Evidence based practice project

A nurse-led interdisciplinary approach to promote self-
management of type 2 diabetes: a process evaluation of post-
intervention experiences
Lisa C. Whitehead PhD,1 Marie T. Crowe PhD,2 Janet D. Carter PhD,3 Virginia R. Maskill MHealSc,4

Dave Carlyle PhD,5 Carol Bugge PhD6 and Chris M. A. Frampton PhD7

1Professor of Research, School of and Midwifery, Edith Cowan University, Joondalup, Australia
2Professor of Research, Centre for Postgraduate Studies, Department of Psychological Medicine, University of Otago, Christchurch,
New Zealand
3Associate Professor, Department of , University of Canterbury, Christchurch, New Zealand
4Lecturer, Centre for Postgraduate Studies, University of Otago, Christchurch, New Zealand
5Senior Lecturer, Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
6Senior Lecturer, School of Health Sciences, University of Stirling, Stirling, UK
7Professor, Department of Psychological Medicine, University of Otago, Christchurch, New Zealand

Keywords
evaluation, experience

Correspondence
Lisa Whitehead
School of and Midwifery
Edith Cowan University
270 Joondalup Drive, Joondalup
Western Australia
Australia
E-mail: [email protected]

Accepted for publication: 8 June 2016

doi:10.1111/jep.12594

Abstract
Rationale, aims and objectives Self-management of type 2 diabetes through diet, exercise
and for many medications, are vital in achieving and maintaining glycaemic control in type
2 diabetes. A number of interventions have been designed to improve self-management,
but the outcomes of these are rarely explored from a qualitative angle and even fewer
through a process evaluation.
Method A process evaluation was conducted using a qualitative design with participants
randomized to an intervention. Seventy-three people living with type 2 diabetes and
hyperglycaemia for a minimum of 1 year, randomized to one of two interventions (n = 34
to an education intervention and n = 39 to an education and acceptance and commitment
therapy intervention) completed stage one of the process evaluation, immediately following
the intervention through written feedback guided by open-ended questions. A purposive
sample of 27 participants completed semi-structured interviews at 3 and 6 months post inter-
vention. Interview data were transcribed and data analysed using a thematic analysis.
Results The majority of participants described an increase in knowledge around diabetes
self-management and an increased sense of personal responsibility. Participants also de-
scribed changes in self-management activities and reflected on the challenges in instigating
and maintaining change to improve diabetes management.
Conclusion The complexities of implementing change in daily life to improve glycaemic
control indicate the need for ongoing support post intervention, which may increase and
maintain the effectiveness of the intervention.

Introduction

Glycaemic control is the primary goal in diabetes management and
the key factor in the development of long-term complications [1].
Living with diabetes presents many challenges, including daily
choices and actions that have a direct impact on blood glucose
(e.g. exercise, stress, and for many, medication management) [2].
The short-term and long-term effects of hyperglycaemia are multi-
ple, including microvascular (e.g. retinopathy, nephropathy and
neuropathy) and macrovascular (e.g. heart disease) changes.
Interventions to improve glycaemic control can be broadly catego-

rized into educational interventions and behavioural interventions.
Focused educational interventions have generated inconsistent results

with some studies focusing on diet or exercise alone leading to a pos-
itive effect on measures of diabetic control [3]. Group-based, diabetes
self-management education programmes for people with type 2 diabe-
tes have demonstrated improvements in health outcomes including
improved glycaemic control and increased diabetes knowledge, self-
management skills and self-efficacy/empowerment at 6months [4];
however, an understanding of the effective components of interven-
tions have not been generated. Group-administered psychotherapeutic
interventions have described therapeutic effects related to the nature of
groups [5] and caution that factors directly related to the group
dynamic, rather than the ‘intervention’ can influence outcomes [6].
Qualitative evaluations of interventions are rarely reported but

