Self-management education

Self-management education

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Objectives

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Diabetes Self-Management Education

This module will cover both how to teach and how to help people apply their knowledge to self manage diabetes. The desired outcome of teaching in chronic disease is often that people will make a change in lifestyle to improve their quality of life and health outcome. It therefore makes sense to talk about teaching skills along with how to support a person apply their knowledge, make informed decisions and change behaviour. There may be times when you are focusing more on teaching than on changing behaviour or vice versa, but when doing either your interaction with the person will be enhanced if you integrate the principles of both. This section of the curriculum has attempted to do just that.

International Diabetes Federation. (2009). Standards for Diabetes Education, 3rd Ed. Brussels: IDF.

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Evidence for diabetes education

It is rare that knowledge alone is enough to sustain behavioural changes for a lifetime of diabetes.People can and will start to make some changes before they have knowledge. Behaviour changes strategies need to be part of every lesson from the beginning.

Piette, J.D., Weinberger, M., McPhee, S.J. (2000). The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial. Medical Care, 38, 21830.

People do not view the psychosocial and behavioural aspects of diabetes care as separate from the therapeutic aspects. They view their diabetes in its totality.

For example, when teaching about blood glucose monitoring, along with how to do it and interpret and act on the results, other areas that can be addressed are: Do you have the funds to buy strips? How often do you need to test to manage your diabetes effectively? What will help you remember to test? How will you test when you are away from home? How will you respond to others in public places who stare or ask what you are doing? How much attention do you want from your family about your results? What kind of support do you need/want/get? How will you feel and respond if the numbers do not reflect your efforts?

Barlow, J., Wright, C., Sheasby, J., Turner, A., Hainsworth, J. (2002). Self-management approaches for people with chronic conditions: a review. Patient Educ Couns, 48, 17787.Roter, D.L., Hall, J.A., Merisca, R., Nordstrom, B., Cretin, D., Svarstad, B. (1998). Effectiveness of interventions to improve patient compliance: A meta-analysis. Medical Care, 36,113861.

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Evidence for diabetes education

We also need to educate people because we know that it is effective and improves outcomes. These results are based on multiple meta-analysis of educational studies.

Barlow, J., Wright, C., Sheasby, J., Turner, A., Hainsworth, J. (2002). Self-management approaches for people with chronic conditions: a review. Patient Educ Couns, 48, 17787.Brown, S.A. (1999). Interventions to promote diabetes self-management: State of the science. Diabetes Educ, 25(Suppl), 5261.Norris, S.L., Lau, J., Smith, S.J., Schmid, C.H., Engelgau, M.M. (2002). Self-management education for adults with type 2 diabetes: A meta-analysis on the effect on glycemic control. Diabetes Care, 25, 115971.Roter, D.L., Hall, J.A., Merisca, R., Nordstrom, B., Cretin, D., Svarstad, B. (1998). Effectiveness of interventions to improve patient compliance: A meta-analysis. Medical Care, 36,113861.

Norris, S.L., Lau, J., Smith, S.J., Schmid, C.H., Engelgau, M.M. (2002). Self-management education for adults with type 2 diabetes: A meta-analysis on the effect on glycemic control. Diabetes Care, 25, 115971.Skinner, T.C., Cradock, S., Arundel, F., Graham, W. (2003). Four theories and a philosophy: self-management education for individuals newly diagnosed with type 2 diabetes. Diabetes Spectrum, 16,75-80.

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Activity

The good news about diabetes care is that, based on evidence, we know more about how to treat and manage the condition.

Health providers need to try to understand the daily implications of living with diabetes.

Note to the Educator: In order to help your participants to understand the daily implications of living with diabetes, use the questions on this slide to stimulate discussion. You might want to have participants discuss the questions with one other person and then bring their reflections to the whole group. Or, if you have a small group, you could discuss with the group as a whole.

Another suggestion would be to invite someone with diabetes to come and share his or her experiences with the group.6

Activity

Note to the educator: Ask the participants to discuss these questions in their small groups. Be sure to emphasize that this is to look at emotional and behavioural support for the person with diabetes.

This question is not looking for a list of what should be taught to the person with diabetes.7

Why is self-management important?

Through effective self management education, people learn to:Stay healthy and prevent developing a diseaseImprove their health statusBecome more independent and develop a sense of self controlPrepare for surgery or tests and thus have better outcomesControl anxiety

People with diabetes want information to be able to understand their condition and make informed choices. A wealth of information is availablethrough the Internet and other sources. However, people need to be able to discern between information that is reliable and accurate, and thatwhich is not.

