Type 2 diabetes mellitus, henceforth referred to as ‘Type 2 diabetes’ in this paper, is a chronic condition characterized by insufficient insulin production (Robbins, Shaw, and Lewis, 2007). It arises from the depletion of insulin-producing β-cells in the pancreas (Robbins, Shaw, and Lewis, 2007). Insulin is a hormone responsible for maintaining a stable blood glucose level within the approximate range of 3.9 to 6.7 mMol/L (Robbins, Shaw, and Lewis, 2007). Type 2 diabetes results in hyperglycemia and excess blood glucose (Robbins, Shaw, and Lewis, 2007; National Institute for Health and Care Excellence [NICE], 2015a). When poorly controlled, hyperglycemia leads to various complications, encompassing micro- and macro-vascular diseases (Goldstein and Muller-Wieland, 2007; World Health Organization [WHO], 2018).
Type 2 diabetes is highly prevalent in the United Kingdom (UK). In 2017, nearly 3.7 million individuals were diagnosed with Type 2 diabetes in the UK (Diabetes UK, 2017). Diabetes UK (2017), the UK’s leading diabetes organization, estimates an additional 1 million people in the UK remain undiagnosed. Given the widespread occurrence of Type 2 diabetes, nurses across various clinical settings frequently encounter patients with this condition. Therefore, nurses must possess a comprehensive understanding of the appropriate nursing management of Type 2 diabetes. This paper critically analyses the nursing management of Type 2 diabetes.
The primary objective of Type 2 diabetes management is to achieve adequate glycemic control, as assessed by the concentration of glycosylated hemoglobin (HbA1c) in the blood. Glycosylated hemoglobin is an objective indicator of long-term glycemic control and subsequently predicts a person’s risk of disease progression and the development of diabetes-related complications (Zhang et al., 2012). While holistic, multidisciplinary care for individuals with Type 2 diabetes is undoubtedly essential, the research underscores the pivotal role of nurses in managing Type 2 diabetes, particularly in facilitating long-term glycemic control (Richardson et al., 2014).
A substantial body of evidence exists regarding effective nursing management of Type 2 diabetes. The Royal College of Nursing (RCN) identifies no less than eleven distinct nursing roles concerning the management of Type 2 diabetes. However, the literature consistently advises nurses to adhere to the recommendations outlined in the latest NICE guidelines (Nair, 2007). Therefore, the strategies discussed herein are grounded in the NICE (2015a) approach titled “Type 2 Diabetes in Adults: Management,” considered the primary reference for clinical practice in the UK.
Strategy #1 – Patient education: The NICE (2015a) guideline recommends that individuals with Type 2 diabetes. This education should primarily focus on dietary guidance (see Strategy #2 below) and related lifestyle modifications, such as incorporating exercise for weight management (Lawrence, Conrad, and Moore, 2012). A recent systematic review and meta-analysis have found that nurse-led diabetes education significantly enhances glycaemic control, with enduring effects over time (Tshiananga et al., 2011). However, it’s worth noting that conclusive evidence regarding the optimal design for Type 2 diabetes patient education, including frequency, timing, delivery methods, and content, is still lacking (Tshiananga et al., 2011). Nurses should, therefore, adhere to local policies or their healthcare organization’s guidelines.
Strategy #2 – Dietary advice: Patient education, as mentioned in Strategy #1 above, must emphasize dietary advice since dietary choices fundamentally influence the development and management of Type 2 diabetes (Ley et al., 2014). The NICE (2015a) guideline underscores the importance of delivering ongoing, personalized dietary guidance to individuals with Type 2 diabetes, particularly regarding consuming high-fibre, low-glycemic-index (GI) carbohydrates. Nurses should also recommend appropriate meal patterns for glycemic control, such as consuming three balanced meals and right between-meal snacks daily (Lawrence, Conrad, and Moore, 2012). While nurses possess expertise and responsibilities concerning dietary intake (Xu et al., 2017), they should refer patients to dietitians or nutritionists if their needs extend beyond the nurse’s scope.