offer opportunity for the development and evaluation of complex

Journal of Evaluation in Clinical Practice ISSN1365-2753

264 Journal of Evaluation in Clinical Practice 23 (2017) 264–271 © 2016 John Wiley & Sons, Ltd.

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and other health interventions, including the intervention process,
and the feasibility and acceptability of the intervention, to improve
and adapt interventions [7,8]. Qualitative research post interven-
tion can provide valuable insight into the study outcomes gener-
ated by quantitative measures [9]. Although the need for
methodological research on the use of qualitative approaches in
randomized controlled trials has been widely discussed [10], a
review of 100 trials [7] found that whilst associated qualitative
work had been conducted in relation to 30 of the trials, only 19
of these were published. In addition, the majority (n = 14) were
completed before the trial (nine during the trial, and four after
the trial). The paucity of qualitative studies to explore trial results
was further underlined in a systematic review of 296 publications
[11] that reported qualitative findings alongside trial results. Only
1% (n = 5) of the qualitative research related to the trial outcomes.
The aim of the process evaluation was to explore the acceptabil-

ity of the intervention and gain insight into people’s experiences of
implementing the intervention in to everyday life up to 6 months
post intervention.

Methods
Participants were randomized to an education intervention, an
education plus acceptance and commitment therapy (ACT) inter-
vention or usual care. Participants in the usual care group were
advised to continue with their care as normal and for many this
will include visits to their general practitioner and practice nurse,
although the frequency of these visits will be variable. The
national guidelines support at a minimum an annual diabetes check
[12]. Both of the intervention workshops consisted of a 1-day
workshop held at a central city location. The workshop ran from
1000 to 1730 h with a 1-h lunch break. The interventions were
developed by the research team, primary care nurses and an advi-
sory group. The main content was based on the topic areas deemed
to be important across three established international diabetes
education programmes [13–15]. The research team included expe-
rienced educators and clinicians who developed a format for deliv-
ery that promoted engagement in learning and discussion and
included visual learning and active exercises, such as food label-
ling. The interventions were developed into workbooks for the
participants and a PowerPoint slide presentation for the presenters.
The package was reviewed by the advisory group, who included a
consumer, clinicians and Maori and Pacific Island advisors. Both
interventions were piloted with a small group of volunteers who
were diagnosed with type 2 diabetes but who had experienced
hyperglycaemia for just under 1 year and so did not fully meet
the study criteria. Feedback on the content and delivery from the
participants and the nurses were incorporated. Changes were min-
imal and related to using one diagram over another for example
rather than changes to the topics covered.

The education intervention

The education intervention sessions were run by two primary
health care-based nurses who were trained in the delivery of
the intervention by two of the study investigators. The education
intervention covered the topics of the basic pathophysiology of
diabetes, understanding diabetes and glucose, understanding the

risk factors and complications associated with diabetes, food
groups, portion sizes, self-management of diabetes through, diet,
exercise, medication and stress management, monitoring diabe-
tes, including awareness of hypo and hyperglycaemia, and when
to seek help. Underpinning the content were the themes of in-
creasing understanding, how to take control and planning for
the future. The intended changes related to increasing under-
standing of diabetes, satisfaction with diabetes management, an
increase in self-management activities and maintenance or im-
provement of mental health, as measured through anxiety and
depression.

The education plus acceptance and commitment therapy
intervention

In the education plus ACT intervention, time was divided equally
between the education intervention and the ACT intervention.
Participants received the same content in terms of education but
did not have the opportunity to discuss the material in as much
depth as the education only group nor spend as much time on
self-directed exercises in the handbook during the workshop.
The ACT component addressed mindfulness and acceptance train-
ing in relation to difficult thoughts and feelings about diabetes,
exploration of personal values related to diabetes and a focus on
the ability to act in a valued direction whilst contacting difficult
experiences. The ACT component drew on material developed in
a previous study [14]. The workshop was led by a mental health
nurse with expertise in ACT who received supervision from a clin-
ical psychologist. The education component was delivered by one
of the nurses providing the education intervention.

