O R I G I N A L R E S E A R C HLived experience of diabete.docx

O R I G I N A L R E S E A R C H
Lived experience of diabetes among older, rural people
Sharon R. George & Sandra P. Thomas
Accepted for publication 16 January 2010
Correspondence to S.R. George:
e-mail: [email protected]
Sharon R. George PhD RN CNL
Assistant Professor, Graduate Faculty
College of Nursing, The University of
Alabama in Huntsville, USA
Sandra P. Thomas PhD RN FAAN
Coordinator for Doctoral Program,
and Co-Director
Cooperating Site, International Institute for
Qualitative Methodology, The University of
Tennessee, USA
G E O R G E S . R . & T H O M A S S . P . ( 2 0 1 0 )G E O R

G E S . R . & T H O M A S S . P . ( 2 0 1 0 ) Lived experience
of diabetes among older,
rural people. Journal of Advanced Nursing 66(5), 1092–1100.
doi: 10.1111/j.1365-2648.2010.05278.x
Abstract
Title. Lived experience of diabetes among older, rural people.
Aim. This paper is a report of a study conducted to elucidate
experiences and
perceptions of self-management of diabetes as narrated by older
people diagnosed
with insulin-dependent diabetes living in a rural area.
Background. Older people worldwide are disproportionately
affected by diabetes
and are more likely to have co-morbidities and disabilities.
Guidelines for
management, developed by the American Diabetes Association,
are not targeted for
this population. A plethora of quantitative research has
investigated self-manage-
ment issues, with little change to outcomes. This pleads for
consideration of a new
diabetes education model, which includes consideration of
experiences within

clients’ worldviews.
Method. Unstructured interviews starting with an open question
were conducted
from a purposive sample in 2005. Interviews were transcribed
and analysed
according to the tenets of existential phenomenology, a process
which began with
bracketing the researcher’s biases.
Findings. Living with poorly controlled diabetes led
participants to introspection
and existential questioning. Four connected themes were
identified: ‘Your Body Will
Let You Know’; ‘I Thought I Was Fine, But I Wasn’t’; ‘The
Only Way Out is to Die’;
and ‘You Just Go On’.
Conclusion. Currently designed from a medical perspective,
diabetes education
should be based on a nursing model incorporating the client’s
insights and experi-
ences. When managing diabetes is viewed from a client’s
perspective, the focus
becomes solving problems that arise in self-regulation of one’s
own regimen rather

than in complying with doctor’s orders. Nurses need to reframe
the problem by
excluding the compliance/noncompliance model and developing
a conceptual
perspective on self-management that is grounded in world and
body.
Keywords: diabetes, gerontology, nursing, older people,
phenomenology, rural
health, self-management
1092 � 2010 The Authors. Journal compilation � 2010
Blackwell Publishing Ltd
J A N JOURNAL OF ADVANCED NURSING
Introduction
Every 10 seconds, two people develop diabetes and someone
dies from diabetes-related causes. It is the fourth leading
cause of death globally (International Diabetes Federation,
2007). The world is in the midst of an epidemic of diabetes,
which if unchecked will produce an unbearable burden on
quality of life and the worldwide healthcare system over the
next generation. The World Health Organization (WHO)

estimates that more than 180 million people worldwide
currently have diabetes and this number may double by 2030.
India, China and the United States of America (USA) are the
top three countries with the most people with diabetes (WHO
2008). In the USA, over 23 million people are currently
diagnosed with diabetes (American Diabetes Association
2009a, 2009b), and it is the sixth leading cause of death in
the USA, being responsible for 225,000 deaths annually
(Gambert & Pinkstaff 2006). Over 90% of older adults with
type 2 diabetes are diagnosed with either insulin resistance or
insulin deficiency, which is a conundrum for optimal treat-
ment options (DeFronzo 2004). In a meta-analysis conducted
by researchers from Sweden, Zimbabwe and Uganda, under-
lying causes for the pandemic of diabetes were attributed to
genetic and environmental factors, longevity, changes from
active to sedentary lifestyles, and over-eating. The researchers
stated that this illness is a growing public health problem
(Hjelm et al. 2003). The prevalence of diabetes is somewhat

higher in rural than in urban areas, but racial/ethnic,
socioeconomic and lifestyle factors also appear to be strong
risk factors. Rural people with diabetes tend to be diagnosed
later and receive substandard health care compared to their
urban counterparts (Dabney & Gosschalk 2009).
Background
Guidelines for diabetes management developed by the
American Diabetes Association are not specific for the older
diabetic population, only the general adult population. There
are no diabetes treatment differences targeted for patients
who are 65 years of age and older. The American Diabetes
Association in its 2009 revisions addressed new standards.
Explicit in the revisions were inclusion of children, teenagers
and younger adults. Specific recommendations were also
made for people over 40 years of age (ADA 2009a, 2009b),
but unique physiological changes in people aged 65 years and
older were not taken into account. For example, the number
of insulin receptors on cell membranes decreases with age;

accordingly, glucose intolerance increases. There is age-
related change to tissue sensitivity to insulin, and alteration
of insulin receptor sites by the ageing process is thought to
render insulin less effective. Secretion of insulin may be
depressed and the target tissue may have an increased
resistance to insulin. Non-ketotic hyperosmolar coma is a
condition exclusive to older people with diabetes and is
characterized by extreme hyperglycaemia and hyperosmolar-
ity. People with these symptoms exhibit mental status
changes, dehydration and hypotension. This is often viewed
as a neurological event rather than a complication of
diabetes. These changes reflect a disturbing picture of self-
management burdens for older adults and the need for
individualized goal setting as opposed to a prescribed
protocol to fit everyone. According to the study by Selvin
et al. (2006), the higher rate of poor glycemic control in the
older population as compared to middle aged people with
diabetes represents differing burdens of the disease and need

for diverse treatments in each group.
Recently, the American Association of Diabetes Educa-
tors and American Geriatric Society formulated guidelines
for self-management education in older people; however,
the guidelines were based on expert consensus and await
empirical evaluation (Suhl & Bonsignore 2006). The
American Diabetes Association, American Association of
Diabetes Educators and American Association of Clinical
Endocrinologists acknowledge that no long-term studies
have been conducted among older adults with diabetes
(Hainer 2006). Older people with diabetes have not been
included in many studies, which may explain why a specific
protocol for management has not been developed. It is
crucial for our global, older population to be integrated
into studies of diabetes. This will permit development of
specific guidelines for self-management to ameliorate con-
ditions such as co-morbidities and disabilities that can be
prevented by early intervention rather than episodic man-

agement. Advanced healthcare planning may delay onset of
complications, decrease hospitalizations and improve out-
comes.
Individuals with diabetes carry out about 95% of their
own care (Anderson et al. 1995, Funnell et al. 2008), and
diabetes education is used as a tool for the development of
effective self-management practices. Diabetes self-manage-
ment is defined by the American Diabetes Association as the
ongoing process of facilitating the knowledge, skill and
ability for diabetes self-care (Anderson & Funnell 2000,
Funnell et al. 2008). People with diabetes make many choices
every day that affect their disease. The focus of diabetic
education has been to provide information that will improve
patient choices, promote better health and reduce complica-
tions. Educating the patient is essential in diabetes self-
management, and it is considered a crucial factor in achieving
optimal blood glucose levels (Gorawara-Bhat et al. 2008).
JAN: ORIGINAL RESEARCH Experience of diabetes among