Diabetes is also largely managed by the person with diabetes. Thus, caring for diabetes is a personal responsibility.

The number of people with diabetes is increasing worldwide. Health professionals only see a person with diabetes at appointments which adds tojust a few minutes a year.

People with diabetes must therefore be able to manage their own disease. They are the experts in their daily care. To do so they will need supportfrom health professionals, family and friends.

It has been shown that people who are active in the management of their diabetes have better long-term outcomes.

Funnell, M.M., Brown, T.L., Childs, B.P., Haas, L.B., Hosey, G.M., Jensen, B., Maryniuk, M., Peyrot, M., Piette, J.D., Reader, D., Siminerio, L.M.,Weinger, K. and Weiss M.A. (2007). National Standards for Diabetes Self-management Education.Diabetes Care, 30,1630-1637. Norris, S.L., Lau, J., Smith, SJ., et al. (2002). Self-management education for adults with type 2 diabetes: a meta-analysis on the effect onglycemic control. Diabetes Care, 25,1159-1171.Gary, T.L., Genkinger, J.M., Guallar, E., Peyrot, M. & Brancati, F.L. (2003). Meta-analysis of randomized educational and behavioral interventions intype 2 diabetes. The Diabetes Educator, 29, 488-501. Duncan, I., Birkmeyer, C., Coughlin, S., Qijuan, (E)L., Sherr, D., & Boren, S. (2009). Assessing the value of diabetes education. The DiabetesEducator, 35, 752-760.

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Barriers to diabetes care

There are many barriers to diabetes care. We need to put ourselves in the place of people with diabetes considering their culture and how diabetes impacts their lives and relationships - in order to improve the care we are giving.

Look at the diagram and try to think of a couple of specific barriers for each heading. (Or choose one heading and expand on it. What is specific to your target population? What is often not considered?)

Possible barriers:Educational:Low diabetes knowledgeLow knowledge of services

Internal Physical:Physical effects of treatment

External physical (systems)Personal finance issuesPoor physical access to serviceLack of community-based servicesNeed for more helpful health professionalsInappropriate diabetes care

PsychosocialGroup pressurePrejudiceLack of public awarenessLack of family supportCommunication difficultiesLack of cultural support

PsychologicalHealth beliefsPublic health beliefsPoor motivationLow self-efficacyNo symptom cuesDifficulty setting prioritiesNegative perceptions of timeEmotional issuesPrecontemplative stage of change

Simmons, David. (2001). Personal Barriers to Diabetes care: Is It Me, Them or Us? Diabetes Spectrum, 10-129

Depression (1 of 2)

Although we should not see feelings as problems to be solved, sometimes there is a need for concern.

IDF. (2009). Diabetes Atlas, 4th ed. Brussels: IDF Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2008). 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab. 32,(suppl 1), S82-83.

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Depression (2 of 2)

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. (2008). 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab. 32,(suppl 1), S82-83.

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Activity

Note to the educator: Ask the group as a whole or in pairs to consider the supporting factors and barriers in their culture to self-management on the part of the person with diabetes.

Use the next slide when discussing the barriers.12

Barriers to self-management

The barriers might be obvious, such as lack of money and resources, distances to medical facilities, etc. Or health care professionals may be working from an acute care perspective instead of a chronic care perspective. The do as I say and I will fix you attitude rather than the what do you think would help? attitude.

The knowledge level of the health professional may also be a barrier to self-care Health care professionals require specialized training in diabetes and diabetes self-management education in order to be able to teach and support people with diabetes.

It is important to point out that the person with diabetes has more experience living with their own disease than anyone else.

Piette, J.D., and Glasgow, R. (2001). Education and Home blood Glucose Monitoring. In Gerstein, H.C., and Haynes, R.B. (Eds.). Evidence-Based Diabetes Care. Hamilton, ON: BC Decker Publishers.

Harvey J. N., Lawson V. L., (2009) The importance of health belief models in determining self-care behaviour in diabetes. Diabetic Medicine, 26, 513.13

What do people need to understand?

Along with content about diabetes, people also need other information.

