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2009), continues to evolve and develop. in

addition, methods for research integration
and mixed methods synthesis are developing to combine both qualitatively and quantitatively derived findings (Thorne, 2009).
Despite the complex nature of this synthesis,
work on these approaches continues because
nurses are motivated to extend nursing
knowledge.
Public and private funding of nursing
research has allowed for an expansion of
nursing knowledge based in research. of
the many studies funded by the national
institute of nursing Research, Sigma Theta
Tau, and private foundations, descriptive
research continues to command a large portion of research dollars.
Many nursing organizations and associations have delineated priorities for a
nursing research agenda that include health
promotion, disease prevention, and wellness,
eliminating health disparities, improving
quality of life, and improving end-of-life care
and research on minority groups and culturally different views of health and illness.
Adding to nursings knowledge base in these
areas will require using descriptive research
along with other research methodologies and
incorporating the results of these studies into
nursing practice and research endeavors.

Anita J. Tarzian
Marlene Zichi Cohen

Diabetes r esearCh
Diabetes is a chronic, debilitating disease
affecting individuals of all ages and diverse
ethnic populations. nurses deliver evidencebased care for persons living with diabetes in primary care settings, hospitals, and
long-term care facilities. Key research efforts
are imperative to ensuring optimal health
outcomes for those afflicted by this potentially, devastating disease. The purpose of

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this entry is to review major historical, societal, economical and contemporary practice
issues, theoretical and research perspectives,
and future directions.
The care and treatment of individuals
with diabetes was revolutionized with the
discovery of insulin in 1921 by Drs. Frederick
Banting and Charles Best at the University of
Toronto. one year later, insulin for human use
was administered to save the life of a 14-yearold boy who was dying from the disease
(Banting, Best, Collip, Campbell, & Fletcher,
1922). The health care community, persons
living with diabetes, and their families owe
much to Banting et al. (1922) for their groundbreaking discovery. Since then, tremendous
strides in scientific discovery for diabetes
treatment have occurred to allow optimal
glycemic control. Despite these advances, our
society is faced with a significant economic
burden because of the increasing numbers of
individuals diagnosed with diabetes annually. According to the most current available
data from the National Diabetes Statistics 2007
fact sheet (national institute of Diabetes and
Digestive and Kidney Diseases [niDDK],
2008), diabetes was the seventh leading cause
of death as reported on U.S. death certificates
in 2006. The major contributor to mortality
risk was cardiovascular disease, which has
rates two to four times greater for adults
with diabetes than those without the disease.
Estimated U.S. diabetes prevalence rates total
23.6 million people, with 17.9 million diagnosed and 5.7 million who remain undiagnosed (niDDK, 2008).
The major types of diabetes are type 1
and type 2 diabetes. in adults, approximately
90% have type 2 diabetes, with the remainder diagnosed with type 1 diabetes. The
etiology of type 2 diabetes includes insulin
resistance and insufficient insulin secretion.
Type 1 diabetes is caused by autoimmune
pancreatic beta-cell destruction that requires
exogenous insulin administration. Although
the majority of persons with type 1 diabetes develop the disease during childhood,
increasing numbers of youth have been