older, rural, people
� 2010 The Authors. Journal compilation � 2010 Blackwell
Publishing Ltd 1093
Diabetes education is usually carried out using a pedagog-
ical approach which includes lecture content, knowledge
tested for accuracy and demonstration-return demonstration
of the necessary skills for self-management (Brown 1992,
Bradley 1995). This strategy does not necessarily lead to
long-term adherence to diabetes regimens. It is presumed by
healthcare providers that if people are given adequate
education, they will self-manage their disease.
An older individual, however, has accrued years of
established patterns and behaviours, making adherence to,
or change in, a diabetic protocol very difficult and challenging.
There are several unique problems in the management of
65-year and older persons with diabetes. Visual disturbances
occur as a result of the normal ageing process, which in this
group are further exacerbated by poor glucose control. A

decrease in activities of daily living results in decreased food
intake, which may in turn contribute to a hypoglycemic state.
If older people are physically inactive, they are more disposed
to obesity. Adding to this conundrum, it is expected that
many will become cognitively impaired, which may further
decrease adherence to diabetes self-management. Although
effective medications, methods of delivery and methods for
self-monitoring have improved diabetic clients’ ability to
control hyperglycaemia, normal metabolic control remains
difficult to achieve.
Jack et al. (1999) determined that diabetic education has
not taken account of the impact of patients’ social circum-
stances and environmental contexts. The isolation inherent in
rural environments of older people with diabetes may be
particularly challenging. A few researchers have studied rural
and homebound populations but were not exclusively
concerned with older diabetic participants. Adults living in
rural areas often find it difficult to obtain adequate health

care due to such factors as inability to drive, financial
constraints, mistrust, illiteracy, or communication problems
(IOM 2004). Rural women are known to have a greater risk
of death from diabetes (U.S. Rural Assistance Center 2005).
African Americans living in rural areas with high rates of
poverty may not even be able to afford to purchase the
prescribed medications. Studies indicate that this information
is rarely discussed with their physicians (Saver et al. 2004).
The study
Aim
The aim of the study was to elucidate experiences and
perceptions of self-management of their diabetes as narrated
by older people with insulin-dependent diabetes living in a
rural area.
Methodology
The study methodology was influenced by the phenomenol-
ogy of French philosopher Maurice Merleau-Ponty which
‘tries to give direct description of our experience as it is,

without taking account of its psychological origin and the
causal explanations which the scientist, this historian, or the
sociologist may be able to provide’ (Merleau-Ponty 1945/
1962, p. vii). According to Thomas and Pollio (2002, p. 13),
‘The aim of Merleau-Ponty’s phenomenology is to describe
the human experience on its own terms’. Based on these
assumptions, phenomenology was the method of choice for
capturing the experience of older people with diabetes.
Merleau-Ponty, heavily influenced by the work of Husserl
and Heidegger, focused his work on perceptions of lived
experience. In order to describe a lived experience, it must
first be disclosed. Bracketing and phenomenological reduc-
tion are essential components of the methodology (Merleau-
Ponty1945/1962). Bracketing presumes that researchers are
capable of separating their knowledge from personal expe-
rience, at least temporarily, while collecting and analysing
data. The procedure, as defined by Thomas and Pollio (2002),
requires a bracketing interview of the principal investigator.

This is designed to heighten awareness of any preconceptions
or biases arising from personal experiences and minimizes the
potential for distortion of during data collection and analysis.
The principal investigator (SG) reflected upon, and thema-
tized the transcript of her bracketing interview prior to
commencing participant interviews.
Participants
A purposive sample was drawn from local agencies on ageing
between January and May 2005, and consisted of English-
speaking people aged 65–85 years who were able and willing
to talk at length about their diabetes, and to allow a researcher
to visit them in their homes. Among the group were eight
African American and two White women, all confined to their
homes and living in a rural area. Everyone received Social
Security as their only source of income. Length of time with
diabetes ranged from 7 to 39 years. Five participants had been
diagnosed over 25 years previously, and five were diagnosed
less than 12 years previously. All had visible evidence of

diabetes-related complications, and all had more than one
chronic condition in addition to diabetes. All but one was a
widow.
Data collection
All interviews were conducted face-to-face in the partici-
pants’ homes, at a date and time of their choosing. No
S.R. George and S.P. Thomas
specific directions were supplied to participants. They were
free to discuss any life experience they perceived as repre-
senting their diabetes, and their experiences with diabetes
self-management issues. Each participant was told that they
could take as long as they needed to talk about their diabetes.
Interviews lasted from 1 to 2 hours and began with the
prompt: ‘Please tell me what it is like for you living with
diabetes’. From this point, participants could discuss the topic
in any way they chose, and all started with an account of how

terrible diabetes is to them. Comments and questions were
followed-up with prompts such as ‘Tell me more about that’
and ‘Tell me what that is like’. Following the interviews, a
short survey was used to assess issues of self-management,
such as frequency of testing blood glucose levels.
Ethical considerations
This study was approved by the appropriate research ethics
committee. Initial contact with the participants was accom-
plished through a visit from the agency’s home health nurse.
The nurse gave potential participants the following informa-
tion: purpose of the study, nature of the data to be collected,
approximate time required, benefits and risks related to
participation in the study. Informed consent was obtained
from each participant at the time of the interview.
Data analysis
All interviews were audiotaped and transcribed verbatim.
All transcripts were read and re-read while listening to the
audiotape. This was done to ensure accuracy of the

transcription. The transcripts were then read and re-read
again to gain insight and a sense of the lived experience as
described by the participants. To determine emerging
themes, the data from selected transcripts was reviewed
and read aloud by members of an interpretive, interdisci-
plinary, phenomenology research group. Group members
have extensive experience using the Thomas and Pollio
(2002) method of analysing phenomenological research
data, and many have participated in the group for more
than a decade. The group comprises phenomenological
research students from a doctoral programme and doctor-
ally prepared university staff member. Thomas and Pollio’s
(2002) interpretation procedures were used for data anal-
ysis. Existential-phenomenological interpretation is a
process of relating parts (known as meaning units) to the
whole narrative. Analysis is a constant process of seeking to
grasp the meaning of the whole while also scrutinizing
words and phrases line by line. Meaning units and themes

(patterns observed across interviews) were identified and
related to one another until a final thematic structure was
delineated and presented to the research group.
Rigour
The analysis procedure provided an analysis of the data that
was systematic, disciplined, and reflective, and afforded the
opportunity for meaningful comparisons across all the data.
In addition to presenting the formalized thematic structure to
the research group, Thomas and Pollio (2002) recommend
that it be presented to participants for their response to its
validity. The principal investigator revisited two participants
and asked them if the thematic structure was accurate. Both
were able to recognize their own experiences in the findings.
One participant added, ‘This is really good’. The second
participant expressed being amazed at the themes and stated,
‘You really knew what I meant’.
Findings
Survey results

