Newly diagnosed type 1 diabetes: needle fear and wanting to go home
You are the diabetes nurse on an adolescent ward. Mr Callum Reid, 19, was admitted 2 days ago with diabetic ketoacidosis. He is now stable on basal-bolus insulin: glargine 18 units at night and aspart 6 units three times daily with meals. He has never injected himself; his mother has been doing it. He says, “I’m not doing it. I’ll just take the tablets. I want to go home tomorrow.” His mother says, “He faints at the sight of needles.” He is due for discharge in 24 hours and needs to demonstrate self-injection and carbohydrate counting before discharge. He is quiet, avoids eye contact, and has not eaten breakfast.
1. Write the opening 60–90 seconds of your conversation and explain two communication choices.
Read the worked answer
Opening
“Callum, I’d like to talk about what happens when you go home, and I want to start with what you think. You’ve had a rough couple of days. Can you tell me what worries you most about the injections?”
If he shrugs:
“That’s okay. A lot of people hate needles, and some people feel faint. I’m not going to make you inject today without talking first. I want to understand what would make it easier, and what would make it harder.”
Choices explained
- Open question before education. Starting with his concerns rather than a needle demonstration reduces resistance and gives information about the real barrier.
- Explicit reassurance about control. Saying ‘I’m not going to make you inject today without talking first’ preserves autonomy and reduces threat. It does not remove the discharge requirement, but it separates the conversation from a power struggle.
I would avoid saying ‘it’s easy’ or ‘you’ll get used to it’; that dismisses the fear and can shut down the conversation.
2. How would you respond when Callum says he will “just take the tablets”?
Read the worked answer
Response
“I can hear that injections feel like the thing you want to avoid. I need to be honest with you: insulin cannot be taken as a tablet at the moment, because your stomach would digest it before it could work. If you stopped insulin, your blood sugar could rise again and you could become very unwell with ketoacidosis. That is why I am not able to agree to tablets instead.”
Then explore:
“What is the worst part for you - the pain, the sight of the needle, feeling out of control, or something else?”
Reasoning: correct the misinformation clearly but without shaming; link the explanation to his recent DKA, which he has experienced; separate the fear from the decision. I would involve his mother only with his permission, because he is 19 and has capacity. I would also consider a pen needle, distraction, lying down during injection, and a desensitisation plan with the diabetes team.
3. What discharge plan would you negotiate, and what would make you delay discharge?
Read the worked answer
Negotiated plan
- Start with a supervised practice session today, using a pen and a practice pad, not his own body first.
- Identify two injection sites and a routine: aspart before meals, glargine at night.
- Teach hypoglycaemia recognition and treatment, sick-day rules, sharps disposal, and when to call for help.
- Ask him to demonstrate carbohydrate counting with one meal before discharge.
- Arrange a diabetes nurse follow-up within 48–72 hours and a diabetes team contact number.
Delay discharge if: he cannot safely demonstrate injection, cannot state a hypoglycaemia plan, has no responsible adult support at home, or remains unable to eat and monitor glucose. A fear of needles alone is not a reason to delay; an unsafe plan is.
Reasoning: the goal is safe self-management, not forcing a single technique. Shared decision-making should include his mother if he agrees, but the plan must be owned by Callum.