Diabetes Asia

1. Self-management education

2. Objectives • After completing this module the participant will be able to • Discuss the value of education in helping women have healthy pregnancies • Implement all components of the teaching process, that is assessment, planning, implementation and evaluation • Discuss ways to make communication more effective • Define what is meant by a patient centered approach to care. • Discuss the impact of gestational diabetes and psychological needs of women and their families

3. Diabetes Self-Management Education • Purpose • To prepare those affected by GDM to • Make informed decisions • Cope with the demands of a pregnancy complicated by GDM • Make changes in their behaviour that support their self-management efforts

4. Evidence for diabetes education • Traditional knowledge-based diabetes education is essential but not sufficient for sustained behaviour change. • While no single strategy or programme shows any clear advantage, interventions that incorporate behavioural and affective components are more effective. (Piette, Weinberger, McPhee, 2000) Barlow, Wright, Sheasby, Turner, Hainsworth, 2002 Roter, Hall, Merisca, Nordstrom, Cretin, Svarstad, 1998

5. Evidence for diabetes education • Diabetes self-management education (DSME) is effective for improving psychosocial and health outcomes, particularly in the short-term. • On-going support is critical to sustain progress made by participants during the DSME program. Barlow, Wright, Sheasby, Turner, Hainsworth, 2002 Brown, 1999 Norris, Lau, Smith, Schmid, Engelgau, 2002 Roter, Hall, Merisca, Nordstrom, Cretin, Svarstard, 1998 Norris, Lau, Smith, Schmid, Engelgau, 2002 Skinner, Cradock, Arundel, Graham, 2003

6. Why is self-management important? People want to be healthy and have healthy babies. Gestational diabetes needs to be self-managed. Person is responsible for their day-to-day care. 24-hours-a-day management is necessary. Active, informed self-management leads to better long-term outcomes. Funnell, Brown, Childs, Haas, Hosey, Jensen, et al., 2007 Norris, Lau, Smith, 2002 Gary, Genkinger, Guallar, Peyrot, Brancati, 2003 Duncan, Birkmeyer, Coughlin, Ouijan, Sherr, Boren, 2009

7. What do people need to understand? • Their own personal goals, values and feelings • Diabetes care and treatment (advantages/ disadvantages) • Behaviour change and problem-solving strategies • Who is the decision-maker – the woman, the husband, the mother-in-law? • How to assume day-to-day responsibility Funnell, Anderson, 2004

8. Self-management abilities • The ability to self-manage is enhanced by • Considering the individual’s need(s) • Teaching skills to optimise outcomes • Facilitating behaviour change • Providing emotional support Von Kroff, Gruman, Schaefer, 1997 Fisher, Brownson, O’Toole, Shetty, et al., 2005

9. A change in philosophy Teacher knows all, makes decisions Didactive Teacher and patient learn and work together Collaborative

10. So what should we do? Tell the person Cover the basics Judge compliance Teachtothe person Medical Model Patient centered Ask the person Learnwiththe person Partnership approach Self- Management Education

11. Reframe our attitudes and behaviours • Educate for informed, self-directed decisions and problem-solving • Ask questions • Identify problems • Address concerns

12. Teaching • Deliberate interventions that involve sharing information and experiences to meet intended learner outcomes. Bastable, 2008

13. Teaching does not necessarily result in learning • When was the last time someone taught you? • Did you learn anything?

14. Learning • Active, ongoing process that results in changes in insight, behaviour, perception or motivation • Change may be positive or negative

15. Who is the Learner and Who is the Teacher?

17. Communication Skills

18. Communicating feelings or attitudes • Verbal 7% • Vocal 38% • Visual 55% Mehrabian, 1999 "What you do speaks so loudly that I cannot hear what you say." Ralph Waldo Emerson

19. Watch your body language! • Avoid looking like a school teacher!

20. Tips for plain speaking • Introduce your subject and state a purpose • Paint a picture, make it visual • Keep it organised • Move from simple to complex • Repetition is important – three times • Summarise • Evaluate Belton, Simpson, 2010

21. Tips for plain speaking • Use the active voice • The person should be the subject of the message • You may require medication to achieve target blood glucose levels • Vs • Some women may require medication to achieve target blood glucose levels

22. Communication • Open-ended question • At what time do you take your medication at home? • Closed question • Do you take your medication on time at home?