The intended changes related to increased acceptance of diabe-
tes-related thoughts and feelings and a reduction in the extent to
which thoughts and feelings interfere with valued action, increase
in understanding of diabetes, satisfaction with diabetes manage-
ment, an increase in self-management activities and maintenance
or improvement of mental health, as measured through anxiety
and depression.

Inclusion criteria for the wider trial were aged 18 years or over
with a confirmed diagnosis of type 2 diabetes and HbA1c outside
of the recommended range (4–7%, 20–53 mmol/mol) for
12 months or more. Persistent, suboptimal glycaemic control was
defined as having at least two records of HbA1c > 7%, 53 mmol/
mol, in the past 12–18 months, including HbA1c > 7%,
53 mmol/mol on recruitment. Exclusion criteria were non-English
speaking, pregnancy, short-term or serious medical conditions,
currently in psychotherapy or participation in a diabetes education
programme in the past 12 months. The intervention took place in a
community-based location in a city in New Zealand. The primary
outcome of our study identified that those who received the educa-
tion-alone intervention demonstrated a statistically significant im-
provement in glycemic control at 6 months (P = 0.01). Glycaemic
control in the usual care group deteriorated at 6 months, and some
improvement in glycaemic control was noted in the education plus
ACT group at 6 months although this did not reach statistical sig-
nificance. Participants in the intervention groups provided data on
their perspectives of the process of the delivery of the intervention,
and a subsample (n = 27) provided follow-up data on the outcomes
of the intervention.

Evaluation of a nurse-led interventionL.C. Whitehead

265© 2016 John Wiley & Sons, Ltd.

For the qualitative evaluation, all those who completed the
intervention (n = 73) were invited immediately following the
intervention to provide written feedback on the intervention.
A subsample of participants (n = 27) selected purposively by
gender, age and time since diagnosis (≤5 years, 6–9 years and
≥10 years) to ensure representation across the three variables,
were invited to complete a semi-structured interview at 3 and
6 months post intervention, the same data points for which
quantitative data were collected.
At baseline, data were collected through written responses to

open ended questions and at 3 and 6 months through semi-struc-
tured interviews. At baseline, the open-ended questions related to
the areas participants felt were the most valuable, least valuable
and any areas that were not covered in the intervention. Partici-
pants were also asked about completing the intervention in a
group setting and to add any further comments and suggestions.
At 3 and 6 months post intervention, semi-structured interviews
were completed by one author (V. M.) either by phone or in per-
son (based on participants’ preference). The interviews were dig-
itally recorded and then transcribed verbatim. The interview
questions directly related to what participants felt they had
gained (or not) from the interventions, the impact of this on dia-
betes management and any issues that may have impacted on di-
abetes management.
The process of thematic analysis has been described by Braun

and Clarke [16] as a theoretically flexible method that organizes,
describes and interprets qualitative data. The first step in the the-
matic analysis involved becoming closely familiar with the data
by reading and re-reading the interview transcripts. Following
this close reading, initial codes were generated. This involved
examining the data keeping the research aim at the forefront.
One author (L. W.) conducted the close reading of the tran-
scripts, generated the codes and clustered these into categories.
These categories were then integrated into themes following dis-
cussion with the research team members. Once the themes were
identified, they were named, defined and described. This was
followed by a process of illustrating each theme with relevant
excerpts from the transcripts. A process of thematic verification
involved another author (M. C.) examining the audit trail of
codes, categories and themes in relation to the transcribed inter-
view. The final phase was a synthesis of themes. This involved
exploring the relationship of the themes to each other and to the
sociocultural context within, which they emerged [17]. It is at
this point that the presentation of the process shifted from a de-
scriptive process to an interpretive process to identify meanings
embedded across the data and what Braun and Clarke [16] de-
scribe as making an argument in relation to the research
question.

