ARTICLE IN PRESS G​ Model ​ COLEGN-576; No.

of Pages 7

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Contents lists available at ​ScienceDirect

Collegian
Please cite this article in press as: Baines, C., et al. Patient reported experience of blood glucose management when undergoing hyperbaric oxygen
treatment. Collegian (2018), ​https://doi.org/10.1016/j.colegn.2018.11.004

Patient reported experience of blood glucose management when undergoing

hyperbaric oxygen treatment

Carol Baines *​​ , Geraldine O’Rourke, Charne Miller, Karen Ford, William McGuiness
Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, Liverpool Street 7053 7000, Australia
Nursing Ltd.

articleinfo

Article history: Received 1 August 2018 Received in revised form 16 September Problem
2018 Accepted 18 November 2018 Available online xxx
What this paper adds

Keywords: Hyperbaric oxygen Blood-glucose Diabetes Interviews

Interpretive-description Thematic analysis There is little known about the self-management of blood glucose
abstract levels, in people living with diabetes, when undergoing hyperbaric
oxygen treatment (HBOT).
Background: Patients who have diabetes and require hyperbaric treatment
for wound healing are an increasing population. Hyperbaric oxygen
treatment (HBOT) has been shown to reduce a patient’s blood glucose What is already known?
level during an individual treatment. Anecdotal evidence suggests patients
with diabetes are concerned about suffering a hypoglycaemic episode Currently it is observed that people living with diabetes who
during HBOT. It is suspected that patients who have diabetes undertake undergo HBOT experience a decrease in their blood glucose level.
protective health behaviours by intentionally increasing their blood
glucose levels prior to HBOT.
Aim: To explore the emotional and physical experiences of patient
self-management behaviours of their blood glucose levels during a course
* ​Corresponding author at: Department of Diving and Hyperbaric Medicine,
of hyperbaric oxygen treatment.
Method: The use of semi-structured in-depth interviews, each interview Royal ​Hobart Hospital, Liverpool Street, Hobart, Tasmania 7000 Australia.
was audio recorded and transcribed verbatim. Participants (n = 15), were E-mail address: ​carol.baines@ths.tas.gov.au ​(C. Baines).
prior patients living with diabetes who had undergone HBOT at a tertiary This paper provides commentary on the experiences and per-
hospital in an Australian state during 2014–2017. Interpretive description ceptions of people with diabetes who have undergone hyperbaric
along with thematic analysis of all interviews was undertaken.
oxygen treatment; describing the impact of individual self-
Findings: Four themes emerged from the interviews, each deriving from management behaviours on their blood glucose levels.
the participants’ experiences 1.Varying recognition of self-management
requirement of diabetes; 2. Hypoglycaemia fear; 3. Treatment- based
adaptation; and 4. Ownership / monitoring. Participants reported that they
altered their diabetic regime/blood glucose management to undertake a 1. Introduction
course of HBOT.
Discussion: Patient engagement throughout HBOT, leads them to elevate Amongst the most common, costly, and preventable of all health
their blood glucose, although not advocated, to above normal levels, problems faced worldwide are those related to obesity, heart
adopting these behavioural changes as a self-protective mecha- nism. disease, stroke, cancer, arthritis and diabetes. Diabetes is a well
Conclusion: Improving the patient experience of hyperbaric oxygen acknowledged cause of long-term health complications, as evi-
treatment is multifactorial and often dependant on the relationship denced by the 13point diabetes complication severity index
between the clinician and the patient. Consistent monitoring of blood
(DCSI) developed by ​Young et al. (2008)​) and modified by
glucose during HBOT, may ameliorate negative feelings that are often
Chang, Weiner,
associated with this treatment option.
© 2018 Published by Elsevier Ltd on behalf of Australian College of

https://doi.org/10.1016/j.colegn.2018.11.004 ​1322-7696/© 2018 Published by Elsevier Ltd on behalf of Australian College of Nursing Ltd.
journal homepage: ​www.elsevier.com/locate/coll