There are always both advantages and disadvantages for all therapeutic options. People need to know how to weigh the plusses and minuses based on their personal goals and values. It is important to realize that ultimately people have the responsibility of making the final decision.Although we expect people to make multiple behavioural changes, we rarely provide information about strategies for behavioural change. Providing this information is most effective if it is incorporated into each content area so that people can apply the information.We need to acknowledge that people are the experts on their own lives and that while we know about diabetes, we can not and do not know what is best for their diabetes or their lives. It takes our shared expertise to create a plan that will work. If it does not work, it doesnt mean that either of us have failed, it just means that we need to keep trying until we get the right plan.We also expect that people will assume the role of decision-maker in their own care but rarely make this explicit. It is important that we let people know that their outcomes largely depend on their efforts. In order to assume responsibility people need both initial diabetes education and on-going self-management support.

Funnell MM, Anderson RM: Empowerment and self-management education. Clinical Diabetes 22:123-127, 2004.

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Self-management abilities

In order to teach self-management, the needs of the individual and family (support) should first be considered.

Teach skills such as: Monitoring blood or urine glucose Quantifying food intake Making adjustments in food, medication and activity Problem solving Coping skills Establishing realistic short and long-term goals Developing a supportive network

Professionals can support people and teach them behaviour change strategies. However, changing behaviour does not happen in a short period of time. Most people benefit from the support of a health professional who understands the complexities involved, and who can provide emotional support as well as the tools to change.

Fisher, E.B., Brownson, C.A., OToole, M.L., Shetty, G. et al. (2005). Ecological Approaches to Self-Management: The Case of Diabetes, Am J Public Health, 95,15231535.Von Kroff, M., Gruman, J., Schaefer, J., et al. (1997). Collaborative management of chronic illness. Ann Intern Med, 127(12), 1097-102.15

A change in philosophy

As more research in this area has been carried out and published, education has changed in response to the evidence.

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Components of self-management

In order for collaborative management to occur you must have:

Self-directed goals these must always be determined with the person with diabetes/family or support givers; they are the persons goals and not those of the healthcare professional

Sustainable working relationship mutual respect and a collaborative atmosphere will lead to a sustainable relationship

A mutual understanding of roles and responsibilities should be fostered

Both the person with diabetes and the healthcare professional require the skills to carry out their roles

For more information go to www.realdiabetes.com and click on 8 lessons17

So what should we do?

Note the highlighted words to and with. In a true partnership approach, the health professional will learn along with the person with diabetes about his diabetes and what helps and doesnt help in his life. Remember diabetes is best managed individually each person has different needs and responses. 18

Reframe our attitudes and behaviours

We need to provide information in ways that help people make decisions and solve problems and overcome barriers that arise each day.

One of the most important and under utilised educational tools educators have is asking questions and then actively listening to the responses. Asking what and why helps people identify problems and concerns that they can then address.

Listen to yourself the next time you are with a person how much are you talking? How much are they talking? Who is asking the questions?19

Teaching

A key component of diabetes self-management education is teaching. In diabetes education, teaching can be perceived as offering people with diabetes the opportunity to learn.

A person cannot be forced to learn something; effective teaching creates an interest in a subject so that students will want to grasp the opportunity to learn.

Bastable, S. (2008). Nurse as Educator. Sudbury MA: Jones & Bartlett Publishers. 20

Teaching does not necessarily result in learning

Ask the participants to think about the last time they were taught not necessarily related to diabetes.

Then ask them whether they thought it was an effective learning experience or not.

Ask participants to give examples of effective and ineffective learning situations and the factors that made these effective or not.

For instance, someone might say that they learned because the teacher allowed students to ask questions; others might say that they did not learn because the teaching followed a lecture format offering no opportunity to discuss questions.21

Learning

Learning, it is hoped, will result in some changes. But the changes may not be what the health professional anticipated; people may decide not to change. It is important that the decision is based on evidenced based information and therefore an informed decision. Health professionals should respect the decisions people make.

Many people learn about the negative consequences of smoking, yet they continue to smoke. Why is that?

Ask the participants: Can you think of something you have learned but then decided not to carry out?

Although it might be difficult for others to accept, people have the right to make their own choices.

As teachers, we have to accept peoples choices and continue to work with them and support them.

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Who is the teacher and who is the learner?