Results
Twenty-seven people were interviewed, with a balance by gender
(female n=13, male n=14), age (43 to 65years, average age
55years), and by time since diagnosis (n=8≤ 5years, n=8 6–9years,
n=11≥ 10years).
One core theme and three sub-themes emerged from the anal-

yses. The core theme, ‘managing diabetes is vital, but challeng-
ing’, described the participants’ over-arching response to the

interventions. The sub-theme, ‘increase in knowledge’, described
change in knowledge in relation to specific areas of diabetes self-
management. The sub-theme, ‘increased sense of personal re-
sponsibility’, described changes in participants’ understanding
of their role in managing diabetes. The third sub-theme, ‘changes
in self-management activities’ related to changes and challenges
in instigating and maintaining change to improve diabetes
management.

Managing diabetes is vital, but challenging

All participants described a recognition that active management of
diabetes is vital to health and well-being. All participants acknowl-
edged that they had a role to play in managing their health through
self-management but described making changes and sustaining
these over time as challenging. The core findings were directly
related to the intervention, and the sub-themes illustrate how
participants reached these positions through the intervention in
relation to an increase in knowledge and awareness of personal
responsibility, which, in turn, impacted on the management of
diabetes and outcomes.

Increase in knowledge

Immediately following the intervention, two-thirds of participants
described an increase in knowledge in relation to specific areas of
diabetes management as the most valuable aspect of the interven-
tion. The nature of the knowledge described immediately follow-
ing the intervention was synthesized into knowledge related to
diabetes as a disease, the consequences of diabetes and the man-
agement of diabetes

Even though I’ve had diabetes for many years I learnt a great
deal about what exactly diabetes is. EDACT56

Understanding diabetes and the consequences if you don’t do
anything about your diabetes. ED 92

In the follow-up interviews, the majority of participants (n = 21)
described learning a substantial amount, with a major increase in
knowledge

Oh it gave me a bigger understanding well I understood an
awful lot more than I did before, although I went to a diabetic
session at the hospital I came out and I still didn’t know some of
the things. ED166

I really understood after the workshops before it was really just
a hit and miss type of situation all the time. EDACT112

Six participants described a mix of learning new information
and refreshing knowledge in other areas.
In relation to the education workshop (both groups), the areas

participants described as most useful were an introduction to the
pathophysiology of diabetes (n = 2), understanding the pharma-
codynamics of the medications they were taking (n = 8), recog-
nizing the warning signs of hypoglycaemia and how to
manage this (n = 2), dietary advice (n = 9), understanding the

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266 © 2016 John Wiley & Sons, Ltd.

benefits of exercise in relation to glycaemic control (n = 2) and
the long-term effects of diabetes and the importance of check-
ups (n = 6)

I didn’t realise, what is it, the beta cells in your pancreas
because of the ongoing high sugar levels actually get killed
off and you can never recreate those. EDACT171

I basically didn’t know that the pill I take (Glipizide) opens up,
she said to take it half an hour before your meal, well I was told
to take it at meal times. EDACT174

I understand a lot more about why I was testing because I didn’t
understand it before exactly why I was testing, you know what
affects me, what food affects me ED166

I think the business about the, you know, how the three month
testing works, because I couldn’t see how you could take a
blood test on one day and know what had happened over the
next three months EDACT126.

If you don’t do your exercise, well it just, I was going to say
makes the diabetes worse, you know, you struggle with your
blood sugars more. EDACT147

I learnt a lot about your feet and foot care and pins and needles
and things like that ED195.

There were no differences in the proportion of participants in
each intervention group who demonstrated an improvement in
glycaemic control by type of change described (e.g. change in
medication management or diet) by intervention group.

Increased sense of personal responsibility

The sub-theme, increased sense of personal responsibility,
encompassed the changes participant’s described in understanding
their role in managing diabetes following the intervention. Directly
following the intervention, one-third of participants described the
most valuable aspects of the intervention as related to an increased
understanding of their own role and responsibilities in managing
diabetes

to now understand what I can do to control my condition
EDACT142.