23. Develop listening skills • You can’t talk when you listen • Listen – don’t plan your response • Give the person your full attention • Paraphrase and ask if you heard correctly • So, you are saying…. • It sounds like….. • You are wondering if.... • I hear you saying….

24. Reflective listening The words the speaker says What the speaker means The words the listener hears How the listener interprets the words

25. The teaching process Assessment Planning Implementation Evaluation

26. Assessment • Goals • Establish trust • Determine priorities • Assess current health status, knowledge and self-care practices • Determine family role or other support • Identify available resources • Identify barriers to learning and self-management

27. There is a difference • Health professionals and women with GDM may have different opinions on what is important • Ask the woman what is important to her. Suhonen, Nenonen, Laukka, Valimaki, 2005 Timmins, 2005

28. Giving the diagnosis • Will my baby be ok? – 1st question often asked • Is this temporary? – 2nd question • Questions provide an opportunity for teaching • Must answer truthfully • Must convey importance of management during pregnancy for healthy outcome but also for future health of baby and mother • Risk of type 2 • Risk of obesity

29. Assessment Considerations • Should be non-threatening and non-judgemental • Consider the cultural and health beliefs of the person • Consider physical environment • Building rapport takes time

30. Planning • Develop together • What do you want to know? • What must you know? • Offer choices • Individual • Classes • Write learning objectives together

31. Planning • Objectives for each topic • Reviewed and updated regularly • Objectives should be • Measurable • Timely • Specific • Mutually agreed

32. Implementation • Communication is the key • Simple words • Open-ended questions • Encouragement • Positive feedback • Positive, caring attitude • Active listening • Repetition Belton, Simpson, 2010

33. Implementation • Determine priorities • Begin with the learner’s wishes • Most important topics first and last • Conducive environment • Simple to complex • Be specific • Repeat! Repeat! Repeat! Belton, Simpson, 2010

34. Evaluation • Integral part of programme management • Through all phases • Plans should include how and when to evaluate • Not an afterthought!

35. Evaluation • Clear description • Objectives that are • Measurable • Specific • Centered on the person • Timed

36. Evaluation • Individual evaluation • Have objectives been met? • Open-ended questions • How are skills used? • “Do you understand?” is not a valid question • Ask the person with diabetes to explain information to you – “teach-back” Belton, Simpson, 2010

37. 5 steps to self directed goal setting for behaviour change • Identify the problem • Explore feelings • Set goals • Make a plan • Evaluate the results Funnell, Anderson, 2004

38. What is the problem? • What do you find the easiest thing to manage in your diabetes? • What is the most difficult/worst thing about caring for your diabetes? • What are your greatest concerns/fears/ worries? • What makes this so hard for you? • Why is that happening? Funnell, Anderson, 2004

39. How do you feel? • What are your thoughts and feelings about? • How will you feel if this doesn’t change? • Do you feel ________ about _______? Funnell, Anderson, 2004

40. What do you want? • How does this need to change for you to feel better about it? • What will you gain/give-up? • What can you do? • What do you want to do? • On a scale of 1-10, how important is this? Funnell, Anderson, 2004

41. What will you do? • Can you/do you want to/will you? • What might work? • What has/hasn’t worked? • What do you need to do to get started? • What one step can you take this week? Funnell, Anderson, 2004

42. SMART behavioural goals • Eat three meals • I will eat three meals every day starting tomorrow. • I will walk more • I will walk for 10 minutes at my lunch hour for four days next week Funnell, Anderson, 2004

43. How did it work? • What did you learn? • What barriers did you encounter? • What support did you have? • What did you learn about yourself? • What would you do the same or differently next time? Funnell, Anderson, 2004

44. How to respond? • Avoid judgments • Avoid minimising negative experiences • Celebrate with - not for • Repeat process

45. Patient-Centered education • Interventions are more effective when • Tailored to individual preferences • Tailored to the person’s social/cultural environment • Actively engage the person in goal-setting • Incorporate coping skills • Provide follow-up support Piette, Weinberger, McPhee, 2000

46. Activity • Imagine you have just been told you have gestational diabetes • Think of three things you would need to change to manage your diabetes • Then ask yourself • What would be easiest for you? • What would be hardest?

47. Activity • What do you feel is supportive behaviour from close family, friends, or the health professional? • What is not supportive? • If you had gestational diabetes, what would you expect from the people listed above?