Remember that as health professionals we learn from people with diabetes and their families. We must listen to what they are teaching us about diabetes and how it affects their lives. We must recognize when it is time to learn and when it is time to teach. We must reflect on how our experiences, knowledge and skills influence how we learn. All parties need to recogniSe who owns the problem that is presented and as a result who must develop and own the solutions.23

Communication skills are key to the teaching process as well as to the process of helping people develop strategies for behaviour change.24

Communicating feelings or attitudes

Non-verbal communication (visual/body language) can increase or decrease our ability to communicate effectively.Verbal words spokenVocal includes tone of voice, volume, pitch, rhythm (paralanguage)Visual includes body language, facial expression (body language)

Words are not enough! When communicating feelings or attitudes, if there is an inconsistency between the spoken word and the body language or paralanguage, the latter will have a greater impact.

You may not want to communicate your feelings or attitudes if you feel negatively towards what the person is telling you. Dont let your body language give a different message than your words.

In fact words may only influence your communication by 7%.

Think about how quickly you speak. Do you sound angry, frustrated, happy, bored? All of this will have an impact on the way the words are understood.

Think about what you are doing while you are speaking: are you checking your watch, walking out of the room, turning away from the person? Or are you making eye contact, looking as if you care, seeking the persons reaction?

Always be aware of the image you are giving of yourself.

Mehrabian A. (1999). In P. Bender. Secrets of Power Presentations. Webcom: Toronto The Achievement Group. 114

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Watch your body language!

Note the different styles of teaching. The teacher on the left is in a position of power and may have more difficulty engaging the participants than the teacher on the right.26

Activity

Note to the educator: Ask the participants to work in pairs for this exercise.

Ask them to explain each of the following medical terms in common language so that a person with no medical background will understand why these words have meaning for their diabetes management. What do each of these words mean to me in terms of my diabetes self-management?

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Tips for plain speaking

Plain speaking is a term that is used to describe making ourselves understood using clear, simple language. Besides using simpler language, here are some tips for plain speaking.

Always introduce the topic and let people know your purpose. If you do this at the start, people will not waste time or lose concentration wondering where a session is heading Use analogies and help people to visualise as much as possible Keep your discussion organised; avoid going off on tangents or bringing up things that are not related to the topic Start with simple items and concepts and move towards more complex ones In order to remember them effectively, people need to hear things an average of three times. Do not be afraid to repeat yourself! Conclude your discussion by summarising the most important points Check understanding by asking open-ended questions

Belton, A.B., Simpson, N. (2010). The How to of Patient Education, 2nd ed. Streetsville ON: RJ+Associates.

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Tips for plain speaking

People become engaged in what you are saying if it applies to them. They do not want to know about diabetes..they want to know about their diabetes. Remember to personalise teaching messages.

To personalise messages, use the active voice and make the person the subject of the message.

Discuss the example sentences with the group and how might each of them impact on a person in terms of emotions and memory.

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Communication

Open-ended questions cannot be answered by yes or no.

Open-ended questions should be used as much as possible when carrying out an assessment or evaluating teaching. Allowing time for the person to tell you his story will help you better understand his needs and his understanding of his diabetes management.30

Develop listening skills

When listening pay attention! If you are thinking about how you are going to respond you are not really listening.When the person with diabetes stops talking ask questions to see if you have understood correctly this not only gives you a better understanding but gives the person another chance to reflect on what he has said.31

Reflective listening

The process of reflective listening is to connect the bottom two boxes - to clarify and check whether what the listener thinks the speaker means IS the same as what the speaker means.

Reflective listening bridges the gap between what the speaker means and what the listener thinks the speaker means.32

The teaching process

The teaching process is comprised of 4 steps: assessment, planning, implementing and evaluation.We will next look at each step in some detail.33

Assessment (1 of 4)

The assessment is the foundation upon which a respectful, trusting relationship and an effective teaching plan is built.

The assessment provides the diabetes health professional information on what diabetes means to the person, what resources are available to them and what next steps they would like to take in managing their health.

The priorities of people with diabetes might differ from yours. Until you focus on peoples needs, you will not have their full attention. It is important to assess the priorities and the learning goals of the person with diabetes.

Family members or other support people may or may not play a role in the management of a persons diabetes. They may need to be involved in the learning; find out in the assessment who needs to be included.

During the assessment, you may find barriers that will influence the way you set up a teaching intervention, such as: time constraints the person is only able to attend on certain days, or for a short time available resources or support - the person does not have a supportive social network or help at home; can not afford health care supplies such as monitoring strips or wound care supplies; do not have a computer to use as a learning tool. physical barriers the person may have poor eyesight or hearing loss literacy level other concerns the person may not be able to attend to issues affecting diabetes due to other concerns, such as financial worries, another diagnosis or family problems

Time, resources, physical contraints, literacy level, and other priorities are examples of barriers to learning and self-management that need to be considered when developing a learning and action plan.