Two-thirds of participants responded that they felt they now had
an increased awareness and ability to self-manage as a result of
attending the intervention sessions, and one described the
interrelationship between self-management and an increase in
knowledge base

It’s given us enough knowledge to help ourselves EDACT142

I learnt lots and now I have to put it to use EDACT56

Two-thirds of participants who described an increased aware-
ness of the importance of self-management and an increase in

the ability to self-manage following the intervention described this
as a refocusing on diabetes

To be reminded that it is all up to me. A chance to refocus on
my diabetes EDACT71

Being encouraged to think about my diabetes, rather than push
it aside EDACT127

In the interview data at 3 and 6 months post intervention, five
people described a significant change in their outlook on diabetes
and their health, a ‘wake-up call’ (EDACT171) as a direct result
of the intervention.

At the follow-up interviews, nine participants described devel-
oping an increased sense of confidence in relation to managing
diabetes that allowed them to take greater control of the manage-
ment process. Participants described an ability to interact with
their primary health care provider in a more confident and knowl-
edgeable way

I probably learnt quite a lot about the medications you know
like I didn’t know what the medications were, what Glipizide
did and of course the doctor was quite surprised when I told him
what it actually did and he said oh how did you know that I said
oh I read a lot of books no actually I’ve been going on a course
so I explained what was going on and he said oh that’s good
and he’s actually got your results too. EDACT210

The increased sense of confidence led nine participants to
actively address what they now saw as deficits in their care. Partic-
ipants either discussed these with their primary care provider
(n = 7) or changed their primary care provider (n = 2)

It was made quite clear that you know the seminar wasn’t a
checklist for what your doctor should be doing but you know
like there’s quite a lot of stuff that I had never heard of that was
brought to my attention then so yeah I’ve sort of come to terms
that I was with my first doctor who sort of hadn’t done a great
deal about it so I’m sort of hoping that my new doctor will do
more, yeah. ED106

Well it got about really through the education programme that
initially after I went to the education day next time I spoke to
my doctor I talked about it oh you know how I’d been advised
on that to actually get a blood monitor and with my previous
readings I should really be on medication. And he basically his
attitude was well you’re in a busy job you probably don’t have
time to be doing that, you’re better to keep trying just with diet
and exercise and see how it goes. Now when I had the three
month test went back I was still pretty unhappy so I went back
to him and said no look it’s not working, I need a kick start
because I was either conscious about what had happened in the
education or what had been said and he said yeah ok and he put
me on the medication, he also gave me a referral to the diabetes
centre… EDACT171

The participant earlier reported that her average blood glucose
levels had reduced as a result of using the glucometer to under-
stand her blood glucose levels across the day and in response to

Evaluation of a nurse-led interventionL.C. Whitehead

267© 2016 John Wiley & Sons, Ltd.

her diet. The HbA1c results at 6 months confirmed an improve-
ment in glycaemic control.

Changes in self-management: impact of the intervention

The majority of participants (n = 23) described a change in their
daily diabetes management at 3 and 6 months post intervention
and attributed these directly to completing the intervention. The
specific changes in management practices related to modification
of diet (n = 13), blood glucose monitoring (n = 9), medication man-
agement (n = 7), prevention of secondary effects (n = 4), exercise
(n = 3) and managing hypoglycaemic events (n = 3). Ten partici-
pants described changes in two or more areas.
Three people described the impact of the intervention on man-

aging hypoglycaemic events. They now recognized the symptoms
and acted upon these

…the symptoms of when you go into a high or when you go
into a low. I had been going into lows and not really doing
anything about it and I’d just rest up and maybe have a cup of
coffee where I should have been having something a wee bit
sweet to get my sugar up but now that I test quite regularly I can
go down and you know I’ve got to have food and I’ve got to
have sweetness just about straight away. EDACT 112.

