resources and Services Administration (HRSA; Grants UD7HP2987 and M01HP41994) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling approximately $1.5 million and $1.9 million, respectively. The contents are those of the author(s) and do not necessarily represent the official views of or an endorsement by HRSA, HHS, or the US government. For more information, please visit HRSA.gov.
Katie Crawford Buys https://orcid.org/0000-0003-3092-9905
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