Essay: Type 1 diabetes: biological, psychological, sociological perspectives / life course theory / multidisciplinary team

John was 17 years old with a history of type one diabetes mellitus (type one diabetes). John was diagnosed with type one diabetes aged three and had previously been very well controlled, with an excellent Hb1AC. When John turned 16 years old is care was transferred to an adult diabetic service. Since this transition occurred, John’s glycaemic control had slipped, and he was no longer engaging with the diabetic service. John presented at the emergency department with a three-day history of nausea, vomiting and increased capillary blood glucose levels. John was diagnosed with diabetic ketoacidosis (DKA) and was admitted to the ward for treatment. This essay will aim to explore initially how the biological, psychological and sociological perspectives combined with the life course theory can provide us with an understanding into John’s condition and its management, and will then assess how multidisciplinary team (MDT) working has contributed to his care. Finally, it will evaluate his care, and if necessary, make recommendations on how this episode of care could be improved in the future.
The biological approach views humans as biological organisms and plays particular attention to form and function (Watson, 2018a). The emphasis of the approach is on reductionism, which explains the processes and behaviours of a disease by analysing the smallest component of a system and informs thinking which underpins methods of inquiry in modern science (Watson 2018a). The model aims to find cures to conditions (Watson, 2018a) and has made a significant contribution to many of the advancements in healthcare and informed evidence-based practice and has increased longevity and improved quality of life globally (Watson, 2018b).
Type one diabetes is a physiological condition which can be explained from the biological perspective; it is caused as a result of the destruction of the beta-cells found within the pancreatic islets, which is often caused by an autoimmune reaction (Higham, 2018a). Beta-cells within the pancreatic islets are responsible for the homeostatic production and release of insulin into the blood stream (Higham, 2018a). Type one diabetes causes an insulin deficiency which results in an alteration in the metabolism of carbohydrates, lipids and proteins (Higham, 2018b). Type one diabetes is a condition which is lifelong and life threatening, which can lead to significant illness and disability, and is associated with increased incidence of mental ill health (Higham, 2018b). It is managed through monitoring of capillary blood glucose levels, subcutaneous administration of insulin and carefully planned diet and exercise regimes (Higham, 2018b). DKA is described as an extreme metabolic state triggered by insulin deficiency which is characterised by hyperglycaemia, metabolic acidosis, dehydration and ketosis (Misra et al., 2015). The condition is managed with intravenous fluids & insulin to correct hyperglycaemia, dehydration, electrolyte imbalances and to supress ketogenesis (Misra et al., 2015).
Psychology is the scientific study of the human mind and examines how it alters our patterns of behaviour, it focuses on what makes us tick and why, which helps us to understand many of the problems faced in modern society (The British Psychological Society, 2018). It offers an insight into people and the way in which they function, which can enable us to provide effective, person-centred care (Clark,2018a), and can enable us to alter behaviour (Clark, 2018b). Research in psychology routinely takes three forms; observational research were the researcher visits the place of study and monitors behaviours, survey research, were research is completed through the use of surveys, or experimental research were psychologists complete an experiment, these research forms should be repeatable to obtain the same outcome (Clark, 2018b). Although type one diabetes is a physiological condition it has been linked to increased incidence of mental illness (Higham, 2018c). Secondary to this, DKA meets the criteria for being classed as a traumatic event, leading to rebound feeling of anxiety, depression, physiological arousal such as breathlessness and can consequently cause post-traumatic stress disorder (Moffett, et al., 2013). It is felt that the psychological approach of managing patients with diabetes can feel stigmatic, as the approach in many diabetic services is not routinely used (Moffett, et al., 2013). In John’s case, type one diabetes can have an impact on body image, many young diabetics have issues with body image as a result of rapid weight loss and weight gain dependant on how well their condition is controlled (Higham, 2018d).
Sociology is the scientific study of human societies (Hickman, 2018a). Health and illness occurs within societies; the sociological perspective examines what health and illness means, how it is produced, why it occurs and how it is experienced, which also includes the impact which it has on families (Hickman, 2018a). Sociology also investigates the impact of health inequalities, where life expectancy for men in the most affluent areas now exceeds the life expectancy for women by on year in the most impoverished areas (Hickman, 2018a). Sociology can help explain some of the causative factors for complications in diabetes and the impacts which it has; socioeconomic status can affect the diet of individuals, which is one of the factors for managing diabetes; poor diet leads to poor health and can impact on the long-term management of the condition (Weaver, et al., 2014). The detection of DKA and long-term management of diabetes also requires a sociological response, in Moffett et al.’s study the severity of illness in all of the respondents was detected by family members (Moffett e al, 2013). Following the resolution of DKA and discharge from hospital many of the respondents required prompting from family to check capillary blood glucose and to administer insulin (Moffett et al., 2013). John lived at home with his parents, diabetes can lead to conflict between adolescence and their parents due to day-to-day management of their condition, such as dietary restrictions, capillary blood glucose monitoring and insulin administration (Higham 2018). John’s relationship with his parents seemed strained, and he did not wish for his condition to be discussed with them.
The life course theory relates to the concept that people’s transition through predictable stages of change from birth to death (Rogers, 2018a). This said, the stages of the life course and what one encounters in each one depends upon the culture and context in which one lives (Rogers, 2018a). The life course can be disrupted by serious illness and life events, and ca be impacted upon by differences in culture, religion and socioeconomic status (Rogers, 2018a).