Other advantages of the assessment phase are:You will use your time efficiently by tailoring the lesson to the learning needs and goals of the learner and spending your time on the topics that are timely and are a high priority for the person for the person with diabetes.

The person with diabetes will be more motivated and engaged in their learning as it directly relates to their own learning goals.

Learning plans based on a thorough assessment are more effective and efficient.

Belton, A.B., Simpson, N. (2010). The How to of Patient Education, 2nd Ed. Streetsville ON: RJ+Associates. A persons most pressing concerns should be dealt with initially. This will prevent increasing anxiety over these issues.Building rapport with a person is at the same time an objective and a technique of assessment. 34

Assessment (1 of 4)

Your teaching will be improved if learners have the opportunity to participate. Carrying out a needs assessment encourages people to participate by answering questions and engaging in a dialogue with the health care professional.

You will be able to make the session more effective by integrating the persons learning style, cultural and health beliefs into your method of teaching and follow-up support. What method of learning has the person found helpful in the past individual or group learning? ; visual or oral learning?.

A persons most pressing concerns should be dealt with initially. This will prevent increasing anxiety over these issues.Building rapport with a person is at the same time an objective and a technique of assessment. 35

There is a difference

As healthcare providers, we might believe that we know the learning goals of people with diabetes.

Too often we only teach what we think the person with diabetes should learn and forget about what the person wants to learn.

Studies have shown that there is a significant difference between what people want to know and what we want to teach.

While healthcare providers want to teach about pathophysiology, the first thing many people with diabetes want to know is what they can eat.

Suhonen, R., Nenonen, H., Laukka, A., Valimaki, M. (2005). Patients informational needs and information received in hospital. J Clin Nursing. 14(10),1167-76.

Timmins, F. (2005). Contemporary issue in coronary care nursing. New York: Routledge.

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Assessment (2 of 4)

When carrying out an assessment, it is important to keep the following principles in mind:

Assessment must be non-threatening and non-judgemental Building rapport takes time.

Your attitude will play a big part in the success of the assessment. If you are caring and show interest in the person, you will be able to gather more information.

The physical setting needs to be considered.

Make sure the teaching area is quiet and that you are not interrupted.

Sit at the same level, preferably around a table rather than at the other side of a desk as this can put you in an authoritarian position.

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Assessment (3 of 4)

One of the dilemmas we face is the conflict between meeting peoples learning wishes and providing information that we feel the person must know in order to be safe.

You should always ask what people want to know and address that but at the same time you should never let them go home if they will not be safe. Just about the only critical piece of information that a person with diabetes must know to survive is hypoglycAemia; its symptoms, causes and treatment; whether to take insulin or a sulfonylurea.

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Assessment (4 of 4)

Assessments can be done in a variety of ways, depending usually on the setting. It is important to allow time for the person with diabetes to talk to you.

Interviews Are a good way to build rapport and get to know the person Being interviewed can cause anxiety for some people. It is important to apply the principles of good communication when interviewing a person.

QuestionnairesIf you do not have much time to spend with a person, you can send out a questionnaire. Limitations to this include: People may not be able to read it Many will forget to bring it in Many will want to complete it when they come in People might interpret the questions differently You may not have time to review the questionnaires before the teaching intervention

Pre- and post-tests Usually only test knowledge recall People might not be able to read them People may interpret questions differently Can be very threatening people do not usually like to be put in a position where they do not know the answers May make people feel like failures before they start

Records/reports: Reviewing logs or reports from other healthcare providers gives you an opportunity to know how a person was assessed by others.

Observation: A good way to assess peoples ability is to observe them carrying out a task. But remember, being observed might make people nervous; this might cause them to make mistakes.

People will be nervous and feel vulnerable when meeting you for the first time. By applying good communication skills, you can turn the situation into a positive experience and reduce perceptions of threat, even for a pre-test.39

Planning (1 of 2)

Plans for teaching should be developed with the person with diabetes.

The teacher should find out what people want to learn and how they prefer to learn.

Be sure to write the goals and objectives with the person. Remember, these should be the goals of the person, not the teacher.40

Planning (2 of 2)

Objectives help you to select items, when to teach them, and how to evaluate the teaching.