The short survey, administered following the interviews,
revealed erratic diabetes self-management. When asked how
often they self-tested for blood glucose, participants indicated
haphazard testing. One did not check because the glucometer
was broken. Another admitted that she did not check at all.
Four participants reported checking from 3 to 5 times a week,
and four reported checking from 1 to 2 times a day. When
asked if they knew whether they had ever had an HgbA1C
(glycosylated haemoglobin), everyone responded, ‘Don’t
know’.
When questioned about eating habits, such as eating
differently since their diagnosis of diabetes, nine responded
that they had made changes; one said ‘No’. All participants
reported eating at least once per day, but no one ate
according to their healthcare provider’s recommendations
or recommendations of the American Diabetes Association.
When asked if they had received any special teaching about
diabetes, responses varied. For example, one participant had

learned from her doctor and from the television. Other
responses included family and friends, self-teaching, and
obtaining diabetes knowledge through experience and obser-
vation with other diabetic family members.
Interview findings
All participants described what their life was like with
diabetes and how they managed in their own way. Each
spoke in a quiet tone and discussed experiences with sombre
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affect. There was little laughter during the interviews, and
descriptions of specific events seemed to bring back to
immediate consciousness the reality that they had a serious
and intrusive disease, for which there is no known cure. Each
person seemed pleased to have the opportunity to talk about
diabetes without any restrictions on scope or time. Voices

would often trail off at the end of describing an experience, as
though this had left them with lingering thoughts or questions
about their long experience with diabetes. Past experiences
were recounted as though still fresh in the memory. Expres-
sions would change as painful experiences such first using a
needle were described. Pain was reflected in facial grimaces,
and from time to time a melancholy appearance and sadness
permeated the discussion.
Figural themes
In existential phenomenology, predominant aspects of
participant perceptions (termed ‘figural’) must be under-
stood within their environmental context (termed ‘ground’).
Using participants’ own words, specific themes emerging
from this research will be discussed. Four figural themes
were identified across the interviews and were contextuali-
zed by the existential grounds of World and Body. The
world of an older, homebound diabetic in a rural south-
eastern environment is greatly restricted. Few people

populate this small world. Most participants had few
visitors and left their homes infrequently, perhaps to go
church or a family gathering when someone provided
transport.
Theme 1. ‘Your body will let you know: If you miss it you’ll
wind up in a coma’
This poignant comment described how diabetes was experi-
enced as a bodily phenomenon, most notably when the body
signalled that they that must take action. Participants’ nar-
ratives were dominated by frightening episodes of hypo-
glycaemia. ‘Awful’ changes in their body mandated action,
lest adverse consequences ensued. Participants vividly
described feelings in their bodies as an antecedent to hypo-
glycaemia. The bodily cues included ‘started floating’,
‘swimmy headed’, ‘knees like jelly’ and ‘slipping away’. One
person said, ‘You feel like you’re gonna die’. This was
participants’ biggest fear.
Frantic attempts to find something to eat occurred. One

participant said that it was important to be physically close to
the refrigerator so that she did not have far to go when she
became hypoglycemic. Her descriptions of experiences with
hypoglycaemia indicated how she coped. Gesturing, she
declared, ‘There is my bed and there is the refrigerator. I
know when it [blood sugar] has got low, I have to make it to
the freezer, and back in the bed before I black out’.
Experiences of hypoglycaemia generated fear of sleep. Not
responding to bodily cues about hypoglycaemia could cause a
coma. One participant stated, ‘I’m afraid I would have just
slept, slept, slept, if they hadn’t found me’. What stood out
most for people was dread of falling asleep and not being
found. They worried they would not be able to wake up;
being alone intensified this apprehension: ‘I’m afraid I won’t
wake up’. Driven by fear of falling asleep at night, creative
ways were adopted to stay awake as much as possible during
the night. One participant said she consumed ‘coffee all day
and evening to stay awake’.

Participants asserted that conventional diabetes manage-
ment techniques did not work for them. They perceived
healthcare providers as being unwilling to listen, and as
directing them to adopt a regimen they could not follow. This
created frustration and mistrust. Descriptors of provider
responses included ‘Didn’t believe me’, ‘Wouldn’t listen’,
‘Tried to tell them’. Their self-prescribing diabetes manage-
ment ultimately led to accelerating progression of the disease,
leaving them to wonder what went wrong: ‘I did everything I
was supposed to’.
Theme 2: ‘I thought I was fine, but I wasn’t’
The disconnection between participants and providers is
captured in Theme 2. Participants had unwittingly chosen
high-risk behaviours that had worked for many years.
However, as the disease progressed they developed irrevers-
ible, disabling, diabetic complications. They thought that
they would be fine with diabetes if they took their insulin and
ate ‘right’. They believed ‘doing the right thing’ would keep

their diabetes under control. For most, their sense of ‘fine’
was demonstrated by self-management behaviours and
strategies that gave them the greatest degree of freedom
without causing adverse consequences. One person
explained, ‘Sometimes I cut my shot in half’. She made this
decision because taking the entire amount of insulin would
require eating more food, which she mistakenly believed
would have an undesirable outcome: ‘Too much eating, I’d
gain weight’. Participants struggled between what the doctor
advised and their personal knowledge and experience. Most
felt compelled to devise their own diabetes regimen without
the advice of a healthcare provider.
Theme 3: ‘Only way out is to die’
Participants knew that diabetes is a lifelong process and a
disease for which there is no known cure. They perceived that
diabetes had taken over and dictated how they were to live
each day for the remainder of their lives. Neither traditional

medicine nor their own experience gave them any hope for
significant improvement in their condition; in fact, quite the
contrary, most were faced with escalating degradation in the
quality of their lives and the condition of their diabetes. They
believed that ‘The only way out is to die out’. They are aware
and realistic about the prognosis and were sombre in their
acceptance of their condition. Illustrative quotes included
‘They say they don’t have no cure for it’, and ‘You never will
get well’.
Theme 4: ‘You just go on’
‘You just go on’ reflected the stoic endurance exhibited by
these older diabetic participants, resigned to management of
a disease which they perceived would ultimately claim their
lives. One person, a diabetic for 35 years and facing another
amputation, stated, ‘You just go and do what you got to do’.