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DiABETES RESEARCh

DiABETES RESEARCh

125

2009), continues to evolve and develop. in

this entry is to review major historical, socidiagnosed with type 2 diabetes in the past
Medicine (2009a) recently identified national
decade, particularly because of childhood
priorities for comparative effectiveness
research to aid in the translation of best pracobesity, inadequate nutrition, and sedentary
tices for preventing, treating, monitoring and
lifestyles. Similar to the higher rates of obedelivering care. Best practices result from the
sity that are seen in African Americans and
most informed decisions of clinicians, conhispanics (ogden, Carroll, Curtin, Lamb,
sumers of care, and policy makers generated
& Flegal, 2010), the incidence of type 2 diaby well-designed investigations that explore
betes is also greater in these populations
alternative therapeutic approaches. The
than in non-hispanic Whites (Mayer-Davis,
conundrum facing nurse researchers is how
2008). Epidemiological trends show that one
best to participate in transdisciplinary teams
in three youth in the 2000 U.S. birth cohort
to develop and to evaluate interventions
will develop diabetes during their lifetime
that promote effective, individualized self(narayan, Boyle, Thompson, Sorensen, &
management for optimal glycemic control in
Williamson, 2003).
persons with diabetes and to also implement
Projections of the numbers of individuscreening procedures for early detection and
als who will be diagnosed with diabetes
prevention in those most at risk for developindicate steady growth to epic proportions in
ing diabetes.
elders older than of 65 years and in African
Tighter glycemic control is shown to
and native Americans and hispanics (Boyle
decrease
the progression of microvascular
et al., 2001; Engelgau et al., 2004). in 2007, the
diabetes
complications
in persons with type
estimate for the prevalence in adults of pre1
and
type
2
diabetes
(Diabetes
Control and
diabetes, a condition where fasting blood
Complications
Trial
[DCCT]
Research
Group,
glucose levels are higher than normal (i.e.,
1993);
United
Kingdom
Prospective
Diabetes
100125 mg/dl) but not yet at the level to
Study [UKPDS] Group, 1998). Longitudinal
be deemed diabetes (i.e., >126 mg/dl), was
follow-up of individuals enrolled in the
57 million (niDDK, 2008). Diabetes-related
DCCT, called the Epidemiology of Diabetes
complications such as heart disease, stroke,
interventions and Complications (EDiC) trial
kidney disease, blindness, and premature
(nathan et al., 2005) and the UKPDS studies,
death are all more common in African and
demonstrated that intensive glucose control
native Americans or hispanics versus nonearly in the course of the disease decreased
hispanic White adults (niDDK, 2010). in
the incidence of myocardial infarctions and
2007, the total estimated cost of diabetes
cardiovascular mortality (Brown, Reynolds,
was US$174 billion, including US$116 bil& Bruemmer, 2010). in contrast, the Action
lion in excess medical expenditures and
to Control Cardiovascular Risk in Diabetes
US$58 billion in reduced national productiv(ACCoRD) trial (Gerstein et al., 2008), the
ity (American Diabetes Association [ADA],
Action in Diabetes and Vascular Disease:
2008). Given these sobering statistics, there
Preterax and Diamicron Modified Release
is strong evidence that the United States
Controlled Evaluation (ADVAnCE) trial
will face ongoing public health challenges to
(Patel et al., 2008), and the Veterans Affairs
address the potential burgeoning onslaught
Diabetes Trial (VADT; Duckworth et al.,
of individuals who face declining health sta2009) results suggested that intensive glycetus, quality of life (QoL), and lost productivmic control to near normoglycemia (e.g., A1C,
ity related to an earlier onset of diabetes.
6%6.5%) in older adults with type 2 diabeWith the continual onslaught of persons
tes had either no effect on cardiovascular
afflicted with diabetes, research funding
outcomes or potentially detrimental effects
for newer pharmaceutical agents, technolobecause of severe hypoglycemia (Brown
gies, monitoring devices, and clinical trials
et al., 2010).
is needed more than ever. The institute of

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on the basis of evidence from the

UKPDS, DCCT, and EDiC trials and the
current recommendations of the ADA, the
American College of Cardiology Foundation,
and the American heart Association, the
target A1C level for adults should remain
at 7% (Skyler et al., 2009). To minimize risks
of hypoglycemia, the ADA recommends
A1C levels <8% for school-age children and
<7.5% for adolescents (ADA, 2010). To prevent microvascular or macrovascular complications in adults with type 2 diabetes <10
years, a more stringent A1C level <7% may
be appropriate. however, on the basis of post
hoc findings of the VADT, persons older than
60 years with 12 years of diabetes duration
experienced cardiovascular events that were
either unchanged or increased with intensive
glycemic control (Duckworth, 2009). Current
evidence supports the need for further investigation of individualized goals for diabetes
self-management, particularly for those with
longstanding diabetes and with consideration of comorbid conditions, risks for severe
hypoglycemia, and life expectancy.
nurse researchers are addressing major
strategies for developing and evaluating
interventions to improve self-management
and diabetes outcomes. Presented here is an
overview of some of the current theoretical
approaches, study aims, and outcomes of
nurse-led investigations. Although this information is not intended to provide an exhaustive review, it does demonstrate a focus on
studies supported by the national institutes
of health and information retrieved from
the national institutes of health Research
Portfolio online Reporting Tools (http://
p r o j e c t r e p o r t e r. n i h .g o v/r e p o r t e r. c f m).
Theoretical perspectives used to guide diabetes research conducted by nurse researchers
are based on the concepts of social learning, self-efficacy, coping, self-management,
cultural competence, stages of change, and
chronic care.
The majority of nursing studies focus on
adults with type 2 diabetes. Research conducted by Sharon Brown at the University

