Elizabeth Blair, MSN, PARN, BC, CDE
The week’s excerpt answers the following questions:
- How do you determine the patient’s knowledge and skill base?
- What is the emotional component?
- How can you negotiate goals with a patient?
- What are the important survival skills that every patient needs to know?
- What are the National Standards for Diabetes Self-Management Education recommendations?
- What about the person who does "nothing" between your encounters?
Diabetes self-management education is an important component of care for those individuals with diabetes. It is more than the provision of knowledge. The goal of diabetes education is to help individuals with diabetes learn new behaviors and change current behaviors to maximize their health. Optimizing diabetes management requires that people with diabetes have the basic skills and knowledge to monitor glucose levels and understand how their medications, food and activity affect their blood glucose. Also, as diabetes is a condition that impacts multiple organ systems and processes, people with diabetes must also be knowledgeable about and actively involved in risk reduction. The role of the healthcare team is to help people with diabetes develop self-care and problem solving skills that can promote confidence so that they can better self manage their condition.
The Emotional Component
Before an education plan can be completely implemented, feelings about the diagnosis of diabetes as well as the burden of its everyday diabetes management need to be acknowledged. For a patient to hear that he or she, a significant other, or a child, has diabetes is a significant life event. The patient’s knowledge about, and experience with, diabetes must be assessed. Incorrect information — or no information — is often scarier than the facts. It can be overwhelming to add the time and the emotional burden of caring for diabetes to the day-to-day stress of contemporary life. Before educating patients and others about the pathophysiology and management of diabetes, address patient’s questions and concerns, then add to the person’s knowledge and skill base.
Some of the initial questions you may hear the person with diabetes ask include: Will I lose my vision? Will I lose my legs or feet? Will I be able to continue to work? A young woman may wonder about childbearing potential and have concerns of "passing" diabetes on to the next generation. People may have questions about nontraditional treatments and purported cures based on information obtained on the internet or from other sources. Some questions may not be directly asked, but may be alluded to instead. Careful listening can help elicit these concerns, giving the healthcare team an opportunity to clarify and educate.
Take time to ask the patient what came to mind when they were told they had diabetes. Discuss their experiences with friends or relatives who have diabetes. To help explore and resolve issues related to having a chronic illness, many people with diabetes benefit from group education and from support groups. Groups allow interaction with other people with diabetes who have experienced similar issues and, in many instances, have overcome obstacles. Some people will also benefit from a referral to a mental health professional for individual counseling. (See Chapter 23 for more information about the psychological issues surrounding diabetes.)
Evaluation, Negotiation and Goal-Setting
Because so many issues face the person with diabetes and his or her healthcare team, priorities for interaction and education need to be negotiated. Ideally, all people with diabetes should have a thorough assessment of their past and present diabetes treatment and education programs. Sort out what worked, what didn’t work, and why. Barriers to medical care and to education need to be identified and evaluated. Familiarity with the person’s cultural and religious beliefs will also help the healthcare team tailor education strategies. When developing educational and treatment priorities, goals need to be agreed upon and established for and with the person who is being treated. Together, the team and that person should develop a plan for action if goals are not met. Examples of goal-setting for glucose control include establishing:
- Frequency and timing of glucose monitoring
- Fasting and post-prandial glucose targets
- A1C goals
- Weight targets, both the amount of weight change and the time frame for the change
- Activity goals, including frequency, duration and intensity
Successful management of diabetes is primarily dependent upon the patient’s understanding of diabetes principles and the ability to make informed decisions on a daily basis. Learning occurs over time. It is unrealistic to expect a person to learn everything about diabetes self-care in one or two sessions. Prioritizing education is determined by what the person needs to learn to be safe and by what the person wants to learn.
"Survival skills" are the minimal skills required to maintain safe, but not necessarily optimal, glucose control for the short term. In general, when faced with limited time, ensure that the person with diabetes knows the following:
- When and what to eat
- When and how to take diabetes medication
- The major side effects of their diabetes medication
- How and when to check blood glucose levels
- How to detect and treat hypoglycemia
- When to call the healthcare team to report high glucose levels
- When to call the healthcare team with questions or concerns
The National Standards for Diabetes Self-Management Education recommend that education for people with diabetes include the following content areas:
- A description of the diabetes disease process and treatment options
- Appropriate nutritional management
- How to incorporate physical activity into lifestyle
- Utilization of medications
- Glucose and ketone monitoring and use of the results
- Prevention, detection, and treatment of acute complications (hypoglycemia, hyperglycemia, sick days)
- Prevention, detection, and treatment of chronic complications
- Goal-setting to promote health and problem-solving for daily living
- Integrating psychosocial adjustment into daily life
- Promotion of preconception care, gestational diabetes information and diabetes management during pregnancy.
Effective Diabetes Education
Effective diabetes education requires an ongoing relationship between the person with diabetes and the healthcare team. The effectiveness of education is maximized when the healthcare provider:
- understands the characteristics of the learner
- incorporates the special needs of each individual
- develops specific, realistic goals with each person
- delivers the message in a creative, interactive and memorable way
- anticipates patient challenges and obstacles that may impede behavior change
- prepares the person with diabetes for situations that may cause a lapse into old behaviors
The education process begins with an assessment, and is followed by establishing priorities, setting goals, and then evaluating outcomes and process.
Assessment is a crucial first step to any successful intervention. It provides an opportunity to explore the person’s expectations and past experiences, to determine the feasibility of treatment plans, and to anticipate potential barriers to successful change.