Participants had spent a lifetime managing diabetes to the
best of their ability. In essence, they believed that they were
doing everything they knew to keep their lives going with
diabetes. They did not expect to get better and reconciled
themselves to the limitations produced by the disease. This
was reflected in expressions such as ‘I’ve been a diabetic for
so long, you gets used to it. In other words, you have to do it
so long, and you just do, I says, doing what come naturally’.
Part of ‘Just going on’ was sometimes to defy what people
told them because, after all, they already knew that the ‘only
way out is to die’. For example, one participant stated, ‘I love
chocolate and they don’t know where chocolate goes in my
sugar. It doesn’t run my sugar up. I can eat all I want’.
Another confessed, ‘I love sweets; I’d make a cake every
weekend and eat it up all through the week. My sugar’d be
over 600’.
Thematic structure
The thematic structure is illustrated in Figure 1. The structure

represents the interrelationship between all four themes as
never ending. It shows ‘You just go on’ at the top of the
structure because that is where participants can begin or end
their diabetes experiences. Going on represents the resigna-
tion described as a result of living with frightening hypo-
glycaemia episodes, expressed in ‘Your body will let you
know, if you miss it, you’ll wind up in a coma’. Across from
this theme are participants’ perceptions of ‘I thought I was
fine, but I wasn’t’. From the sequence of life events, they
arrived at the conclusion, the ‘Only way out is to die’, which
is illustrated as linked to the first two. If their only way out is
to die, then ‘You just go on’, which is inextricably connected
to the other three themes.
Discussion
Study limitations
Although the small sample size may be viewed as a limitation,
in a phenomenological study it is common for samples to be
small: ‘An appropriate sample size for phenomenological

research can range from 6 to 12 persons’ (Morse 1994, p. 220).
The goal is depth of understanding of the phenomenon;
saturation or redundancy is achieved when no new thematic
material is heard in the interviews. Generalizability of the
study is limited by the environmental location (rural, southern
USA), absence of men and absence of other minority groups
such as Hispanic Americans, Asian Americans and Native
Americans, who have a high prevalence of diabetes. However,
the descriptions provided by this predominantly African
American rural sample are a valuable contribution to litera-
ture: their voices have not been heard. Moreover, transfer-
ability of phenomenological findings largely depends upon the
reader of the research report; a clinician can apply findings of a
phenomenological study when they are judged applicable to
patients expressing similar concerns (e.g. isolation, chronic
illness, fear of dying alone). Fear of dying alone, for example,
is undoubtedly a universal theme among human beings.
Self-management by older people with diabetes

What is new in this study is the first-person perspective of
self-management provided by the narratives of older persons
with diabetes. This allows nurses to step into the world of
rural older individuals with diabetes and understand the
fright of hypoglycaemia, bewilderment when well-inten-
tioned self-care did not have the intended results, frustration
with healthcare providers who do not listen, and stoic
endurance while waiting for death. Tragically, many of the
You just go on
Only way out is to die
Your body will
let you know, if you
miss it, you’ll wind up
in a coma
I thought I was fine,
but I wasn’t
Figure 1 Themes of the experience of older rural adults living
with
diabetes.

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participants had misunderstandings that had never been
dispelled (e.g. eating chocolate will not affect blood sugar).
They believed that they were doing their best to coexist with
the debilitating disease that had caused their bodies to
decline. Similarly, ‘Doing My Best’ was thematic in a recent
study of another vulnerable group: patients having both
schizophrenia and diabetes (El-Mallakh 2007). As in the
present study, limited education, income, and other barriers
constrained participants’ ability to care for themselves. These
barriers affect millions of people with diabetes.
The sombre effect of the women in our study matches that
of diabetics in a study by Moskowitz et al. (2008). They
assessed affect as a risk predictor for diabetes mortality in
715 participants with diabetes and 2,673 participants with-
out chronic illness. Those with diabetes reported lower
Positive Affect subscale scores and higher Negative Affect.

Those with diabetes had a statistically significant higher risk
of mortality.
Research by Brody et al. (2008) has shown that self-
management is compromised when individuals live alone in a
rural setting with lack of family, friends, community, and
neighbours who could provide emotional or physical support.
In this structural equation modelling study of older African
American adults with type 2 diabetes, better social support
was positively related to improved self-management of the
disease. The rural women in the present study did not have
access to social support. They were seemingly doomed, based
on location, fearing that they would die alone in the night.
The self-reliance and stoicism shown by these older women
was typical of rural women interviewed about health
information seeking by Wathen and Harris (2007). Regard-
less of age, the mantra of these women was ‘I try to take care
of it myself’. Self-reliance is perhaps the only available option
for people with diabetes when the disease management

regimens prescribed by healthcare providers fail to prevent
the recurrence of terrifying hypoglycemic episodes. Only their
own bodies seemed to be reliable indicators of needed self-
care actions. Dissatisfying relationships with healthcare
providers were also prominent in a grounded theory study
with insulin-dependent diabetics conducted by Zoffman and
Kirkevold (2007); many people in that study expressed
frustration when providers did not listen to them, and they
engaged in resistance to the ‘orders’ they received. Similar
resistance, traditionally labelled ‘noncompliance’, was
displayed by the older participants in our study.
Findings from this study suggest that healthcare profes-
sionals need to listen more carefully to the voices of clients.
Misunderstandings of the disease and the desired treatment
regimen abounded. Experiences related by participants in
this study did not reflect ‘noncompliance’ in their own
views. Each described how they managed diabetes, knowing
that their self-management regimen was not considered

appropriate according the instructions of their healthcare
providers. It was self-management within their own world-
views.
Conclusion
The international community of nurses has been educating
people about diabetes using guidelines designed from a
medical perspective. Diabetes self-management education
should be based on a nursing model incorporating cli-
What is already known about this topic
• Older people diagnosed with diabetes have more
co-morbidities and complications, but guidelines for
self-management are not targeted for clients who are
65 years and older and have concomitant ageing
impairments such as visual changes and decreased
mobility.
• The majority of people with diabetes manage their own
care based on what they were taught from a pedagog-
ical approach, based on a presumption by healthcare
providers that if people are provided adequate educa-

tion, they will successfully self-manage their disease.
• An older individual has accrued years of established
patterns and behaviours, making adherence to or
change in a diabetic protocol very difficult and chal-
lenging.
What this paper adds
• Living with poorly controlled diabetes led participants
to introspection and existential questioning.
• Four connected themes were identified: ‘Your Body Will
Let You Know’; ‘I Thought I Was Fine, But I Wasn’t’;
‘The Only Way Out is to Die’; and ‘You Just Go On’.
Implications for practice and/or policy
• Improved education is needed, based on the Interna-
tional Diabetes Federation model adapted to the older
population and specifically individualized to clients’
experiences and patterns.
• Nursing care should be provided with understanding
and sensitivity toward cultural values.
• An approach to diabetes is needed that is grounded in
understanding of clients’ contextual world and experi-
ence of their own body.

ents’ insights and experiences. Nurses should consider a
client’s pattern if any adaptations or modifications are
required, rather than continuing to force diabetes care
into an intellectual, financial and psychological system that
will continue to frustrate clients and providers and may
not improve blood glucose levels, complications, or escalat-
ing costs associated with diabetes. When managing diabetes
is viewed from a participant perspective, the focus becomes
solving the problems that arise in self-regulation of the
person’s own regimen rather than complying with (or not
complying with) a doctor’s orders. Noone had worked
collaboratively with the participants in this study to reduce
the frequency of the hypoglycaemia that was the figural
problem in their day-to-day existence. Perhaps participants
did not realize that hypoglycemic episodes could be reduced

with better control of their disease.
Our findings challenge the traditional compliance paradigm
in which current diabetes education is grounded. Healthcare
providers need to develop a new approach to diabetes
education for older adults that is grounded in understanding
of clients’ contextual World and experience of their own Body.
Homebound clients need to be heard in order for healthcare
providers to become creative with addressing their diabetes
concerns. Reframing the problem of noncompliance may offer
a new view for developing nursing interventions that could
make a difference by improving the quality of life for this
population. What is needed, based on this study, is an
innovative approach to self-management with potential for
global applications. The International Diabetes Federation,
Section on Diabetes Education, has developed an International
Curriculum for Diabetes Health Professionals (International
Diabetes Federation 2009). The document was developed to
assist healthcare providers in preparing a high quality diabetes

education programme that can be used throughout the world.
It includes planning timely nursing care, with evaluation of
clients’ environments and experiences; furthermore, it empha-
sizes that diabetes education should be individualized and
negotiated in partnership between nurse and client. If client
views and beliefs are not taken into account, only short-lived
changes in self-management may result. Adoption of the
International Diabetes Federation model, with consideration
of unique client experiences with self-management such as
those described in this study, will promote a collaborative
relationship. The voices of our participants call us to act, so
that they do not spend their older years merely waiting to die.
Funding
This research was partially funded by grants from Sigma
Theta Tau International Honor Society of Nursing, Beta Phi,
and Gamma Chi Chapters. This research received no specific
grant from any funding agency in the public, commercial, or
not-for-profit sectors.

Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
SG was responsible for the study conception and design. SG
performed the data collection. SG performed the data
analysis. SG and ST were responsible for the drafting of the
manuscript. SG and ST made critical revisions to the paper
for important intellectual content. SG obtained funding. SG
provided administrative, technical or material support. ST
supervised the study.
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July-August 2014 • Vol. 23/No. 4 231
Caralise W. Hunt, PhD, RN, CMSRN, is Assistant Professor,
School of Nursing, Auburn
University, Auburn, AL.
Bonnie K. Sanderson, PhD, RN, is Professor, School of
Nursing, Auburn University, Auburn,
AL.
Kathy Jo Ellison, PhD, RN, is Associate Professor, School of
Nursing, Auburn University,
Auburn, AL.
Note: The corresponding author received the Academy of
Medical-Surgical Nurses Cecelia
Gatson Grindel Evidence-Based Practice Research Grant Award
to conduct this study.
Support for Diabetes Using
Technology: A Pilot Study to Improve
Self-Management
A
ccording to the American
Diabetes Association (ADA,

2013a), 25.8 million people
in the United States currently are
living with diabetes. Approximately
90%-95% of these have type 2 dia-
betes (T2DM). If not managed prop-
erly, diabetes leads to multiple com-
plications, including heart disease,
stroke, high blood pressure, kidney
disease, blindness, and limb ampu-
tation. Management of diabetes
requires participation in a multifac-
eted program. The complex nature
of diabetes treatment plans makes it
difficult for people living with dia-
betes to understand and maintain
daily self-management (Sevick et
al., 2008). Technology may assist
with processing the complexities of
a self-management plan by provid-
ing education and visual feedback
of self-management behaviors.
Review of Literature
People living with diabetes are
encouraged to follow a healthy diet,
monitor blood glucose, exercise,
take prescribed medications, and
monitor for diabetes-related com-
plications by daily inspecting skin
and feet and obtaining an annual
eye examination (ADA, 2013b).
Self-care management interven-
tions improve glycemic control in
people living with T2DM, leading

to greater well-being and decreased
complications (Minet, Moller, Vach,
Wagner, & Henriksen, 2010; Renders
et al., 2009). Prior to study onset, a
literature review was conducted for
the years 2007-2012 using PubMed,
CINAHL, and PsycINFO databases.
Search terms included diabetes self-
management, diabetes self-manage-
ment behaviors, diabetes and self-effi-
cacy, and diabetes and technology.
Research indicates self-efficacy is
linked closely to diabetes self-man-
agement, with higher levels of self-
efficacy being related to increased
participation in diabetes self-man-
agement behaviors (King et al.,
2010; Lanting et al., 2008; O’Hea et
al., 2009). Methods to promote self-
efficacy in persons with diabetes
have the potential to improve dia-
betes self-management, thereby
improving overall disease control.
Technology is being used increas-
ingly to assist people living with
diabetes with self-management.
New technological advances can
improve self-management by en -
couraging patients to participate in
practices and routines related to
their illness and providing educa-
tional and motivational support for
day-to-day diabetes management.

Technological interventions offer
promise for enhancing self-efficacy
and support for diabetes self-man-
agement. One study evaluated three
different methods of diabetes educa-
tion delivery, including two different
web interactive methods and a tradi-
tional face-to-face education (Pacaud,
Kelley, Downey, & Chiasson, 2012).
Improvements in diabetes knowl-
edge, self-efficacy, and self-manage-
ment were noted for all three meth-
ods. Significant correlations were
found between higher website
usage and higher diabetes knowl-
edge, self-efficacy scores, and meta-
bolic control. Researchers conclud-
ed diabetes education delivered
electronically can be as effective as
the traditional face-to-face delivery
method and may offer options for
meeting the increasing demands for
diabetes self-management educa-
tion.
Another study evaluated the effect
of a text message-based diabetes
program on diabetes management
Research for PracticeResearch for Practice
Caralise W. Hunt
Bonnie K. Sanderson
Kathy Jo Ellison

Technology may assist people living with type 2 diabetes with
self-
management. A pilot study that used Apple® iPad® technology
to
support diabetes self-management is described.
July-August 2014 • Vol. 23/No. 4232
(Nundy, Dick, Solomon, & Peek,
2013). Participants received daily text
messages about taking medications,
weekly reminders about foot care,
and appointment reminders for dia-
betes-related visits. They also could
request additional messages related
to diabetes care, such as reminders
about glucose monitoring. The
intervention im proved self-efficacy
for self-management by providing
feedback on self-management and
relating symptoms to self-manage-
ment behaviors. Qualitatively, par-
ticipants re ported the text messag-
ing intervention increased self-
awareness and control, provided
reinforcement and feedback, in -
creased realization of the signifi-
cance of diabetes, and provided car-
ing and support.
An online diabetes self-manage-
ment program was evaluated by
Lorig and co-authors (2010). Par -
ticipants accessed a website for edu-

cational sessions and weekly learn-
ing activities. They also formulated
an action plan for each week.
Participants in the intervention
group had significant improve-
ments in self-efficacy for diabetes
self-management compared to the
usual care control group.
Research has been conducted
using handheld devices to promote
diabetes self-management. A ran-
domized controlled trial of 151 par-
ticipants tested the use of personal
digital assistants (PDA) for improv-
ing diabetes regimen adherence
(Sevick et al., 2008). Researchers
found the PDA self-monitoring
enhanced accuracy of estimated
caloric intake and expenditure,
enhanced vigilance to the dietary
regimen, allowed problem-solving
for glucose control issues by exam-
ining dietary intake and glucose
values, and allowed positive rein-
forcement and goal revision as
needed.
A qualitative study used a mobile
phone and web-based collaborative
care intervention for patients with
T2DM (Lyles et al., 2011). Smart -
phones and other technology to sup-
port diabetes self-management were
provided to study participants. Most
participants appreciated email com-