ARTICLE G​ Model ​ COLEGN-576; No. of Pages 7 ​ IN PRESS ​ 2 C. Baines et al. / Collegian xxx (2018) xxx–xxx

including heart attack, stroke, kidney failure, leg amputation,

Richards, Bleich, and Segal, (2012)​. The World Health Organisa- vision loss and nerve damage which can increase the overall risk
tion (​WHO, 2016​) reports that long-term consequences of diabetes of dying prematurely.
impact significantly on quality of life, leading to complications Hyperbaric oxygen treatment is an established treatment modality,
prescribed for patients who concomitantly have diabetes and a
wound (break in their skin integrity), that is non-responsive to
healing over a conventional timeframe (​Heyboer, Sharma,
Santiago, & McCulloch, 2017​). HBOT has been identified as use-
ful in the promotion of wound healing, thereby reducing the risk of
amputation (​Jain, 2017​). Previous studies have documented an
inconsistent and unpredictable impact on blood glucose levels
(BGL) in patients with diabetes during HBOT (​Peleg et al., 2013​;
Ekanayake & Doolette, 2001​). All patients, regardless of primary
diagnosis and co-morbidities, who undergo hyperbaric oxygen
treatment, demonstrate a drop in their blood glucose level
(​McIIroy & Banham, 2013​). The magnitude of the blood glucose
reduction associated with HBOT is slightly amplified in the
population of patients who also have diabetes (​Ekanayake &
Doolette, 2001​). One regular, risk reduction strategy for patients
who have diabetes and receive HBOT is to undertake increased
point of care blood glucose testing (​Heyboer et al., 2017​).
2. Literature review
2.1. Diabetes as a chronic condition
Diabetes is a chronic illness, that affects the long-term health of
people in a number of ways, with the resulting need for multi-
disciplinary approaches to ongoing care within hospital and com-
munity settings (​AIHW, 2018​). In 2014-15, more than 11 million
Australians (50%) were reported as requiring highly complex
health needs arising from multiple chronic diseases, and many in
this group will need to access acute care services to receive
treatment (​AIHW, 2018​). Based on self-reported estimates from
the Aus- tralian Bureau of Statistics 2014–15 National Health
Survey, more than 1 in 20 (6.1%, or 1.2 million) Australian adults
had diabetes (​AIHW, 2018​). Diabetes was recorded as the
principal and/or addi- tional diagnosis in around one million
hospitalisations in 2015–16, accounting for 10% of all
hospitalisations in Australia (​AIHW, 2018​). A chronic
complication of diabetes is micro and macrovascular
complications causing poor peripheral circulation, resulting in skin
wounding and ulceration (​Chawla, Chawla, & Jaggi, 2016​).
Hyper- baric oxygen treatment is one option available to the
diabetic population as an adjunctive treatment to assist in wound
healing, it should be noted work by ​Katarina, Magnus, Per, and
Jan, (2009) ​indicates that patients who have diabetes consider a
high technol- ogy treatment such as HBOT to be both burdensome
and stressful.
2.2. What is hyperbaric oxygen treatment?
HBOT involves individuals breathing 100% oxygen, while inside
a hyperbaric chamber that is pressurised to greater than sea level
pressure (1 atmosphere absolute, or ATA), usually for a 110-
minute timeframe, for repeated episodes. Treatment regimens are
delivered using either a mono-place hyperbaric oxygen chamber
which accommodates a single patient only, or a multi-place hyper-
baric oxygen chamber which accommodates two or more people
(patients, nurses) (​Jain, 2017​) (see ​Fig. 1​). Each hyperbaric
chamber is a pressurised vessel / chamber, therefore, once the door
is closed and treatment has commenced there is potential cause for
tech- nical, psychological and physical complications, which could
pose a need for intervention. HBOT has been demonstrated to
increase tissue oxygenation, stimulate angiogenesis and restore
stem cell
mobilisation from the bone marrow, thus contributing to wound
healing (​Prabowo et al., 2014​; ​Peleg et al., 2013​).
2.3. Hyperbaric treatment and measurement of blood glucose
levels​Monitoring blood glucose levels during HBOT is always
per- formed
​ using the intermittent finger-prick method which is
standard clinical practice (point of care) and is recognised as safe
and normal for the patient (​American Diabetes Association, 2018​;
International Diabetes Federation, 2017​; ​WHO, 2016​). It has been
identified in previous studies, that HBOT patients have experi-
enced a hypoglycaemic episode at depth (​McIIroy & Banham,
2013​; ​Wilkinson, Noting, Mahadi, Chapman, & Heilbronn, 2015​).
Hypo- glycaemia itself is not viewed as a contraindication to
HBOT, but is a situation requiring ongoing medical management
and clinical support. There is potential for a multitude of
physiological changes that present with similar clinical symptoms