You should set objectives for all topics you teach.

One idea is to prepare a list of objectives. People select those they think they need, thereby individualising the learning experience rather than developing new objectives for each person you are going to teach. This is especially useful if you frequently teach about the same topic.

Objectives should always be written from the point of view of the learner, not the healthcare professional: After attending this class I will be able to

These should be reasonable and measurable. Avoid setting objectives that will be impossible to reach or so vague that nobody can know whether it has been reached or not.

Objectives should be specific. This will help you to make them measurable. Most importantly, people should agree that the objectives address the topics they want to learn.

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Implementation (1 of 2)

When you have a plan, you will be ready to teach.

Communication is of vital importance.

Keep language simple Ask open-ended questions this will encourage people to participate Use verbal and non-verbal communication to express a positive attitude towards the topic and the person Listen to feedback if many questions arise regarding something you taught recently, for example, perhaps your explanations were not clear enough. If the questions are on a different topic, perhaps learners are not interested in the subject you are covering As mentioned previously, people need to hear things three times; An item should be introduced, discussed, and summarised, and the most important information repeated at least three times

Belton, A.B., Simpson, N. (2010). The How to of Patient Education, 2nd ed. Streetsville ON: RJ+Associates.

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Implementation (2 of 2)

Decide what items to teach first by establishing with people what they want to know and what they need to know.

People with diabetes may not perceive one of the topics chosen by you as essential treating of low blood glucose, for instance. In such cases, your task is to ensure people with diabetes understand the importance of the information and that it is relevant to them.

Look at the objectives and determine priorities. Determine also whether prior knowledge is necessary to be able to work on a certain objective. For example, before learning to interpret blood glucose readings, a person must understand the numbers.

Studies have shown that people remember the first and the last things they hear to a greater degree than the content of the middle of a conversation. Present the most important things first and last.

Remember: move from simple to complex; be specific; speak plainly; introduce, review, summarize and repeat.

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Evaluation (1 of 4)

Evaluation should be an integral part of any teaching.

Evaluation should not be an afterthought; it should be thought of and planned from the start.

It should be formative (carried out throughout the teaching) as well as summative (at the end).44

Evaluation (2 of 4)

If individualised objectives were set, evaluation should follow the objectives can the person do what was expected?

If your objectives are specific and measurable, and written from the point of view of the learner, you will be able to gauge whether or not learning has been effective.

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Evaluation (3 of 4)

Individual evaluation, as well as helping the facilitator, enhances the learners understanding of his or her progress in terms of the level of knowledge and skills reached.

From the evaluation you will determine the needs that remain unmet. Your evaluation should match the objectives and the content of the intervention.

The evaluation will also provide input for clinical decisions. If, for instance, a person is unable to measure carbohydrate intake, he or she may not be a good candidate for self-adjustment of insulin.46

Evaluation (4 of 4)

Individual evaluation is often best done by asking questions and observing new behaviour.

If you ask do you understand?, people, through a desire to please you, are likely to answer yes

Ask the person: In your own words, how do you think you will feel when you experience hypoglycaemia?

Observe while the person uses a new skill to draw up insulin and test blood glucose.

Ask: Where and how will you carry out these tasks at home or at work?

Ask the person to summarise the discussion in his or her own words. This is sometimes called the teach-back method. A positive approach to evaluation is needed. If the person with diabetes does not recall the information correctly it is not a failure. It is an indication that further explanation is required. The teacher takes the responsibility when the person has not learned.47

5 steps to self directed goal setting for behaviour change

This next section will discuss how to help people develop strategies for behaviour change. This method includes the following 5 steps: Identify the problemExplore feelingsSet goalsMake a planEvaluate the results

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What is the problem?

The assessment should identify the problem. It is important to identify the problem from the perspective of the person with diabetes, not from that of the educator.

Ask questions to help the person to obtain clarity. Most of the time, asking why is that multiple times will help you get to the heart of the problem.

Solutions that do not address the real problem, are doomed to fail.

We are not responsible for solving peoples problems. Solutions that are the most meaningful and effective need to be determined by the person with the problem. Our job is to ask questions that will help the person with diabetes to develop a solution.

Funnell MM, Anderson RM: Empowerment and self-management education. Clinical Diabetes 22:123-127, 2004.

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How do you feel?

We need to determine how this problem affects the person with diabetes and their behaviour. Asking the person to describe their thoughts may be less threatening than asking about feelings.