munications with the nurse and
found it easy to upload glucose infor-
mation from meters. However, most
participants found the smartphones
to be frustrating. These participants
had not used a smartphone previous-
ly and had difficulty with basic oper-
ation of the phone. Participants and
re searchers recommended using the
technology with devices already
familiar to patients. Although partic-
ipants found the smartphones frus-
trating, most believed the program
increased awareness of their health
and helped them to be more focused
and accountable for self-managing
diabetes.
An experimental study was con-
ducted to evaluate the effects of
interactive multimedia on partici-
pants’ diabetes knowledge, ability
to control blood glucose, and self-
care (Huang, Chen, & Yeh, 2009).
Following the 3-month interven-
tion, members of the experimental
group had significantly higher dia-
betes knowledge levels than those
in the control group who received a
routine education program. Re -
searchers found no significant dif-
ferences between groups for glyco-
sylated hemoglobin (A1C) values or
self-care behaviors. A1C im proved
for the experimental group, but not

to a level of significance. Addi -
tionally, the experimental group
showed improvement in all self-care
behaviors except exercise for the
study period; however, improve-
ments again did not reach a level of
statistical significance. Participants
in the experimental group were sat-
isfied with the diabetes interactive
multimedia, indicating this may be
an acceptable method for diabetes
self-management education.
Diabetes self-management inter-
ventions also are being delivered
using the Internet. An Internet
computer-assisted diabetes self-
management intervention utilized
goal-setting for medication adher-
ence, physical activity, and food
choices (Glasgow et al., 2012).
Participants recorded progress
toward goals and created action
plans to address barriers to goal
achievement. Health behaviors
improved significantly for experi-
mental group participants com-
pared to control group participants.
Researchers noted greatest improve-
ments at 4 months with small
effects at 12 months.
Tang and colleagues (2013) con-
ducted a multicomponent random-
ized controlled trial to evaluate an

online disease management system
to support people living with
T2DM. The intervention included
wireless uploading of glucose read-
ings with graphical feedback, nutri-
tion and exercise logs, online mes-
saging with the health care team,
personalized text, and video educa-
tion. At 6 months, A1C values for
intervention group participants
were significantly lower compared
to control group participants. The
difference was not significant at 12
months, however, possibly due to
significant improvements in A1C
among control group participants
at this time. Intervention group par-
ticipants also had significantly bet-
ter low-density lipoprotein choles-
terol values at 12 months, but no
differences were seen for blood pres-
sure or weight.
Self-management behavior track-
ing, as well as improved access to
diabetes education and health care
providers, can increase knowledge,
self-efficacy, and participation in
self-management behaviors, and
ultimately may improve diabetes
outcomes (Pacaud et al., 2012).
Health care professionals should
develop and implement self-man-
agement support technology pro-
grams to meet the need to deliver
individualized, cost-effective care

that can reach into communities
and homes (Fisher & Dickinson,
2011). While literature supports the
use of technology to meet the needs
of people living with diabetes, more
re search is needed to determine
which types of technological inter-
ventions are most beneficial. Tech -
nology should be evaluated for
motivation for diabetes self-man-
agement, user satisfaction, and dia-
betes outcomes.
Purpose
The purpose of this pilot study
was to determine if the use of appli-
cations on Apple® iPad® technology
that support diabetes self-manage-
Research for Practice
Support for Diabetes Using Technology: A Pilot Study to
Improve Self-Management
ment will increase self-efficacy for
self-management, increase participa-
tion in self-management behaviors,
and improve diabetes outcomes in
persons with T2DM in an employer-
sponsored diabetes self-management
program. Specific aims for the proj-

ect included the following:
• Increase self-efficacy for diabetes
self-management.
• Increase participation in diabetes
self-management behaviors, in -
cluding monitoring blood glu -
cose, taking medications, exer-
cising, and following a recom-
mended eating plan.
• Improve diabetes control (A1C).
Theoretical Framework
The study was guided by Self-
Determination Theory, a general the-
ory of human motivation which sug-
gests people have three innate psy-
chological needs: autonomy, comp -
etence, and relatedness to others
(Deci & Ryan, 2002). Au tonomy
involves self-regulation of behaviors
through experience and reflective
self-endorsement. Com petence refers
to a person’s confidence in the ability
to self-manage and is similar to the
self-efficacy concept. Relatedness in -
volves feeling meaningfully connect-
ed to others. Feeling a partnership
with health care providers increases
de sire to participate in self-manage-
ment behaviors. Self-Determination
Theory indicates support for these
three needs will enhance both men-

tal and physical health. People are
more likely to adopt healthy behav-
iors when these basic needs are sup-
ported. This intervention can in -
crease autonomy by allowing self-
management behaviors to be tracked
and reviewed. This permits re flection
on self-management through visual
representation of how day-to-day
activities affect outcomes such as
blood glucose. The use of technology
to track self-management can in -
crease competence when people liv-
ing with diabetes see positive results
based on behaviors. Relate dness can
be accomplished through feedback
obtained from health care providers
based on documented self-manage-
ment behaviors.
Methods
Design and Sample
This pilot study used a two-group,
crossover, repeated-measures design.
Participants were recruited from the
employee health group of a diabetes
and nutrition center at a local med-
ical center in an urban area of the
Southeast. Repre sentatives from the
employee health program posted
study informational flyers at the cen-
ter. An informational email blast
describing the study and providing
researcher contact information was

sent by a representative to all
employees enrolled in the health
program. Interested persons were
referred to the primary investigator
for questions about study enroll-
ment if they met the inclusion crite-
ria. Inclusion criteria were people liv-
ing with T2DM, age 19 or older, and
able to read and write English. The
goal was to enroll 20 employees in
the pilot study. Approximately 60
people contacted the primary inves-
tigator about study participation; 17
met inclusion criteria and agreed to
participate. The primary reason
given by potential participants for
not enrolling in the study was a lack
of time.
Procedures
The study proposal was reviewed
and approved by the institutional
review boards from the university
leading the study and the participat-
ing hospital. The primary investiga-
tor met with potential participants at
the diabetes and nutrition center.
Study details were explained and a
written informed consent document
was provided. Potential participants
were given the opportunity to ask
questions. Those who were interest-
ed in participating in the study
signed the consent document and
were given a copy. Following in -

formed consent, participants com-
pleted pre-intervention demograph-
ic, self-efficacy, and diabetes self-
management questionnaires. Base -
line A1C values were collected by
diabetes and nutrition center staff
and documented by researchers.
Participants were assigned ran-
domly either to the intervention
(iPad) or control (journal) group. The
primary investigator distributed the
Apple iPad devices and provided
instructions on using the diabetes
self-management application to log
behaviors. Participants also were
instructed how to email logs to the
primary investigator once per week
using a single GMail account estab-
lished for the study. The control
group participants were given
instructions on how to log diabetes
self-management activities in the
provided journal. Participants in
both groups were asked to log dia-
betes self-management behaviors in
the following categories: monitoring
blood glucose, following a recom-
mended eating plan, exercising, and
taking medications on a daily basis.
Contact information for the primary
investigator was provided in case
participants required assistance or
had questions during the study peri-
od. The initial meetings, which last-