to hypoglycaemia, in patients receiving HBOT. Close monitoring
of BGL allows for the rapid recognition of hypoglycaemia as a
potential cause of these symptoms and establishes a practice
standard for patient safety (​Trytko & Bennett, 2003​; ​Stevens et al.,
2015​).
2.4. Hypoglycaemia fear
International consensus defines hypoglycaemia as a blood glu-
cose level of less than 4.0 mmol (ADA, 2018; IDF, 2017; &
Diabetes Australia, 2018​). Personal experience with symptomatic
hypo- glycaemia can vary and symptoms may can include
sweating, faintness, rapid heart rate, shakiness, anxiety, or
irritability (Dia- betes Australia, 2018). A hypoglycaemic event
can be a frightening and medically serious situation. If not
recognised and treated quickly, the BGL can continue to fall,
which is linked to poor attention and cognitive function,
potentially resulting in fit- ting, unconsciousness or coma. Patients
often self-manage these unpleasant and harmful physical
manifestations through non- adherence to their medication
regimes. (​Walz et al., 2014​; ​Bron, Marynchenko, Yang, Yu, &
Wu, 2012​; ​Leiter et al., 2005​).
This paper reports findings from an interpretive descriptive study
that aimed to explore individual patient experiences and develop
an understanding of the self-management initiatives peo- ple with
diabetes take to prevent hypoglycaemia whilst undergoing
hyperbaric oxygen treatment.
3. Methods
A qualitative method of interpretive description (​Thorne, Reimer,
Kirkham, & O’Flynn-Magee, 2004​) was adopted to allow the
construction of inductively derived understandings of the
participant’s experiences. The qualitative research methodology
interpretive description as described by ​Thorne, Reimer, Kirkham,
and MacDonald-Emes, (1997) ​is founded in the smaller scale
quali- tative investigation of an area of clinical interest for the
purpose of capturing themes and patterns within the subjective
experiences and the generation of an interpretive description that
can inform clinical practice (​Thorne et al., 2004​). Interpretive
description is an inductive method that informs the research
design, data collection and analysis (​Thorne et al., 2004​).
Interpretive description acknowl- edges the clinical expertise and
Please cite this article in press as: Baines, C., et al. Patient reported experience of blood glucose management when undergoing hyperbaric oxygen
treatment. Collegian (2018), ​https://doi.org/10.1016/j.colegn.2018.11.004
ARTICLE IN PRESS G​ Model ​
C. Baines et al. / Collegian xxx (2018) xxx–xxx 3
Fig. 1. ​Illustrated picture of Mono & Multi-place Hyperbaric Oxygen Chamber Reprinted with permission ​Bird Medical Devices. (2018, May 9)​.
participant’s chosen time and was conducted in a private,
confiden- tial manner. Interviews were audio recorded and
supplementary field notes were taken and later consulted to
characterise any non- verbal nuances. Each audio recording was
transcribed verbatim. All interviews were transcribed by the
interviewer within five days of the interview taking place. The
computer software program NVivo, was employed to manage and
store data. Thematic analysis as described by ​Braun & Clarke,
2006​, underpinned by the principles of interpretive description
(​Thorne et al., 2004​) was undertaken.
The first two interviews were analysed by a second member of the
research team and regular meetings were held to discuss the
preliminary codes and developing themes; this support is an
experience of the researcher, and this provides a stepping off point
for the research design (rather than providing an overarching
structure) (​Hunt, 2009​). Individ- ualised interviews are frequently
the primary data source and findings provide clinically applicable
insights, which ultimately inform clinical practice (​Thorne et al.,
1997​).
Data for this study were gathered using individual semi-
structured, in-depth interviews. Each interview took place at the
COLEGN-576; No. of Pages 7
acknowledged methodological core activity of supervision
sessions and team meeting in support of this approach to the
research (​Barbour, 2001​).
3.1. Research team
The team was responsible for the study design. The first author
undertook recruitment and data collection. Members of the
research team were involved in the thematic analysis
The interviewer is female, a Registered Nurse with over thirty
years’ experience, of which eighteen years, are in the specialist
field of hyperbaric and diving medicine. The interviewer adopted a
highly reflexive approach to engagement with participants with
careful consideration of the (previously) established clinical rela-
tionship when the participant was receiving HBOT. No
participants were receiving HBOT care at the time of interview.
3.2. Setting
The study setting was The Department of Diving and Hyperbaric