Strategy #3 – Blood pressure management: People with Type 2 diabetes face an elevated risk of vascular diseases (Goldstein and Muller-Wieland, 2007; WHO, 2018), potentially leading to new or exacerbated hypertension. Consequently, the NICE (2015a) guideline recommends regular blood pressure monitoring (at least every 2 months) for individuals with Type 2 diabetes and managing hypertension using antihypertensive medications when necessary. The NICE (2015a) guideline establishes specific blood pressure targets for Type 2 diabetes patients: <140/80 mmHg and <130/80 mmHg for individuals with vascular diseases. Nonetheless, an emerging body of literature questions universal blood pressure targets in Type 2 diabetes management due to a lack of robust supporting evidence, advocating for individualized targets instead (Grossman and Grossman, 2017; Kai, 2017).
Strategy #4 – Drug treatment: In cases where the aforementioned strategies do not enable individuals with Type 2 diabetes to achieve adequate glycaemic control, the NICE (2015a) guideline recommends initiating drug therapy. Metformin inhibits liver gluconeogenesis and is the first-line anti-hyperglycaemic medication suggested for Type 2 diabetes management in the UK (Downis, 2015). Metformin may be combined with one or more second-line drugs, including but not limited to sulphonylureas or thiazolidinediones, and insulin if the condition progresses (Downis, 2015). Unless they possess independent prescribing capabilities related to Type 2 diabetes medication management (RCN, 2018b), nurses may be limited to education and monitoring tasks, as described earlier.
As highlighted earlier, the primary objective of Type 2 diabetes management is achieving adequate glycaemic control. Surprisingly, the NICE (2015a) guideline recommends against routine self-monitoring of blood glucose levels for individuals with Type 2 diabetes. This recommendation is based on a meta-analysis that elucidates the reasons: although self-monitoring of blood glucose levels improves glycaemic control in Type 2 diabetes patients (as measured by glycosylated hemoglobin, as previously described), this improvement is statistically insignificant and excessively costly (NICE, 2015b). Instead of regular self-monitoring, the NICE (2015a) guideline advocates for individualized HbA1c targets and at least bi-annual formal HbA1c measurements.
Strategy #5 – Managing complications: As noted earlier, individuals with Type 2 diabetes are at an increased risk of various complications, often related to vascular diseases (Goldstein and Muller-Wieland, 2007; WHO, 2018)—these complications, even if acute, frequently present without symptoms. However, if not promptly identified and addressed, they can lead to hyperosmolar hyperglycaemic states significant morbidity and potentially rapid mortality (Downis, 2015). Consequently, the NICE (2015a) guideline identifies the management of complications as a crucial nursing responsibility. Nurses should be alert that patients with Type 2 diabetes-related complications may present with these as their primary complaints or as underlying secondary concerns. During their standard clinical assessments, nurses should be skilled in recognizing and interpreting the often subtle signs of diabetes-related complications (Alfadda and Abdulrahman, 2006).
Most cases of Type 2 diabetes can be attributed to modifiable lifestyle factors, rendering it a preventable condition (Jermendy, 2005). In addition to their role in managing Type 2 diabetes, nurses play a crucial role in preventing this condition in individuals at risk (Downis, 2015). The Royal College of Nursing (RCN, 2018a) underscores that, in Type 2 diabetes, a nurse’s primary responsibility is education for prevention, secondary to management. While this paper does not delve into nurse-led strategies for preventing Type 2 diabetes, they largely mirror the straightforward management strategies like education and monitoring (Downis, 2015) described earlier. By implementing these strategies with individuals at risk of Type 2 diabetes, nurses can contribute significantly to mitigating the burden of diabetes.
Conclusion: Type 2 diabetes mellitus is a multifaceted condition characterized by inadequate insulin production, resulting in hyperglycemia and associated complications. Due to its prevalence in the UK population, nurses working across various clinical settings will likely care for patients with Type 2 diabetes. Therefore, they must comprehensively understand the appropriate nursing management of Type 2 diabetes. This paper has explored this topic, referencing the NICE (2015a) guideline titled “Type 2 Diabetes in Adults: Management.” It has delineated key evidence-based strategies, including education, dietary guidance, blood pressure control, and drug therapy, all centred around the overarching goal of achieving optimal glycemic control (measured by HbA1c levels) and managing diabetes-related complications. These strategies apply to nurses in any clinical setting, allowing them to enhance outcomes for patients with Type 2 diabetes significantly.