ed approximately 1 hour, were con-
ducted either in groups or individu-
ally according to participant prefer-
ence.
Researchers met with participants
from both intervention and control
groups 3 months following the ini-
tial meeting to complete mid-inter-
vention assessments. At this time,
participants in the iPad group were
given a paper journal to log diabetes
self-management activities for the
next 3 months. Participants in the
paper journal group were given an
iPad to document diabetes self-man-
agement behaviors for the next 3
months. A final assessment was
completed after this 3-month study
period. A diabetes educator from the
diabetes and nutrition center was
available throughout the study peri-
od to answer participant questions
related to their medical treatment
programs.
Measures
Demographic information in -
cluding age, sex, race, length of
time diagnosed with diabetes, and
highest level of education was ob -
tained prior to the study. Pre-inter-
vention, mid-intervention, and
post-intervention measures of self-
efficacy and diabetes self-manage-

ment were obtained. The Diabetes
Management Self-Efficacy Scale
(DMSES) (van der Bijl, Poelgeest-
Eeltink, & Shortridge-Baggett, 1999)
was used to measure self-efficacy.
The 20-item instrument includes
questions about self-care activities
people living with T2DM must per-
form to manage the disease, includ-
ing eating a heart healthy diet, par-
ticipating in physical activity, mon-
itoring blood glucose, taking med-
ications, and monitoring for com-
plications. The 10-point Likert scale
assessed patients’ confidence in
their ability to manage their dia-
betes, with higher scores indicating
higher levels of self-efficacy. In -
ternal consistency of the total scale
measured by Cronbach’s alpha
ranged from 0.81 to 0.92 in previ-
ous studies (Coffman, 2008; Hunt et
al., 2012; van der Bijl et al., 1999).
Participation in diabetes self-
management behaviors was meas-
ured using the Summary of
Diabetes Self-Care Activities-Revised
(SDSCA) questionnaire (Toobert,
Hampson, & Glasgow, 2000). The
instrument contains 11 items to

evaluate the frequency with which
participants engage in self-manage-
ment behaviors, including diet,
exercise, medication use, blood glu-
cose testing, and foot care. Re -
spondents indicate the frequency
with which they participated in each
self-management behavior in the
last 7 days. Mean number of days is
calculated for each category of self-
management behaviors, with higher
scores indicating more frequent
participation in self-management
behaviors. Overall internal con -
sistency as measured by Cronbach’s
alpha ranged from 0.65 to 0.84
in previous studies (Eigenmann,
Colagiuri, Skinner, & Trevena, 2009;
Hunt et al., 2012).
An iPad application (Diabetes
Buddy®) was loaded on each device
to track self-management behav-
iors. Diabetes Buddy was chosen
because it allows tracking of the rec-
ommended diabetes self-manage-
ment behaviors of glucose monitor-
ing, eating a healthy diet, exercis-
ing, and using medication. The
application also allows emailing of
data from within the application as
well as unlimited logging of behav-
iors. Participants logged behaviors
each day and emailed a report of
activities each week to the primary

investigator. Control group partici-
pants logged the same behaviors
using a paper journal.
Data Analysis
Descriptive statistics were used to
analyze demographic data and A1C
values. Pre-test and post-test meas-
urements of self-efficacy and dia-
betes self-management behaviors
were analyzed using a mixed model
analysis of variance with the group
(monitoring method) as the be -
tween-subjects factor, and self-effi-
cacy and diabetes self-management
behaviors as the repeated factors. A
repeated measures analysis also was
used to determine changes in self-
management behaviors over time.
Results
Demographic Characteristics
During the first phase of the
study, 3 of the 17 participants with-
drew due to time constraints or
family issues; the final sample was
14 participants (see Table 1 for
demographic characteristics). Ten
participants (59%) were female and
11 (65%) were over age 50. Thirteen
(77%) of the participants had been
diagnosed with T2DM less than 10
years.

Hemoglobin A1C
The sample for this pilot study
had good glycemic control at base-
line with an average A1C of 6.59%.
No additional A1C values were
available during the study period.
Self-Efficacy
The mean and standard deviation
(SD) self-efficacy score for the entire
sample as measured by the DMSES
was high at 8.55 (+/- 0.89). This self-
efficacy mean score falls within the
“certain can do” for the DMSES. The
group using iPads in the first arm of
the study had significantly higher
baseline self-efficacy scores than the
second group with means (SD) at 9.1
(+/- 0.76) and 8.1 (+/- 0.43), which
continued throughout the study.
Self-efficacy scores for the first iPad
group (n=6) remained relatively the
same from baseline to mid-interven-
tion and post-intervention (9.1, 9,
and 9.2). Self-efficacy scores for the
second iPad group (n=8) decreased
slightly from baseline to mid-inter-
vention after logging using the jour-
nal and increased after using the
iPads, but not to a level of signifi-
cance (8.1, 7.9, and 8.7). Analysis of
t-tests revealed no statistically signif-

icant change in either group with
iPad use, indicating the intervention
did not impact self-efficacy in this
sample.
Diabetes Self-Management
The mean diabetes self-manage-
ment score for the sample as meas-
ured by the SDSCA was 5.1 (+/-
0.89) at baseline. For the group
using iPads first, SDSCA scores
remained the same, but decreased
slightly after using the journals to
log behaviors (5.4, 5.3, and 5). For
the group using iPads for the sec-
ond half of the study, SDSCA scores
decreased after journal use, but sig-
nificantly increased at post-inter-
vention after using the iPads (4.8,
4.6, and 5.2). Analysis of t-tests
revealed no significant differences
between groups.
Activity Logs
A comparison of self-manage-
ment behavior activity logs between
iPad use and journal use revealed
mixed results. Some participants
logged more self-management be -
haviors when they used the iPad
and others logged more activities
using the journal. This may indicate
the process of tracking self-manage-
ment behaviors may be more

important than the method used to
track behaviors. Personal prefer-
ences must be considered.
Discussion
Results revealed no difference in
self-efficacy scores between the iPad
and journal study groups; however,
self-efficacy scores were very high at
baseline, making it difficult to iden-
tify improvement. A larger, more
varied sample is needed for addi-
tional evaluation. Additionally, the
average A1C of 6.5% for the sample
indicated good glycemic control.
These findings support previous
research indicating higher levels of
self-efficacy are linked with im -
proved glycemic control. Self-effica-
cy areas that were scored lowest by
participants involved following
a healthy eating plan. This also
supported previous research indi-
cating people living with diabetes
struggle with dietary self-manage-
ment (Booth, Lowis, Dean, Hunter,
& McKinley, 2013; Franks et al.,
2012; Song & Kim, 2009).