Medicine at a tertiary hospital in a state of Australia from 2014 to
2017. The tertiary hospital provided hyperbaric oxygen treat- ment
to a total of 112 patients during this period of which 70 have
diabetes, each patient undertook up to forty separate treatment
sessions over a period of eight weeks. This study involved a subset
of 15 people who consented to audio recorded in-depth interviews.
Thorne (2008) ​suggests that interpretive description can be applied
to small studies ranging from 5 to 30 participants.
3.3. Recruitment
Potential participants were purposively selected and were pre-
vious adult patients living with diabetes (Type 1 or Type 2), and
who had completed a course of HBOT in the preceding three years
at the study hospital. Patients were invited via a letter sent to their
home address to participate in an audio recorded, in-depth inter-
view. A consent form was included and if they wished to
participate, they were asked to return the signed consent form, in
the reply- paid envelope that was provided. Due to the
retrospective nature of the project, those patients who had most
Please cite this article in press as: Baines, C., et al. Patient reported experience of blood glucose management when undergoing hyperbaric oxygen
treatment. Collegian (2018), ​https://doi.org/10.1016/j.colegn.2018.11.004
ARTICLE G​ Model ​ COLEGN-576; No. of Pages 7 ​IN PRESS ​
Table 1 ​Demographic characteristics of study population.
Characteristics Value n = 15
Gender 13 males / 2 females Diabetes type /number of participants T1DM (1)
T2DM (5) T2DM on insulin (9) Age (mean) 61 years Interview duration (mean) 45
minutes Time since last HBOT (mean) 10 months HBOT sessions (average) 35
sessions Reason for HBOT Diabetic wound
Radiation proctitis Radiation cystitis
Note. T1DM type 1 diabetes mellitus; T2DM type 2 diabetes mellitus; HBOT
hyper- baric oxygen therapy.
concerned. Written participant information was provided to each
participant. Each participant consented to the inclusion of their
data in the study were informed that they could withdraw at any
time.
3.5. Findings
Of the 17 patients identified as meeting the inclusion criteria, 15
agreed to participate (see ​Table 1​). The duration of the interviews
ranged between 25–65 min.
The four themes generated from analysis of the interviews and
recently finished HBOT were the first invited to participate as
these were considered to be ‘closer’ in time to their experience.
Letters were mailed out in clus- ters of five, and responses were
received within 14 days of initial contact. At interview, the
researcher verbally confirmed with the participants their
willingness to take part in the study prior to com- mencing any
recording, and it was reiterated that all reported data would be
used under a pseudonym.
Recruitment ceased when the researchers were confident that no
additional relevant knowledge was being obtained from new
participants, and thus data sufficiency had been reached. ​Thorne
(2008) ​advises that in smaller interpretive description studies, the
findings can be justified with the recognition that there will always
be more to study.
It was acknowledged that there may be occasions of emotional
discomfort, as a result of re-living the hyperbaric experience. The
offer of professional support from a Diabetes Nurse Practitioner
was made at the close of each interview. This support was not
required by any participants.
3.4. Ethics
This study received ethics approval from the University of Tas-
mania, Human Research Ethics Committee (HREC) (H0016456),
La Trobe University and site approval was obtained from the
hospital
4 C. Baines et al. / Collegian xxx (2018) xxx–xxx
derived from the participant’s subjective experiences, were
varying recognition of self-management requirements of diabetes;
hypogly- caemia fear; treatment-based adaptation; and ownership /
monitoring (see ​Fig. 2​).
3.6. Theme 1 – varying recognition of self-management
requirements of diabetes
Individual participants were able to describe some aspects of their
diabetes management regimes, however, further discussion
revealed that their willingness to participate in the ongoing man-
agement of their diabetes varied. One participant, in explaining
their prescribed oral medication schedule, stated that ‘I only take
my medication when l felt like it’ (participant three). Several
partici- pants glossed over the issue of daily management and
monitoring with answers such as, ‘it has been out of control for a
long time’ (par- ticipant one), and ‘I am a slack diabetic’
(participant four). When asked about their individual management
strategies, and if they experienced any unusual blood glucose
readings, participant four explained ‘It wasn’t because of the
treatment (hyperbaric) l don’t manage my diabetes properly’.
From the responses given the require- ment to self-manage their
