Educating the ‘experts’: diabetes patient education programme – Patient Education
Education is an important part of diabetes management. An audit of the education provided to people with diabetes, carried out in Taff Ely, Wales, led to the development of an educational programme, which is described in this article. Evaluation of the programme by questionnaire survey revealed that knowledge improved across all categories including monitoring and control, hypos and complications. The limitations of the study are discussed and recommendations for future studies are made.
The current explosion in numbers of people with diabetes (Krans et al, 1995) means that we must think of innovative ways to address the major health implications for this patient group (British Diabetic Association, 1996).
Education is an essential component of management, as people with diabetes need to develop the skills to enable them to become ‘experts’ in self-care. It is well documented that a multidisciplinary approach to education is vital to enabling people to make informed choices about their self-care, thus facilitating true empowerment (British Diabetic Association, 1997; NHS Executive, 1997).
Background to the programme
In light of the Testing Times report (Audit Commission, 2000), a baseline review and needs assessment was undertaken in Taff Ely with the participation of 10 general practices. Practice nurses and GPs were encouraged to analyse whether patients in their practices were being ‘educated’ in diabetes self-management or provided with ad hoc advice and information.
The results revealed that patients were not being educated in any structured way, but were given only ad hoc, opportunistic information and advice. This came as a shock to the majority of practices, who initially thought that their provision of ‘education’ was good.
It was therefore decided that a collaborative, multidisciplinary, structured education programme should be developed and piloted in the Taff Ely locality.
Patients would be given a prescription for education from the GP or practice nurse and would be referred into the group sessions if appropriate and acceptable to the individual patient.
Aims and objectives
The Taff Ely Partnership and Pontypridd & Rhondda NHS Trust endorse the national and international recommendations published by the International Diabetes Federation (IDF), World Health Organization (WHO) and Diabetes UK, and incorporated these into the programme.
The aims of the diabetes education programme were as follows:
* To significantly increase general awareness of diabetes in Taff Ely.
* To raise awareness of the complications of diabetes and how to prevent them, in order to increase both quality and quantity of life for people with diabetes.
* To provide a more structured programme of care for people with diabetes, enabling improved self-management.
* To improve communication between secondary and primary care in order to provide an integrated service that can successfully work across boundaries.
* To highlight the need for a structured approach to diabetes education by producing a replicable model of good practice.
The multidisciplinary programme comprises three 2-hour sessions, which build upon each other to provide patients with the basic education required for understanding and living with diabetes.
Flexibility is integral to the delivery of the Taff Ely programme since patient participation is encouraged throughout each session, thereby meeting the needs of individuals in each group. In general, each group consists of 6-12 patients with diabetes, falling within the recommendations for group education stipulated by Eweles and Simnett (1999). Each group is seated informally, thus providing a non-threatening environment that encourages discussion and participation.
The patient education programme was designed to introduce people with diabetes to the concept of empowerment. Empowerment is a central theme in a number of recent documents, but needs to be underpinned by a comprehensive, structured, patient education programme (Day, 2000; DoH, 2001). This is reinforced by Testing Times (Audit Commission, 2000), which emphasises the importance of incorporating a written curriculum.
The sessions are run by the diabetes facilitator in Taff Ely, who has provided training and obtained funding through the bidding process to purchase protected time for the multidisciplinary team involved in delivery of the programme (practice nurse, dietitian, physiotherapist, podiatrist, lay people with diabetes), thus facilitating professional development.
Empowerment through education
Education has long been considered one of the cornerstones of improved diabetes management for both patients and health professionals (Joslin, 1939). The current trend in helping people to achieve self-management of their diabetes is to ’empower’ them with the information they require in order to make informed choices.
Health professionals need to understand the importance of providing people with the necessary tools to enable them to take responsibility for their own diabetes management. Enabling ’empowerment’ does not just happen. It is analogous to parenting: in order to arrive at maturity, the child has to be cared for, encouraged, and nurtured to achieve independence, and, for this, time is needed.
As the International Diabetes Federation (IDF) guidelines state:
‘It is the responsibility of the diabetes team to ensure the person with diabetes can follow the lifestyle of their educated choice, achieved through the three elements of empowerment: knowledge,’ behavioural skills and self responsibility.
Assessment of the sessions
A patient knowledge questionnaire was completed by all people with diabetes attending the education programme at the beginning of day I and the end of day 3. The questionnaire included three quality of life questions taken from Dr Claire Bradley’s work (Bradley and Gamsu, 1994) (which were also included in Testing Times).
A random sample of 50 people with diabetes who had completed the education programme were audited. Results before and after are presented below.
Table I shows the results for before and after the programme for the nine categories.