There are five key principles underpinning the life course theory (Rogers, 2018b). The first of these principles is ‘linked lives’, this considers the importance of relationships held by the individual, which may span generations (Bengtson et al., 2005). These relationships can have a negative or positive impact on one’s life (Bengtson et al., 2005). In John’s case his relationship with his parents was strained, despite the support they previous offered him in managing his condition. This may be because it restricted his autonomy, a common feeling in this group (Higham, 2018e).
The second principle examines the importance of transitions and their timing within an individual’s life, relevant to their social context (Bengtson et al., 2005). Transitions have what is regarded as a ‘best fit’ time which is related to the development of the individual (Bengtson et al., 2005). These transitions in healthcare can be destabilising to the individuals care and management (Rogers, 2018b). The transition between children’s, young adult’s and adult’s diabetic services has been cited as a difficult transition (Higham, 2018f), and this was a challenging transition for John, which ultimately led to the deterioration in this condition. This transition was imposed on John, he did not have the option remaining with children’s services, something that likely made it more difficult (Rogers, 2018b).
The third principle relates historical time and place; which considers the importance of the individuals age, geographic location and events which have occurred in their lifetime which may have altered the way in which they view the world (Bengtson et al., 2005). This principle also considers one’s ability to use modern technology, something that is now incorporated in healthcare through the likes of telemedicine (Rogers, 2018b). This could be applied to John’s case as it could be argued that he does not yet have the required life experience to understand the long-term importance of managing his diabetes to avoid long term health problems, such as renal failure (Higham, 2018c).
The fourth life course principle relates to agency and planfulness, which considers that these two concepts alter the outcome of the lives of individual; something that the individual has control over constructing their life, and deciding the journey they will take (Bengtson et al., 2005). In John’s case having diabetes may constrain his life because of the planning require to manage his condition (Rogers, 2018b).
The final life course principle considers that human development and aging are lifelong processes which are influenced by the experiences and consequences of our earlier life (Bengtson et al., 2005). It has been shown that children who are nurtured in childhood are more likely to have higher self esteem in adulthood (Bengtson et al., 2005). In John’s case his later life could be influenced by the mismanagement of his diabetes now (Rogers, 2018b).
Adolescence is a transitional stage within the life course were an individual is moving from childhood to adulthood (Rogers, 2018c). The developmental tasks of adolescence focus on building independence, development of identity, developing autonomy & connection with others (Bailey, 2006, cited in Higham, 2018g). It is argued that adolescence is one of the most challenging transitions throughout the entire life course (Lerner et al., 2018), and sees the individual reach the pubescent stage, developing cognitively, emotionally, socially, physically and morally (Bailey 2006, cited in Higham, 2018g). In John’s case it was evident that he was trying to build his autonomy and independence by trying to avoid having his parents input in his condition.
A multidisciplinary team involves staff of different professions, training and background working together to meet the complex needs of patients and service users (Rogers, 2018d). It has been demonstrated that the percentage of staff working in well-structured teams is a predictor of patient mortality (West, 2013 cited in Rogers, 2018e). An increase of 5% more staff working in real teams has the potential to reduce patient mortality by 3.3%; equivalent to 40 deaths annually in an average hospital (West, 2013, cited in Rogers, 2018e). Many benefits of well-functioning teams in health and social care have been cited, but it has been demonstrated in studies that there is great variability in their effectiveness (Rogers, 2018e). Factors such as status differentials, gender, and lack of support for teams all impact on their optimum functioning (Rogers, 2018e).
Teams which manage diabetes can be very complex and involve a wide range of healthcare professional’s dependant on the needs of the patient (Diabetes.co.uk, n.d.). The range of healthcare staff involved managing patients with diabetes include consultant endocrinologists or specialist diabetologists, general practitioners, diabetic specialist nurses, practice nurses, pharmacists, podiatrists, optometrists and ophthalmologists, dieticians, psychologists and consultants of other specialties who manage complications associated with diabetes such as nephrologists who have involvement if the patient develops renal disease as a complication (Diabetes.co.uk, n.d.). Not every patient with diabetes will need input from this full range of specialties (Diabetes.co.uk, n.d.).
The team involved in John’s care during his DKA included an endocrinologist, a diabetic specialist nurse, a diabetes specialist dietician, ward nurses and healthcare assistants, critical care outreach nurses and doctors who worked on the ward. The common goal of the team in John’s case was to resolve his DKA and then to assist him in the long-term management of his condition to help him avoid a reoccurrence of his DKA, as reoccurrence of DKA is established to poorer long-term outcomes (Mays et al., 2016).
Multidisciplinary team approaches have been indorsed by The National Institute for Clinical Excellence (NICE) for the management of several different conditions in acute and long-term care (National Institute for Clinical Excellence, 2017). The multidisciplinary team responsible for John’s care had a daily meeting on the ward, which consisted of nursing & medical staff, social workers and allied health professionals. At this meeting each patient was discussed along with their plan of care and estimated date of discharge, which has been shown to improve the efficiency of care and improve rates of discharge from the ward once deemed medically fit (Gallagher et al., 2004). Throughout the day any updates in John’s care was documented in the multidisciplinary care notes and verbally communicated to other team members when necessary.
It is important to recognise that not all members of the multidisciplinary team regularly attended the daily multidisciplinary team meeting; this included the likes of the diabetic specialist nurse who was responsible for John’s ongoing management. This was because the diabetic specialist nurse provided care to a range of patients with diabetes in a number of wards and in outpatients, so this made their involvement in the meetings difficult.
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