diabetes and understand the long-term health implications was not
foremost in the daily routines for these participants.
Incidentally, participants two and eight, who were newly diag-
nosed with diabetes (six-months prior to HBOT), demonstrated the
greatest engagement with their disease process. They knew their
medication doses, regularly monitored their blood glucose, and
understood the subtleties and requirements of a controlled diet and
how this impacted their diabetes.
However, the majority of participant responses indicated a gen-
eral deniability of the long-term chronic effects of diabetes. This
was particularly evident in participants who could not identify the
relationship between poor management of their diabetes, and their
chronic non-healing wound issues, (the reason they were having
hyperbaric treatment). One participant said, ‘I suppose if you con-
trol your blood sugar it must be better for your wound’ (participant
one), but this insight was not shared by all. Participant nine sug-
gested that diabetes ‘is a silent disease’, the medical significance
only
becoming evident when a serious complication occurs.
Participants did not seem to be able to draw a direct correlation
between their blood glucose management; the chronicity of their
diabetes illness; their chronic wound and the need for HBOT.
3.7. Theme 2 – hypoglycaemia fear
All participants voiced the fear of a reduction in their blood glu-
cose, resulting in a hypoglycaemic event, when undergoing
HBOT. Some voiced this fear more specifically, with participant
four saying ‘I didn’t want to be low in the chamber’, and
participant five stated ‘it just lowers it – quite significantly’ and
perhaps most significantly, participant six clearly articulated
concern, saying ‘you come in here it’s gonna drop more points
while you are in the chamber – mine got to 3 once’. Participant
eleven described their experience, ‘it drops in the chamber under
pressure – it can drop in the reading – by up to 4 points, so if l go
in with a reading of 5 that drops to 1, – well l’ m stuffed!’
Participant seven said ‘I just hate being low so much, l will do
anything to avoid getting to such a helpless situation.’
As a result of repeated exposure to the hyperbaric environment,
study participants could articulate a clear association between the
blood glucose level required to have HBOT safely and the BGL
required to prevent a hypoglycaemic event whilst in the chamber,
‘well l came up here with my sugars somewhere near where they
Please cite this article in press as: Baines, C., et al. Patient reported experience of blood glucose management when undergoing hyperbaric oxygen
treatment. Collegian (2018), ​https://doi.org/10.1016/j.colegn.2018.11.004
ARTICLE IN PRESS G​ Model ​
C. Baines et al. / Collegian xxx (2018) xxx–xxx 5
should have been, of course they were too low – we had trouble’
(participant one).​Respondents gave examples of the individual
strategies they employed
​ to raise their blood glucose to what they
perceived to be a ‘safe’ level, in order to undergo HBOT and avoid
a hypoglycaemic event. Participants fourteen and nine, described
the fear associated with an ‘in-chamber hypo’ as being so serious,
they deliberately chose to reduce their diabetic oral medication and
increase their glucose intake, knowing this would push their blood
glucose to abnormally high levels. This indiscretion was not
reported to the hyperbaric practitioners, due to a concern that the
doctor would be ‘cross’ with them, and not allow HBOT to go
ahead on that occasion. The relationship between patient and
HBOT clinician was not openly discussed, but participant seven
voiced they were con- cerned about a hypoglycaemic event only
because the practitioners were concerned ‘you (practitioners) are
worried about a hypo – so l was too’.
3.8. Theme 3 - treatment based adaption
Participants described multiple strategies they employed to adapt
behaviours to forward manage the risk of ‘going low’ dur- ing a
hyperbaric treatment. Participant five reported adapting their
insulin regime, without medical support or supervision, ‘I had to
take less insulin Monday to Friday coz I was down low at 7–8 and
it has to be higher, I had it up in the week and down at the week-
end’. Adaptation of normal diabetes treatment was also described
by participant three, ‘a couple of times l came for treatment and
had some high ones – sort of 20, 22 I was a little concerned, but l
didn’t show it – I knew l was eating too much fruit’. When further
explored, participant three confirmed that ‘it is better being high
than low with the sugars, your treatments hardly ever stopped with
a high’.
Participant thirteen explained, that following their first treat- ment,
they had quickly learned that the potential for a decrease in blood
glucose was an issue that they needed to manage. Participant