When conducting an assessment, help the patient feel comfortable. Establish privacy and physical comfort. Let the person know that you want to learn something about him or her, the nature of his or her diabetes and the particular challenges that it presents. Listed below are seven areas to explore when assessing a patient’s readiness to learn:
- Ask about the person’s experience with diabetes and about personal goals. Use past experiences as "data" to learn how he or she views diabetes as well as what behaviors have been easiest and most difficult to change or maintain over time.
- Ask about current habits. Build on current accomplishments by setting realistic short and long-term goals for behavioral change. Example: In the past week, what has been your routine for checking your blood glucose, taking medication(s) and getting physical activity?
- Find the preferred style of learning. While active learning is the most effective learning style, individuals differ in their comfort level with various modes of teaching. Ask how he or she best learns material (e.g., books, discussion, videos, etc…).
- Inquire about psychological status. Moods and feelings can have a powerful impact on one’s readiness and ability to change. Life events can interfere with the ability to focus on the education session. People who experience "burn-out" with their diabetes or who are feeling depressed may not be ready to make major changes. Sample question: What’s going on in your life? How does diabetes change the way you live? What are your thoughts about that?
- Assess cultural and economic background. Culture and economics influence daily interactions, thoughts and feelings. Areas to evaluate include: cultural expectations about visiting their healthcare provider; role expectations or function of the individual within the family and how diabetes impacts the roles; financial resources available to that person — does he or she have access to health insurance, money for diabetes supplies or for transportation? Sample questions: How do you support yourself? How does diabetes impact this?
- Assess literacy. Printed educational materials are often at an 8th grade reading level. If you are unsure of the person’s reading ability, ask them if they understand the information or have them read instructions back to you. If needed adjust teaching techniques/materials.
- Assess physical health and impairments. Fundamental to learning is feeling well enough to absorb new information. For some people, physical illness may require limiting educational interventions until they feel better. For other people, a recent acute illness (e.g., a cardiac event or foot infection) may provide high motivation to learn lifestyle changes. Assess the impact of the person’s illness on readiness to learn, and adjust teaching techniques to accommodate physical challenges. Explore the individual’s prior and current coping strategies and ways to incorporate diabetes self-care using these strategies.
Once the assessment phase has been completed, it is important to set goals. Goals provide the person with diabetes and his or her healthcare team with concrete behavioral objectives and a way to evaluate change. Behavioral goals or objectives are simple statements that define what the person will do. Goals must be concrete, realistic, and measurable at a later date. After discussing their goals, most people will benefit by having the goals written down so that they can be taken home. Asking a few key questions will help determine the person’s understanding, willingness and interest in making the necessary behavior changes. Here are some questions you might ask:
- What is the most important goal for you in managing your diabetes?
- What are some changes you could make to your present meal plan to more closely follow the diabetes nutrition goals we discussed?
- You said you wanted to begin walking. What time of the day would you do that?
Goals or objectives should be measurable and realistic. The goal should include an action verb such as "demonstrate," "identify," "choose," or "state," as opposed to verbs like "know" or "understand." An example: "I agree to check my blood glucose before breakfast, lunch and supper on Monday, Thursday and Sunday."
Follow-up appointments should include an evaluation of each person’s actual behavior changes. This enables both that individual and the team to track the progress towards each behavioral goal. The evaluation helps determine if the goal is feasible for this person at this particular time in his or her life, as well as to reinforce progress being made. Evaluation can take a variety of formats:
- Some may self-report information about what actions they have and have not been able to initiate, as well the barriers and successes they encountered.
- The provider may examine logs such as meal planning records or blood glucose monitoring diaries.
- The provider may measure related clinical outcomes such as weight, blood pressure, lipids, or A1C.
Encouraging people’s feedback enhances the patient-provider relationship by providing interactive support, motivation, and strategies to enhance current progress. In addition, old goals may be modified and new goals established.
What about the person who does "nothing" between your encounters?
You may discover at a follow up visit that none of the behavior changes have been implemented, even though they were concrete and were agreed to by the individual and the team. It’s not uncommon for people to ask for advice and not use it, or agree to recommendations but then not implement them. These behaviors are an indication of the need for reassessment and redefining goals for that person. Consider finding the answers to the following questions.
- Did both the person with diabetes and the provider share these goals?
- Did the person with diabetes understand them? Was there miscommunication between that person and the provider?
- Were the goals realistic and feasible?
- Did the person feel the need to please the provider during the last visit?
- What about the plan was difficult for the person to implement?
Copyright © 2010 by Joslin Diabetes Center. All rights reserved. Reprinted with permission. Neither this book nor any part thereof may be reproduced or distributed in any form or by any means without permission in writing from Joslin. Note: Joslin does not endorse products or services.
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Please Note: Reasonable measures have been taken to ensure the accuracy of the information presented herein. However, drug information may change at any time and without notice and all readers are cautioned to consult the manufacturer’s packaging inserts before prescribing medication. Joslin Diabetes Center cannot ensure the safety or efficacy of any product described in this book.
Professionals must use their own professional medical judgment, training and experience and should not rely solely on the information provided in this book to make recommendations to patients with regard to nutrition or exercise or to prescribe medications.
This book is not intended to encourage the treatment of illness, disease or any other medical problem by the layperson. Any application of the recommendations set forth in the following pages is at the reader’s discretion and sole risk. Laypersons are strongly advised to consult a physician or other healthcare professional before altering or undertaking any exercise or nutritional program or before taking any medication referred to in this book.