48. Summary • Be selective • Be specific • Prioritise • Categorise • Repeat • Reinforce

49. References (1 of 2) Anderson, R.M., Funnell, M.M., Arnold, M.S). Using the empowerment approach to help patients change behavior. In Anderson, B.J., Rubin, R.R., eds. Practical Psychology for Diabetes Clinicians, 2nd edition. Alexandria: American Diabetes Association; 2002. Anderson, R.M., Funnell, M.M. The Art of Empowerment: Stories and Strategies for Diabetes Educators. 2nd ed. Alexandria: American Diabetes Association; 2005. Bastable, S. Nurse as Educator. 3rd ed. Sudbury, MA: Jones & Bartlett Publishers; 2008. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient EducCouns 2002 (48) : 17787. Belton AB, Simpson N. The How To of Patient Education. 2nd Ed. Streetsville, ON: RJ & Associates; 2010. Brown SA. Interventions to promote diabetes self-management: State of the science. Diabetes Educ, 25(Suppl) 1999: 52–61. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diab. 32,(suppl 1); 2008 :S82-83. Duncan, I., Birkmeyer, C., Coughlin, S., Qijuan, (E)L., Sherr, D., & Boren, S. Assessing the value of diabetes education. The Diabetes Educator 2009; 35: 752-760. Fisher EB, Brownson CA, O’Toole ML, Shetty G et al. Ecological Approaches to Self-Management: The Case of Diabetes, Am J Public Health 2005; 95:1523–1535. Funnell MM, Anderson RM. Patient empowerment: A look back, a look ahead. Diabetes Educ, 2003; 29: 454-64. Funnell MM, Anderson RM, Arnold MS, Barr PA, Donnelly MB, Johnson PD, Taylor-Moon D, White NH. (1991). Empowerment: An idea whose time has come in diabetes patient education. Diabetes Educ1991; 17: 37-41. Funnell MM, Anderson RM. Empowerment and self-management education. Clinical Diabetes 2004 ; 22:123-127. 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. National Standards for Diabetes Self-management Education. Diabetes Care 2007; 30:1630-1637.

50. References (2 of 2) Gary, T.L., Genkinger, J.M., Guallar, E., Peyrot, M. & Brancati, F.L. Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes. The Diabetes Educator 2003;29:488-501. Harvey,J.N., Lawson,V. L.The importance of health belief models in determining self-care behaviour in diabetes, Diabetic Medicine 2009;26:5–13. International Diabetes Federation. Standards for Diabetes Education, 4th ed. Brussels: IDF; 2009. International Diabetes Federation. Diabetes Atlas, 3rd ed. Brussels: IDF; 2009. Knowles, M. The Adult Learner: a neglected species. Houston, Gulf Publishing Co; 1984. Mehrabian, A. In P. Bender. Secrets of Power Presentations. Webcom: Toronto The Achievement Group;1999. Norris, S.L., Lau, J., Smith, S.J., Schmid, C.H., Engelgau, M.M. Self-management education for adults with type 2 diabetes: A meta-analysis on the effect on glycemic control. Diabetes Care 2002;25:115971. Piette, J.D., Glasgow, R.E. Education and self-monitoring of blood glucose. In Gerstein HC, Haynes RB, eds. Evidence-based diabetes care. Hamilton: B.C. Decker, Inc. 2001. Piette, J.D., Weinberger, M., McPhee, S.J. The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial. Medical Care 2000;38:21830. Roter, D.L., Hall, J.A., Merisca, R., Nordstrom, B., Cretin, D., Svarstad, B. Effectiveness of interventions to improve patient compliance: A meta-analysis. Medical Care 1998;36:113861. Simmons, David. Personal barriers to diabetes care: Is it me, them or us? Diabetes Spectrum 2001:10-12. Skinner, T.C., Cradock, S., Arundel, F., Graham, W. Four theories and a philosophy: self-management education for individuals newly diagnosed with type 2 diabetes. Diabetes Spectrum 2003;16:75-80. Suhonen, R., Nenonen, H., Laukka, A., Valimaki, M. Patients’ informational needs and information received in hospital. J Clin Nursing 2005; 14(10):1167-76. Timmins, F. Contemporary issue in coronary care nursing. New York: Routledge; 2005. Von Kroff, M., Gruman, J., Schaefer, J., et al. Collaborative management of chronic illness. Ann Intern Med 1997;127(12):1097-102.