eleven stated, ‘I have not been able to go into the chamber a few
times lately because my sugar has been too low – they sit me out
and I have to wait for it to go up to get in the chamber’. To combat
this from repeatedly happening, participant eleven states ‘I eat my
Weetbix for breakfast –and l have sugar on them, this should push
my sugars up far enough and I can have my scheduled treatment’.
COLEGN-576; No. of Pages 7
Fig. 2. ​Thematic map four main themes.
Participant five said ‘you blokes said l needed to be higher for
treat- ment, so l made sure l arrived for treatment full of sugar’,
indicating acceptance of the increase in blood glucose as a ‘new
normal’. Con- versely, participant twelve, who having lived with
diabetes for 20 years, voiced a clear annoyance that their ‘careful
control was lost for the entire day’. Participant fourteen, expressed
frustration - ‘I am sick of artificially raising my blood sugar just to
have a dive’.
3.9. Theme 4 – ownership/monitoring
According to some participants it was important that they retained
control of their blood glucose management, during HBOT.
Participant ten indicated ‘you lose control at the beginning of a
treat- ment schedule – you accept the risk and start to learn a new
normal’. To comply with the clinical and safety requirements for
hyper- baric treatment, increased finger prick testing of blood
glucose is a necessity. Several participants indicated the additional
monitor- ing during HBOT was a nuisance and not necessarily an
action they undertook outside of the bounds of this clinical
treatment, partic- ipant four complained that their fingers were
sore and enquired if ‘all of this testing is really necessary?’ This
gave substance to the idea that clinician driven activities (i.e.
increased monitoring) can alter normal routines of the patient.
Self-management initiatives were driven from the perspective that
each person with diabetes can and should manage their own
disease. Participant fifteen explained, ‘when living with a chronic
disease such as diabetes, you are aware of your body’s responses,
you learn to control those responses, you don’t hand over control
once you have mastered this because it is a risk that may change
your life – so you manage the risk, you eat the foods you know,
take the drugs in the dose you can predict their action, you control
as much as possible’.
Individual engagement with diabetes monitoring decisions, along
with clinician expertise, can help promote ownership by cre- ating
a patient-centred approach to diabetes care, with participant
thirteen stating, ‘the first few treatments were daunting – we didn’t
know how I was going to behave, but once l was in control of the
sugar level it was fine’. Throughout the interviews it was noted
that as the familiarity with HBOT improved, the responsibility for
blood glucose control improved, this behaviour became accepted
as an
individual norm, participant eleven stated ‘I know when l am
going to hypo so l just sort myself out in the chamber – it’s my
responsibility’.
4. Discussion
The participants in this study who required HBOT to assist in
wound healing, intentionally altered their diet or adjusted their
diabetes medication regime to elevate their blood glucose. One of
the main drivers of this behaviour was the fear associated with a
hypoglycaemic event.
The hyperbaric clinician is required to safely manage each
patient’s glycaemic condition on an individual basis to facilitate
HBOT. This is usually done in collaboration with the patient thus
acknowledging the clinical relevance of a hypoglycaemic event
during HBOTand how this may affect their overall well-being.
How- ever, participants in this study voiced that they
independently altered their normal glycaemic regulatory
behaviours, deliberately elevating their blood glucose levels. This
could considered ‘new normal’ demonstrate a lack of
understanding of how a persistently high BGL might affect their
chronic wound.
The relationship between clinician and patient oscillated between
trust in the knowledge the clinician would keep them safe in the
HBOT environment and the individual need to stay in control,
even if this was having a BGL directly outside of the figure the
clinician had discussed with them. The participants articulated
they were willing to manipulate their BGL to be artificially higher
than prescribed by the clinician, or what would be considered nor-
mal safe levels, to ensure they could complete hyperbaric
treatment without the threat of a hypoglycaemic event. This
Please cite this article in press as: Baines, C., et al. Patient reported experience of blood glucose management when undergoing hyperbaric oxygen
treatment. Collegian (2018), ​https://doi.org/10.1016/j.colegn.2018.11.004
ARTICLE G​ Model ​ COLEGN-576; No. of Pages 7 ​IN PRESS ​
