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Teaching people with diabetes to self-care

Diabetes education is an important part of helping people to take increased responsibility for their own health. Effective teaching is a very complex activity as learning requires change and can be mentally and emotionally challenging both for the health professional and the patient

Alexis Hodgkins
Diabetes Clinical Lead
Community Health Care NHS

The rapid increase in the numbers of people suffering from diabetes has become a major public health concern in the UK.1 In 2001, the government published the Diabetes National Service Framework (NSF), which established 12 national standards aimed at raising quality and reducing variation across diabetes services.2 A delivery strategy followed in 2003.3 The NSF recognised the importance of people being able to look after themselves. A growing body of evidence demonstrates that supporting people with long-term conditions, such as diabetes, to care for themselves means that they improve, both in clinical terms and quality of life.4

Today's major healthcare problems are increasingly related to long-term conditions caused by environmental, lifestyle and risk factors, including obesity, physical inactivity and unhealthy diet.5 In 2007, the Healthcare Commission recommended that primary care trusts (PCTs) should implement the National Institute for Health and Clinical Excellence (NICE) health technology appraisal on structured education for people with diabetes. This document states that education courses should be offered to everyone with diabetes.6

More than just knowledge
Involvement, guidance and support in planning care, combined with education, can help people with diabetes to decide how to manage their condition on a daily basis.7–10 In 1996, research demonstrated that people with diabetes who had never received diabetes education showed a striking four-fold increased risk of major complications.11 An underlying principle of diabetes education is that knowledge is necessary but not sufficient to change health behaviours.

Diabetes education involves much more than telling people what to do or giving them information leaflets. If knowledge alone could accomplish changes there would be far fewer people developing diabetes and the complications associated with poor management of diabetes. Effective patient participation in self-care requires education, motivation, support and guidance. While the healthcare professional may not be able to fulfill all of these needs, they can be pivotal in guiding the process.

The effect of diabetes education can be measured in several ways.12-13 However, the only real proof that diabetes education has been successful is when the recipient experiences subjective reality changes. This is not about having new intellectual knowledge; that is just keeping the same reality but having more information to defend it, support it or stay in it. A subjective reality change is when things are
actually different.

Structured education
It is essential that people with diabetes receive quality-assured education programmes with professional standards that they can rely on. The approach should be based on a firm foundation of research and development. It is important that healthcare professionals have knowledge of what works and what is ineffective, underpinned with an understanding of what is best practice, in terms of delivering education either to a group or on a one-to-one basis.

Structured diabetes education allows the healthcare professional to ensure that basic standards are being met. A structure is any device that reminds you to act; for example, setting your mobile phone to remind you of an appointment. There are millions of structures in our lives. By introducing structure to an education session we can create focus and instruction. Structures are a way of sustaining the action and learning in the time between education sessions or appointment reviews. By making structures meaningful to the person with diabetes, the chances that the person will follow the structure increase.

The task of the healthcare professional is to use advanced skills of listening, questioning and reflection to create highly effective conversations and experiences for the individual receiving the education. The more reasons people have to believe in something the more likely it is that they will take action. From conversations, the healthcare professional will see and hear individuals coming to their own learning, gaining their own insights and new perspectives.

Goal setting
Part of the role of the healthcare professional is to help people with diabetes create goals that are related to their plans and intentions. Without specific goals it is unlikely that change will occur. Goal setting gives people an individual and specific direction and an action plan to make something happen. Goals are not static, and splitting them into manageable chunks can be very helpful for some people. The best goals are specific, measurable, action-oriented and set within a particular time frame.14

The key to successful goal setting is some form of action and/or learning. Action and learning combine to create change. Action will move a person forward, and learning will generate new possibilities, which will lead to the ability to change. What people learn along the way helps them make better choices and, ultimately, makes them more confident and competent in areas in their diabetes management. Over time, this cycle of action and learning leads to ongoing, effective changes.

Role of the healthcare professional
Diabetes education is fundamentally based on a comprehensive assessment of patient need. This may sound obvious, but it is possible for education to be all about what the healthcare professional thinks, knows and does, as though the professional is an example for the patient to follow.

The primary building block for all education is believing in the patient's ability to learn. Sometimes, patients don't think they have the answers. They would rather believe someone else; for example, an expert who has all the answers for them. This can lead to a desire to seek answers and solutions from the healthcare professional, although what tends to happen is that patients will get an answer that does not fit their individual needs. The healthcare professional must have the ability to set aside personal opinions, preferences, judgments, pride, defensiveness, thoughts and ego.

Diabetes education is not about telling someone what they should do, it is about being part of someone else's process, and helping them see different ways in which they can create the results they want. Most people with diabetes do know how to find their way and their own solutions, especially with the help of healthcare professionals. Patients are generally more satisfied and more likely to follow through with action when they come up with their own solutions.

The healthcare professional has a responsibility to disseminate information to the person with diabetes, putting aside the need to be right all of the time. This ability to confidently participate in education, allowing room for counter offers and different interpretations, is key to effective education. This can open the door for people to freely express their thoughts, feelings and educational needs. As a healthcare professional it is important to remember that we are not simply solving problems; we are helping people become more skilful and capable in managing their diabetes. The relationship will feel more like a partnership of equals rather than anything parental or advisory.

Promoting effective education is an important part of intervening in compliance. Groups are helpful in getting people to adopt lifestyle changes and maintain healthy behaviours.16 Within a group, identifying common areas of doubt between individuals can raise areas of concern for the group as a whole.
Those in the group with greater confidence may have information or experiences that can help to raise the confidence of others in the group. These individuals may become "buddies" to other group members and play a part in future support for each other.