Statements such as, It sounds as if you feel embarrassed about having to test at work? show that you are listening to the person and attempting to understand how they feel.

Funnell MM, Anderson RM: Empowerment and self-management education. Clinical Diabetes 22:123-127, 2004.

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Although educators are often uncomfortable with negative emotions, negative feelings often serve as powerful motivators for change. Our discomfort often comes from our belief that we need to solve these emotions or to make the person feel better.

Our job is to acknowledge the feelings without attempting to minimise the negative impact of the feelings or make the person feel better.51

What do you want?

The next step is to help the person decide what they want to accomplish. Asking what multiple times can help the person to obtain clarity about what they will do.

It is also important to find out the level of commitment or the priority the person with diabetes places on this. Asking, On a scale of 1-10, with 10 being the highest, how important is this for you? If the response is a low number, ask the person if this is truly an area that they wish to address right now. If this person with diabetes indicates a high number, acknowledge the level of commitment to the issue.

Funnell MM, Anderson RM: Empowerment and self-management education. Clinical Diabetes 22:123-127, 2004.

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What will you do?

It is very important to help people identify one action that they can take to get started on their goal. This step should be:RealisticCompletely within their controlMeasurablePersonally meaningful

Goals such as pounds lost or blood glucose readings are generally not totally within patients control. It would be more useful to identify behaviors that will help them to reach these goals. As an example, weight fluctuates for many reasons over which I have no control. I may have control however on what I choose to eat.

Funnell MM, Anderson RM: Empowerment and self-management education. Clinical Diabetes 22:123-127, 2004.

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SMART behavioural goals

A goal such as I will lose 10 pounds in 3 months or I will reduce my A1c by 1% are not goals -- but desired outcomes. The person CAN take actions to move them towards these outcomes. (Therefore these are not good examples --- as a person ultimately can not control these outcomes, but they can control activities which may lead to these results.)

Funnell MM, Anderson RM: Empowerment and self-management education. Clinical Diabetes 22:123-127, 2004.

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How did it work?

One approach is to encourage people to think of these step as experiments rather than successes or failures. The benefit of an experiment is that you can always learn from it. In fact, our most helpful learning often comes from experiments that did not work well.

The process then begins again with either the same or a new action step selected.

Funnell MM, Anderson RM: Empowerment and self-management education. Clinical Diabetes 22:123-127, 2004.

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How to respond?

Remember that body language can send strong messages too!56

Similarities between teaching and supporting self-directed goal setting

The teaching process consists of four parts: assessment, planning, implementation, evaluation.

Teaching should include all four aspects.

This does not mean that all teaching interventions have to be lengthy; some will be very short (such as an over-the-counter talk at a pharmacy) but all four steps should be included.

A five step process has been defined to help a person set self management goals. These five steps run parallel to the teaching process. Doing an assessment is similar to identifying the problem and exploring how a person feels about the problem. Planning consists of setting goals, implementation is when the plans are finalized and put into action, and the evaluation process determines whether the goals have been met.

It is impossible to separate teaching from self management education or helping people make and implement plans to manage diabetes. As you work through the following slides think about how your teaching skills mesh with helping people decide to change.

Funnell, M.M., Anderson, R.M. (2004).Empowerment and self-management education. Clinical Diabetes, 22:123-127.

Anderson, R.M., Funnell, M.M. (2005). The Art of Empowerment: Stories and Strategies for Diabetes Educators. 2nd ed. Alexandria: American Diabetes Association57

Patient-Centered education

This summarises findings of critical factors for successful educational interventions.

Adult learners generally have preferences about how they learn best and the topics they want to have addressed. The information provided needs to be culturally relevant and appropriate.

One of the critical factors in improved outcomes for people with diabetes is on-going self-management support. Education is not a one-time inoculation that will provide people with diabetes with all they need to manage diabetes for a lifetime. Without on-going support, behaviours return to pre-intervention levels after about 6 months.

Piette, J.D., Weinberger, M., McPhee, S.J. (2000). The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial. Medical Care, 38,21830.

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Summary

Re-cap the points by going through the points with the group.

Be selective do not overload learners with information

Be specific presenting inappropriate or tangential information will waste limited time and be counter-productive

Enhance memory present the most important information first

Facilitate concentration categorise information I would like to teach you about....

Repeat key points at least 3 times Introduce....provide info....summarise

Reinforce instruction with printed material59

References (1 of 2)

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References (2 of 2)

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