The pre-course scores indicated good knowledge in three main categories: ‘What is diabetes?’, ‘Diet’ and ‘Footcare’. Although there was an improvement in scores, the differences were not as significant as in other categories.
Monitoring and control
When questioned about monitoring and control, only 62% of patients with diabetes answered correctly before the course, whereas 89% answered correctly after the course, indicating a significant improvement.
The change is largely due to a greater understanding of targets such as blood sugar levels, [HbA.sub.1c]’ blood pressure and cholesterol; many patients commented that they had not been told which target levels they should be aiming for.
Understanding of the type of exercise suitable for people with diabetes was generally poor and did not improve significantly post-education. Many people felt that gentle walking should be included as exercise although this does not fulfil the Diabetes UK (2002) criteria or definition of exercise. If gentle walking were suitable, the initial values would have been 84% pre-course vs 98% post-course.
There was only a 12% improvement in scores relating to medications. The number of people with diabetes on medication in the groups was low (13/50) because the programme was funded for newly diagnosed people with diabetes, who were in the main treated with diet.
There was some confusion about the need to carry dextrose and which medication influenced this need. Despite the 24% improvement in knowledge post-education, further improvement is still needed.
An improvement of 24% was seen for complications (from 56% to 80% correct answers). This appears to demonstrate a substantial increase in knowledge about complications. The emphasis within this session is on reducing risks as opposed to dwelling on the morbidity of the long-term complications of diabetes, and the majority of patients responded to this approach. The consequent improvement in confidence that good control can prevent or delay the onset of long-term complications is shown in the responses to the question ‘How confident are you that good control of your diabetes can prevent long-term complications to eyes, feet, kidneys and so on? (Figure 1).
Perception of control
When asked ‘How worthwhile do you think it is to maintain good control of your diabetes?’, all patients, except for one, thought it very worthwhile to maintain good control of their diabetes, both before and after the sessions (the one patient went from ‘no point at all’ to ‘worthwhile’).
Feelings about their diabetes.
Figure 1 gives a breakdown of responses to various questions about how people with diabetes felt about their diabetes.
The majority of participants (44/50) demonstrated a clear improvement in their overall knowledge after completing the 3-day programme; there was a worsening for 4 patients and no change for 2.
Evaluation of education sessions
In general the sessions were rated very highly and many patients commented verbally that it was very helpful having different disciplines present at the sessions. There were also many comments about how helpful it was to have the ‘living with diabetes’ session presented by a lay person with diabetes.
Many participants in the programme did not have sufficient understanding of the targets they should be aiming for in order to achieve ‘good control’ of their diabetes. Consequently, they were undecided about the degree of control they had over their diabetes. After completing the programme, many commented that they would be far more likely to question their healthcare professional to obtain the information they needed to be able to make an informed decision about their own level of diabetes control. Previously they had been content to be told, for example, that their blood pressure was ‘OK’ rather than questioning the reading and how that compared with target values.
After the programme, participants felt that diabetes posed less restrictions on their lives, with 27% feeling less restricted after the course. This suggests that improved knowledge, reassurance and peer group discussion help patients to put their perceived restrictions into perspective, thereby improving overall quality of life.
With improved knowledge as a result of the programme, participants seemed able to make more informed decisions about their level of risk, but there is a change in their perception about the effect of diabetes on their health, particularly if they had been worried previously.
The missing link
The most significant change brought about by the programme was the improvement in patients’ confidence that good blood glucose control prevents long-term complications. This suggests that the programme not only improved participants’ knowledge but may also have motivated them to use their enhanced knowledge to improve their diabetes control.
A number of patients made very favourable comments on the evaluation forms or verbally to the course leaders, indicating a greater understanding of what they, as individuals, should do in order to achieve good control. Whether patients retain this perception or motivation in the longer term will need to be re-evaluated.
The initial funding for the pilot education programme was allocated specifically for newly diagnosed people with type 2 diabetes. The majority of participants in the programme were therefore controlled by diet and ‘exercise’ alone.
Although we advocate exercise as part of the treatment of diabetes, often this can be hampered by multipathologies in patients with type 2 diabetes, who may be afraid to increase their physical activity, or be discouraged from doing so, because of their medical condition. It is perhaps not surprising that there was confusion about the type of exercise considered beneficial to health improvement in this group of patients.
The development of the education programme resulted directly from an audit of whether patients with diabetes in Taff Ely were being ‘educated’ in practice. The audit of patients’ improvement in knowledge demonstrates a general improvement overall and a significant improvement following certain diabetes education sessions.
We acknowledge that improvement in knowledge may or may not be sustained in the long term, but if supportive literature is provided as a resource and all health professionals reinforce consistent messages, then knowledge is more likely to be sustained. We are also aware that improved knowledge does not equate with a change in behaviour and we have to accept that patients have the right to make an informed decision to change or not to change.