The manner in which education is given influences compliance. For example, threats about diabetes complications are less reliable. Long-term complications of diabetes that may or may not occur are very distant concepts, even to well-educated people. A threat may only be of value when it is put into a framework of concern for the individual person. Noncompliance is a sign that the education or form of communication delivered to the patient has been unsuccessful. One could argue that there is, in fact, no such thing as noncompliance, only inflexible education and communication.17

Effective education and communication involves accepting and using all forms of communication, even that which presents itself as noncompliance. Failure can be one of the fastest ways of learning. Patients will often learn more from what does not work than from what does. Failure of any action, even failing to take action, is a learning opportunity. Accepting that patients may need to fail will ultimately lead to further action and learning.

When people are diagnosed with diabetes they may have feelings of helplessness, and of being overwhelmed, and feelings of despair and depression can follow. Emotions are part of the normal functioning of all human beings, not a symptom of disease. When emotions are hidden or denied, noncompliance may occur. Unless emotions can be explored, people may resign themselves to being out of control, as if that is the way it is going to be. There is only one way of looking at it and it looks bad. Diabetes education that focuses on widening the range of perspectives and, therefore, adding more choices to the person with diabetes, offers a way of gaining control and taking responsibility.

Listening for signs of resistance, fear and objection to change embraces the whole picture of the patient. Patients are likely to reveal an habitual way of thinking about certain parts of their life. They tend to apply the same rigid thinking to specific situations. When we listen to a patient's perspective, we are listening to their opinion, a belief, an assumption and expectation. Individual perspectives are very powerful and allow people to see things in a certain way.18 In essence, if something is not part of that perspective, it is often invalid to the person or simply ignored and may be completely dismissed. Diabetes education involves developing flexibility to view life with diabetes from multiple perspectives (see Figure 1).

[[Fig 1 self]]

The main two things that result in noncompliance are conflict between the person's beliefs and their values. A value is something that is of real importance to them and a belief is what the individual currently holds as true for themselves.18 For example, I want to be able to lose weight but I don't believe I can do it. Patients will often see the healthcare professional as the expert and regard what is said as important. Simple and specific instructions are often the most powerful. The healthcare professional can remain supportive while delivering direct messages. They can assist the patient in discovering their readiness to change by asking five simple questions related to goal setting.19 Each question is rated on a scale of 1-10 (see Table 1). Any form of resistance or low scoring to these questions means they have not found a good enough reason, which may lead to noncompliance.

[[Table 1 self]]
Prochaska and DiClemente found that successful self-changes go through a series of six stages.20 Helping a person at one stage requires an entirely different approach from helping someone at another. Fundamental components of change focus on the process of becoming motivated to solve the problem. The authors describe "resistance" as a result of applying a change strategy designed for the wrong stage of change. In every action people make they are trying to fulfil a core need. Healthcare professionals cannot create motivation, but they can provide the right support and conditions for it to develop to its full potential.

Healthcare professionals will never teach anyone anything merely by pointing out what they are doing wrong and trying to educate them into doing something that is believed to be right for them. All that happens is that their current ways of thinking and managing their own feelings and sense of self (which is the only guidance that is currently of any value to them) will be provoked and distorted. Change can only occur when the possibility of getting out of one's comfort zone offers a greater reward than staying in it. People will do what makes them feel good, safe and appreciated. They will not trade their current life circumstances unless they feel that what they are moving towards will be at least as good or better than what they currently have.

Life with diabetes is about learning more about the condition, for both the patient and the healthcare professional. A byproduct of this approach is acceptance, but knowing that there is always more to find out, and fostering an attitude to learn.

Review and evaluation
The healthcare professional needs to strike a balance between how much time is spent reviewing the patient and how much time is spent on education. Too many reviews can disrupt the flow of learning. However, too few can run the risk of missing a problem or an opportunity to improve the effectiveness of an education session. During a review, the nurse might explore what impact the education sessions have had, what progress has been made on the goals and what's not working well. By reviewing progress we are able to affirm learning with the individual. We are linking what the patient is learning with the benefits they are experiencing as a result; benefits such as improved health and mental wellbeing.

Evaluation methods chosen and the data collected should always be a function of the purpose to which data are to be put. It is essential to be clear about why any diabetes education is being evaluated. Reasons may include: to improve local diabetes education practice; to spread good practice; to provide evidence to support the use of trained diabetes educators; and to evaluate the numbers of people receiveing structured education. NICE recommends measures that could be used in an audit of education for people with diabetes. These include measures for both type 1 and type 2 diabetes.21

In summary, diabetes education is a complex activity involving human emotions, beliefs, values and behaviours. A person's readiness to learn is dependent on many factors. These may include past experience, motivation, level of wellness and coping mechanisms. Active participation in healthcare and health decision-making is an outcome of self-empowerment; effective diabetes education will lead to an increased desire to learn more and behaviour changes. Healthcare professionals are widely seen as having a key role in diabetes education whether the desired outcomes are changing behaviours, self-empowerment or improvement of biomedical outcomes.

There is growing recognition of the value of diabetes education,22 which needs to be informed by national guidance and evidence-based practice. If such education is to be effective in primary care it must be provided routinely by trained healthcare professionals. At a time when quality and efficiency are high on the NHS agenda, it is crucial to demonstrate that diabetes education can encourage positive outcomes. Evaluation becomes feedback and allows for continuous quality improvement.

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