a major limiting factor in glycaemic control (​Cryer, 2002​; ​Leiter et
al., 2005​). In managing diabetes and blood glucose levels people
have an acknowledged fear of recurrent hypoglycaemic episodes
and confess to manipulating their diabetes treatment by changing
the dose and time of insulin administration; by altering the type
and duration of physical activity and varying their oral medicines
(​Polonsky, 1999​).
HBOT exacerbated hypoglycaemic fear leads to the protective
behaviour of increased point-of-care blood glucose testing. The
HBOT clinician drives additional monitoring, changing it from a
patient/personal control and preventative strategy into a tool that
the clinician employs as an overarching diabetes management
strategy. Thus, point of care testing (finger-prick) may present as
an imposition to a positive patient-clinician relationship.
The hyperbaric clinician is regularly collaborating with the patient,
to create an acceptable situation where the risk of a hypo-
glycaemic event is minimalised. If a person has a greater
knowledge base from which to make decisions, this may translate
into an increased motivation to better self-manage their chronic
illness, the significance of which is often played down by both
parties (​Norris, Lau, Smith, Schmid, & Engelgau, 2002​). In the
HBOT environment, blood glucose monitoring is a clinical
requirement, this is often not the practice in the greater diabetic
population. The interview data indicated that participants were
frustrated with the long-term self- management requirements of
their diabetes and the fact that they choose not to monitor their
blood glucose with any regularity is their choice.
Johansson, Osterberg, Leksell, and Berglund, (2015) ​note the
process of living with diabetes involves a responsibility that is
imposed on an individual and is constantly present; taking own-
ership and accepting change is paramount for the lifelong health
and well-being of the patient. It may be possible, that through the
continued trust of the HBOT practitioner, (both doctor and nurse),
patients learn to embrace risk, but the responsibility of daily man-
agement stays with the patient. Recognition of the dynamics of the
patient / clinician relationship in treatment decision-making is vital
to the ongoing self-management of chronic conditions, including
behaviour is sim- ilarly demonstrated by ​Katarina et al. (2009)​,
who reported both hypoglycaemic and hyperglycaemic events in
patients undergoing HBOT. The self-reported management
strategy of this cohort was to either consume sugar or self-adjust
their insulin dose.
The interview findings are consistent with the published litera-
ture with respect to patients fearing hypoglycemic events. ​Weiner
and Skipper (1979)​, reported over 30 years ago, that the patients’
fear of having a hypoglycaemic episode is ‘one of the major
limita- tions in achieving and maintaining satisfactory blood
glucose control’. This fear remains prevalent today; ‘hypo anxiety’
is recognised as
6 C. Baines et al. / Collegian xxx (2018) xxx–xxx
diabetes.
This research offers an insight into the heightened awareness
around blood glucose self-monitoring and overall diabetes self-
management initiatives in patients undergoing HBOT. The
impetus for this behaviour change, can be attributed to
hypoglycaemic fear, however, the clinician requirements for
hyperbaric treatment may be a concomitant driver.
5. Limitation
This study was able to provide some new insight into this issue,
but the relatively small number of participants (15) may diminish
the transferability of the findings. Although providing a unique
per- spective on blood glucose management in HBOT, further
research to ascertain if this behaviour is replicated in hyperbaric
units across Australia and internationally, would enhance
collaborative man- agement strategies.
6. Conclusion
These findings support the anecdotal data that patients who have
diabetes and undergo HBOT are adjusting their diet and med-
ication regime while developing their own self-management plan
to lessen the potential of having a hypoglycaemic event in the
hyperbaric chamber. In previous literature it has been demon-
strated that HBOT influences glycaemic control. It has not been
widely reported that patients are adjusting their own diabetes
management to undertake a medical intervention; however, this
work demonstrates that individualised adjustments are occurring to
receive HBOT. Hypoglycaemic fear is central to diabetes man-
agement as a chronic disease; this study adds another dimension to
our understanding of the phenomena.
Conflict of interest
The authors wish to state there is no known conflict of interest.

Disclosures
The authors have no funding acknowledgements or disclosures
concerning this project.
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