DiSCoURSE AnALYSiS

127

of Texas at Austin has revealed that culturally competent self-management education

interventions resulted in improved glycemic
control, with greater improvement related
to session attendance (Brown et al., 2005).
her current work consists of systematically
synthesizing the extant research on psychological, motivational, and behavioral factors
affecting diabetes outcomes using metaanalysis and model testing to best inform
clinical guidelines. Sandra Dunbar at Emory
University is developing and testing an integrated self-care intervention for heart failure patients with diabetes for its effects on
health-related QoL, physical function, health
resource utilization, and cost-effectiveness.
With a focus on prediabetes, Deborah
Vincent at the University of Arizona is
examining the feasibility of translating and
culturally tailoring the Diabetes Prevention
Program (Knowler et al., 2002) into a community-based program for overweight Mexican
American adults and estimating the effect on
weight loss.
Studies of youths with diabetes are
addressing the needs of adolescents and their
families. Family and developmental perspectives are incorporated into the designs
of these studies. Margaret Grey at Yale
University is conducting a longitudinal study
using QoL and glycemic control to evaluate
the effects of an internet coping skills training program in youths with type 1 diabetes.
This investigation is an extension of the longest ongoing clinical trial specifically testing
the efficacy of an intervention for youths who
have type 1 diabetes. in the original face-toface intervention, teens who received coping
skills training and intensive diabetes management had significantly better glycemic
control and QoL than youths receiving intensive management alone after 1 year (Grey,
Boland, Davidson, Li, & Tamborlane, 2000).
Carol Dashiff at the University of Alabama at
Birmingham is conducting a feasibility trial
of a joint parent and adolescent (ages 1517
years) psychoeducational multifamily group
autonomy support program to facilitate

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DiSCoURSE AnALYSiS

127

on the basis of evidence from the

of Texas at Austin has revealed that culturadolescent self-management of type 1 diaresearch methodology is defined in a most
betes during the transition from middle to
simplistic form as that encompassing analytical approaches applied to written or spoken
late adolescence. Consistent with the overall
linguistic texts to derive knowledge regardaim of preventing long-term diabetes-related
ing language use and meanings in text in
complications as teens make the transition
relation to contexts of discursive acts and
to adulthood, Melissa Spezia Faulkner at
texts (Alba-Juez, 2009). Specific analytic prothe University of Arizona is investigating
cedures within discourse analysis are varied
personalized exercise interventions for adoaccording to philosophical and paradigmatic
lescents with diabetes and has shown that
orientations.
those who attain 60 minutes of exercise bouts
Discourse is viewed as an appropriate
improve their overall cardiovascular fitness
subject matter for research by various dis(Faulkner, Michaliszyn, & hepworth, 2010).
improvements in glycemic control
ciplines, including linguistics, philosophy,
through individualized interventions develanthropology, sociology, psychology, inforoped and tested through scientific inquiry
mation science, literary criticism, journalwill increase the odds for minimizing compliism, and practice disciplines such as nursing
cations of diabetes, which affect personal QoL
and medicine. Although the term discourse in
and productivity and contribute to the ecorelation to discourse analysis is defined and
nomic burden associated with diabetes care.
used differently in linguistics and in other
Future research must embrace not only better
disciplines, discourse refers to language in
outcomes, including decreasing health disuse as connected speech or written texts proparities in minorities, but also the enormous
duced in social contexts rather than in terms
need for prevention in those predisposed to
of single sentences considered in terms of
the disease. newer technologies for insulin
grammar and syntax. Discourse analysis
delivery, continuous glucose sensing, and
deals with texts of conversations and written
genetic engineering for individual therapies
texts produced among individuals as well as
are on the horizon. Through their leadership
those produced within larger social and hisin transdisciplinary science, nurse researchtorical environments, such as journal articles
ers will remain integral to the advancement
or newspaper accounts that are not directed
of evidence-based diabetes care.
to specific individuals as their audiences.
Discourse as the object of analysis is usually
Melissa Spezia Faulkner
obtained from natural occurrences rather
than from constructions designed solely for
the purpose of analysis.
The term discourse in discourse analysis
DisCourse analysis
is commonly accepted as a complex noun
with the previously mentioned definition.
however, the use of a discourse or disDiscourse analysis is a methodology that has
courses can be often found in discourse
multiple meanings referring to a wide range
analysis with the poststructural, critical
of analytical procedures. Such methodoperspective. however, the current literature
logical diversity has resulted not only from
abounds with both usages of the term (i.e.,
various philosophical traditions that treat
discourse and a discourse), not necesdiscourse differently but also from concepsarily used consistently within one specific
tualization of discourse analysis by diverse
perspective.
disciplines that emphasize different aspects
Discourse analysis has its historic origin
or meanings of discourse. From its multidisin the ancient Greek differentiation of gramciplinary orientation, discourse analysis as a
mar and rhetoric in language use (van Dijk,