Descriptions of a change in diet were described by nearly half of
the participants (n = 13) and related to healthier eating, such as a
reduction in carbohydrates

ED94: I think from my personal point of view it’s made my
understanding of everything a lot better and I have made some
dietary changes.

Interviewer: Right like what 94?

ED94: Like eating more healthy, staying away from things such
as pastries and you know like the deep fried foods and stuff.

Interviewer: Right how easy was that to do?

ED94: After the workshop relatively easy.

Glycaemic control had improved at 6 months for this partici-
pant, but this pattern was not observed consistently across those
who described dietary changes. In addition, three people described
having lost weight as a result of the changes in diet.
Nine participants described a change in the frequency of blood glu-

cose self-monitoring following the intervention. Of the nine partici-
pants, seven increased the amount of self-monitoring, and this gave
them a better picture of their glycaemic patterns and relationship to
diet and medication. People described the increase in blood glucose
monitoring as related to increased knowledge around why monitoring
was important and the link between blood glucose level, diet and
health. Two people who were not previously testing their blood glu-
cose levels at all started as a result of attending the intervention

ED166: No I thought that was a good workshop that was the most,
she explained it well I could understand a hell of a lot more about

what the testing systems were, some of the terminology and what it
can do for you.

Interviewer: So have you how has that affected how you
manage your diabetes or think about your diabetes now?

ED166: Oh it’s spurred me onto actually testing myself up to
then I hadn’t, I had a brand new tester but never took it out of
the wrapper but I’ve got it out the wrapper now got the batteries
up and running. I test it if I think I’m going backwards if I
suspect I’m going backwards… the nurse said that the best way
to do it is test before you have a meal and then test a couple of
hours later and that will show you if what you ate is affecting
your diabetes before. I didn’t know when to test, and what the
numbers meant.

Again, the descriptions of improved blood glucose management
did not necessarily equate to an improvement in glycaemic
control.
Eight participants described a change in medication self-man-

agement as a result of the intervention. The changes were mostly
related to the timing of taking medication. Five people described
now taking Glipizide 30 minutes before their meal rather than at
meal times. They described being previously unaware that
Glipizide stimulates the release of insulin and therefore the uptake
of glucose. Two further participants described now having a better
understanding of why medication needed to be taken regularly and
not just when remembered and had instigated prompts to help en-
sure medication was taken as prescribed (e.g. a pill box). One per-
son described changing their insulin injection technique.
Four people described taking action to manage the potential sec-

ondary effects of diabetes for the first time, through eye checks and
foot care.

ED163: In terms of things on my feet, you know, sores or
anything like that I’m very conscious.

Interviewer: Ok more conscious since the workshop?

ED163: Absolutely, these are, I mean, I’m in landscaping and
even I wear gloves now where normally didn’t. I sort of ferret
around in soil and get cuts and that type of stuff and you know
now, I mean have gloves all the time now.

For this participant, working in landscaping, taking precautions
such as now wearing gloves at all times had important longer term
implications.

Challenges to making changes in the self-management of
diabetes

Participants described two main areas, diet and exercise, as issues
that challenged them and impacted on their ability to make
sustained changes in diabetes management practices, and these
remained constant at 3 and 6 months post intervention. Two-thirds
of participants described ongoing difficulty and frustration with
eating and diet. Most were aware of how they should be eating
but reported self-control, difficulty avoiding certain foods,

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268 © 2016 John Wiley & Sons, Ltd.

particularly in social situations, cooking for others, eating on time
and access to vegetables as reasons for not being able to make or
continue change. Several participants described frustration that
they had increased their exercise but had not lost weight. A third
of participants spontaneously referred to the need for follow-up
sessions for ongoing support in self-management:

…there’s really no, you know you have that and you feel great
for a month or so and then there’s no one ED106.

The majority felt that the intervention should be made available
to everyone diagnosed with diabetes.
The delivery of the interventions in a group setting was de-

scribed as highly acceptable by the majority of participants. All
participants in the education group described the group setting
for the education intervention as highly …