Anecdotal comments from DSNs working in the ward environment support this view, when they are told that inpatients who have undertaken the education programme take less time to be educated when admitted to the wards than patients who have not gone through the programme.
Evaluations from the patients perspective are very favourable, and although the sessions on exercise and medications along with the patient knowledge questionnaire need to be refined, the authors feel that the programme could be of benefit to other areas and are more than willing to share good practice.
Patients did not rate the delivery and evaluation of the sessions on exercise and medication as highly as other sessions in the programme; this needs to be addressed. Another problem identified related to the scoring of the patient knowledge questionnaires. Some questions had more than one answer, which made them difficult to score, and not all questions had a ‘don’t know’ category. These issues are being addressed by the multidisciplinary team before the programme is rolled out to other areas.
[FIGURE 1 OMITTED]
Knowledge scores for each category before and after the education
What is Monitoring
diabetes? and control Diet Exercise Medications
% correct responses
Before programme 96% 63% 90% 36% 31%
After programme 98% 88% 97% 44% 44%
Hypo Complications Footcare
% correct responses
Before programme 31% 56% 8%
After programme 63% 80% 98%
Audit Commission (2000) Testing Times: A Review of Diabetes Services in England and Wales. Audit Commission, London: 57u60
Bradley C, Gamsu OS (1994) Guidelines for encouraging psychological well being. Report of a working group of the World Health Organization and St Vincent Declaration Action Programme for Diabetes. Diabetic Medicine 11: 510-1
British Diabetic Association (1996) Diabetes in the UK. BDA, London
British Diabetic Association (1997) What Care to Expect BDA, London
Day JL (2000) Diabetic patient education: determinants of success. Diabetes Metabolism Research & Reviews 16 (Suppl I): S70-S74
Department of Health (200 1) The Expert Patient; a new approach to chronic disease management in the 21st century. Department of Health, London
Diabetes UK (2002) Physical Activity & Diabetes. Diabetes UK, London
Ewles L, Simnett 1(1999) Promoting Health: A Practical Guide. 4th edn. Harcourt Brace & Co Ltd, London
Joslin EP (1939) Story of evolution of treatment of diabetes at New England Deaconess Hospital Boston. Nordisk Medicin 2:1261u7
Krans HMJ et al (1995) Diabetes Care and Research in Europe: The St Vincent Declaration Action Programme, World Health Drganization. 2nd edn. WHO, Geneva
NHS Executive (1997) Key Features of a Good Diabetes Service. Department of Health, London
RELATED ARTICLE: ARTICLE POINTS
1 Education is an essential component of management for people with diabetes.
2 A collaborative, multidisciplinary, structured education programme was developed and piloted in the Taff Ely locality.
3 The programme comprises three 2-hour sessions, which build upon each other to provide patients with the basic education required in understanding and living with diabetes.
4 Knowledge increased in all categories, which may or may not be sustained in the long-term.
5 Various issues will be addressed by the multidisciplinary team before the programme is rolled out to other areas.
* Pilot study
1 The patient education programme was designed to introduce people with diabetes to the concept of empowerment.
2 The sessions are run by the diabetes facilitator in Taff Ely.
3 A random sample 3 of 50 people with diabetes who had completed the education programme were audited.
4 Before the programme, there was good knowledge in three main categories: ‘What is diabetes?’, ‘Diet’ and ‘Footcare’.
5 Improvements in knowledge were seen in all categories.
1. Questionnaire answers revealed some confusion about the need to carry dextrose and which medication influenced this nee.
2. There was a substantial increase in knowledge about complications.
3. Sessions were evaluated very highly and many patients commented verbally that it was very helpful having different disciplines present the sessions.
4. Having completed the programme, many patients commented that they would be far more likely to question their healthcare professional to obtain the information required to enable them to make an informed decision about their own level of diabetes.
1 It is acknowledged that improvement in knowledge may or may not be sustained in the long term.
2 Anecdotal evidence suggests that DSNs working in the ward environment support this view, when it is fed back that inpatients who have undertaken the education programme take less time to be educated when admitted to the wards than patients who have not gone through the programme.
3 Issues to be dressed included sessions on exercise and medication and questionnaire format.
Helen Husband is Primary Care Diabetes Facilitator, Rhondda Cynon, Taff Local Health Group, South Wales; Jan Chegwidden is Senior Diabetes Specialist Nurse, Pontypridd & Rhondda NHS Trust, South Wales.
If you are thinking of setting up patient group education sessions, and feel that the Taff Ely patient education programme would be helpful to you, Helen Husband can be contacted, and a CD-ROM obtained free of charge, via:
Royal Glamorgan Hospital
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