Participant scores on the SDSCA
remained the same in the first iPad
group and significantly increased in
the second group after iPad use. The
significant increase in the second
group may indicate tracking of
behaviors using the iPad applica-
tion increases awareness of and
need to participate in self-manage-
ment. Both groups had decreases in
SDSCA scores at midpoint. Perhaps
documenting behaviors led to par-
ticipants’ realization they were not
performing self-management as
often as they thought. Of the
SDSCA categories, taking medica-
tions had the highest score while
exercise had the lowest. Similar
results were found in previous stud-
ies (Al-Khawaldeh, Al-Hassan, &
Froelicher, 2012; Hunt et al., 2012;
Song & Kim, 2009).
A1C values were collected by dia-
betes and nutrition center staff and
reported to the primary re searcher.
Because the majority of participants
were below 7%, staff did not recom-
mend obtaining another A1C for 6
months. At the 6-month point,
most participants did not have
another A1C drawn primarily be -
cause the diabetes and nutrition
center was in the process of relocat-

ing and the primary researcher had
to meet participants at other loca-
tions for the post-intervention data
collection.
Qualitatively, participants off ered
mostly positive comments about
using the iPad application to track
self-management behaviors. Parti -
cipants discussed how the applica-
tion had helped them keep track of
blood glucose levels, food intake,
and exercise. One participant liked
the carbohydrate counter and indi-
cated she had not known how to
track carbohydrates prior to using
the application. Participants found
the summary of activities helpful
and liked having all the self-manage-
ment information available at a
glance. For some participants, seeing
all the information in one place
enabled them to link self-manage-
ment activities with glucose control.
For example, a participant stated he
did not realize until he began track-
ing his exercise that if he exercised
more, his glucose was lower and he
did not have to use as much insulin.
One participant said tracking made
him realize he was not doing enough
to manage his diabetes even though
he thought he was.
Nursing Implications

The complexity of diabetes man-
agement makes the use of technolo-
gy important to improving out-
comes for patients with diabetes.
Technological advances offer prom-
ise for promoting diabetes self-man-
agement (Liang et al., 2011; Lyles et
al., 2011; Pal et al., 2013). Providing
technology to promote tracking of
diabetes self-management encour-
ages patient autonomy. Patients can
visualize progress toward goals
using diabetes applications, which
will promote competence. Sup -
porting patients in self-management
through technology may improve
diabetes outcomes. Effec tive self-
management contributes to blood
glucose control, lowered blood pres-
sure and cholesterol, avoidance of
complications, and improved quali-
ty of life (Funnell et al., 2007; Jones
et al., 2003; Sousa, Zauszniewski,
Musil, Lea, & Davis, 2005). In con-
trast, patients who do not participate
in daily self-management activities
have an increased risk for developing
diabetes-related complications, in -
cluding stroke, heart disease, kidney
disease, limb amputation, and blind-
ness (American Association Diabetes
Educators, 2006).
As identified in this study as well
as previous research, diet and exer-

cise are two areas with which peo-
ple living with diabetes struggle and
could benefit from support. An
Internet-based intervention pro-
TABLE 1.
Sample Demographics
Characteristic n %
Sex
Male 7 41.2
Female 10 58.8
Age
19-50 6 35.3
51 and older 11 64.7
Race
African American 3 17.7
Caucasian 13 76.5
Other 1 6
Educational Level
Less than high school graduate 1 6

High school graduate and some college 11 64.7
College graduate or professional degree 5 29.3
Number of Years Diagnosed with Diabetes
10 years or less 13 76.5
11 years of more 4 23.5
duced significant improvements in
healthy eating and physical activity
for a group of people living with
T2DM (Glasgow et al., 2012).
Nurses can provide education in
these areas and use available tech-
nological resources to help patients
access ongoing education and sup-
port in these areas.
A growing number of people
have access to smartphone and
Internet technology (Brenner, 2013;
Duggan & Smith, 2013). As technol-
ogy and devices become more
accessible, options for use in chron-
ic disease management will increase.
Technology can be used to supple-
ment health care provider education
and support when resources, includ-
ing time, are limited. Technology

that is accessible at the time a patient
needs it offers continuous support
and tools for managing multiple self-
care behaviors (Glasgow et al., 2012).
Nurses should be knowledgeable
about various technological ad -
vances and assist patients to identi-
fy technology that can be used to
facilitate diabetes self-management.
Limitations
This pilot study included a small
convenience sample. Participants
had good glycemic control and
high self-efficacy scores at baseline,
which may have limited the effec-
tiveness of the intervention. An
additional limitation was the use of
self-report measures. The study
required participants to log self-
management activities each day.
Due to time constraints or other
issues, participants may have per-
formed self-management activities
but did not log them using the iPad
application or journal. The logs
may not represent accurately the
number of self-management activi-
ties participants completed each
day. Finally, the food entry section
of the iPad application was reported
to be tedious to use. Participants
had to follow multiple steps to
enter a consumed food and locating
foods was difficult. Every partici-

pant qualitatively listed the food
entry as problematic on the iPad
application evaluation.
Recommendations for Future
Research
Findings from this pilot study will
be used as preliminary data to guide
a larger study to evaluate the effect of
technology to support diabetes self-
management for people living with
T2DM. Expanded re cruitment sites
will be used to obtain a heteroge-
neous sample. Future directions in -
clude exploration of providing dia-
betes self-management education
and social support using smartphone
applications. Provision of both gener-
al and personalized health education
through technological devices is lack-
ing (Chomutare, Fernandez-Luque,
Arsand, & Hartvigsen, 2011). Re -
search should focus on integration of
diabetes management education and
health care provider/peer support for
people with diabetes using technolo-
gy. Current studies indicate technol-
ogy can have a positive impact on
diabetes self-management. The po -
tential for technological advances as
adjuncts to clinical care should be
explored. Future studies should iden-
tify which technologies are most
effective for improving self-manage-
ment and diabetes outcomes. Addi -

tionally, other potential uses of tech-
nology for self-management should
be explored.
Conclusion
Self-management requires peo-
ple living with diabetes to under-
stand the multifaceted treatment
plan, and modify and maintain
daily behaviors. Maintaining daily
self-management is necessary, but
challenging. As technology ad -
vances, health care providers need
to reinvent approaches to educating
and assisting patients to self-man-
age T2DM. Research is needed to
evaluate the most effective forms of
technology for promoting diabetes
self-management.
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Reading Research Literature
Type your answers to the following questions using complete
sentences and correct grammar, spelling, and syntax.
Title: RRL
Name: [replace this text with your name]
The following questions pertain to:
George, S., & Thomas, S. (2010). Lived experience of diabetes
among older, rural people. Journal of Advanced Nursing, 66(5),
1092-1100.
• What is the purpose of this research?
• What is the research question (or questions)? This
may be implicit or explicit.

• Did the authors describe the research design of this
study? If so, give a description.
• Describe the population (sample) for this study.
• Was the sample adequate for the research design that
was selected?
• Describe the data collection procedure.
• How were the data analyzed after collection?
• Discuss the limitations found in the study.
• Discuss the authors' conclusions. Do you feel these
conclusions are based on the data that they collected?
• How does this advance knowledge in the field?
The following questions pertain to:
Hunt, C., Sanderson, B., Ellison, K., (2014). Support for
diabetes using technology: A pilot study to improve self-
management. MedSurg Nursing, 23(4), 231-237.

• What is the purpose of this research?
• What is the research question (or questions)? This
may be implicit or explicit.
• Did the authors describe the research design of this
study? If so, give a description.
• Describe the population (sample) for this study.
• Was the sample adequate for the research design that
was selected?
• Describe the data collection procedure.
• How were the data analyzed?
• Discuss the limitations found in the study?
• Discuss the authors' conclusions. Do you feel these
conclusions are based on the data that they collected?
• How does this advance knowledge in the field.

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