StEP Structured Education for Pumps

1. StEPStructured Education for Pumps Fiona Campbell and Carole Gelder On behalf of the Childrens Diabetes Team at Leeds July 2008

2. Why we developed structured education • Started MDI and Pump service in 2002 • Existing resources not relevant • Approach varied between team members • When busy or stress we became more didactic • Resources available were adult focussed • Resources and approach varied with different pumps • Growing evidence for intensive management, specific training for CSII and structured education meeting DH criteria

3. Literature to support developing structured education for pumps • NSF Diabetes (2001) Structured education for all • HTA (2001) Psycho-educational interventions are most effective • NICE 60 (2003) Rec for Structured education BUT did not cover CYP • NICE 57(2003) Rec specific training in CSII for individuals and HCP’s • DH (2005) Criteria for Structured Education • Winckley et al (2006) HbA1c <0.5% if psych interventions • DH (2007) Engage & empower beh change, prob solve, pract skills • ISPAD (2007/08) Beh mod/ counselling tech/ age appropriate

4. Our progress with meeting DH criteria • Philosophy • Leeds Team AND DEN (adult) philosophy • Honest, curious, respect • Learning theories:- • Bandura’s Social learning theory, • Empowerment approach • Written curriculum – • scripted so whole team involved and consistent • Different teaching methods • Written and visual • Trained educators – • Motivational Interviewing • Group facilitation • Deeper understanding of child development • Quality assured – • Self and informal peer reflection (No external) • Audit - • Numbers, HbA1c, Evaluation, Pre & post Satisfaction and Confidence

5. Childrens Diabetes Team Philosophy- 2005 • The child, teenager and family will be cared for in an individualised and holistic way. • The childrens diabetes team will follow a policy of “Family Centred Care” and each child and teenager will have their own named nurse. • The team will offer the best up to date treatment based on research, which will be delivered to the highest standard. • We recognise the special and changing needs of children and teenagers with diabetes. • We will work in partnership with the family. • The team will empower the child, teenager and family to make informed choices and endeavour to gain their trust by giving honest information and are fully aware of the importance of the parents influence in this process. • The team will aim to support self management through provision of sufficient knowledge and skills to enable individuals to take control of their own condition and to integrate diabetes into their daily lives. • The team recognise that self management in children and teenagers is a shared responsibility that can change daily as well as over time and we will support families to manage this. • We will strive to create a relaxed atmosphere and nurture friendly professional relationships. • Whenever needed we will act as the childs advocate. • We will maintain confidentiality • We acknowledge the child, teenager and families rights to have feelings and opinions and we will encourage their expression by fostering relationships in which they feel comfortable to do this, by listening, giving them time and providing appropriate support. • We respect the value and diversity of all children and families.

6. DEN Philosophy • Type 1 diabetes is a complex condition, which is affected by, and can affect almost all daily activity. Most day to day decisions (eg the taking of insulin, food choices, activity levels), which affect blood glucose levels, are made by the person with diabetes. As such, people with diabetes are responsible for managing their condition (unless due to mental disability they are unable to make informed decisions). • People with type 1 diabetes require knowledge and skills to enable them to understand the effects of lifestyle on their diabetes and vice versa, and how they can manipulate their treatment to enable them to lead the lifestyle of their choice while maintaining stable blood glucose control. They also need information on the consequences of poor control of their diabetes so they can make informed choices in setting appropriate personal goals for the management of their diabetes • The role of the health care professional is to provide support to people with type 1 diabetes to enable them to develop realistic short term and long-term management goals, and to help them acquire the knowledge and skills necessary to achieve those goals.

7. Learning Theories –how the intervention is supposed to work • Bandura’s Social learning theory • Perceived Self efficacy – used most consistently throughout the paediatric literature • Thoughts, feelings and beliefs drive behaviour • Skills based training – nurture mastery • Role modelling –imitation more likely if more similarities and consistency

8. Principles of Empowerment Facilitates exploration of own situation Identify own actions and agree specific action Info given in response to identified need No judgement or blame We shouldn’t give advice, or persuade We should use individuals experience rather than our own Be interactive, use problem solving, Individual gains more control

9. Empowerment and SMBG • How often do you test? • How will you remember when you are at home or away from home? • Do you want family or friends to remind you? • How will you test in public? • How will you respond if others ask what you are doing? • How will you feel if your test is not what you expected? • How will you react? • How will it affect your self care?

10. Health related behaviour change Miller & Rollnick • Motivational interviewing -knowledge is not enough to change behaviour • Focus on shared agendas, solutions and strengths • Good and bad things, how it fits into life, what they have tried – be curious, create discrepancy • Rather than advice giving and persuasive tactics • How important is it to change? • How confident are you? • YP in groups to help generate new solutions • Attitude and qualities of HCP are more important than the technique • acceptance , respect, curiosity, honesty

11. Developmental StagePiaget, Erikson, Snoek and Skinner • Psycho-educational interventions must reflect each stage of development to be effective • 0-7 Parents are primary carers and decision makers • <3yr age range most effective • 8-10yrs; 11-13; 14-16 Acceptance by peers • Parents in separate but concurrent session • Interdependence rather than independence

12. What is important for Children 8-11yrs • Develop a sense of belonging and self esteem through involvement with and acceptance by peers • Feeling different is a major concern (injections BG test, food, sleepovers etc more difficult) • Rely heavily on school support • Variable attendance can impact on educational attainment

13. Adolescent programmes Snoek and Skinner 2005 • 11-14yrs and 14-17yrs are different • 11-14 Ltd abstract thought and developing peer identity • 14-17 Abstract thinking is developing and stronger peer identity • Family based intervention in younger age • More individual behaviour change in older age • YP do not believe they are being listened to

14. Written Curriculum • Theory driven and evidence based • Aims and learning outcomes • Flexible (age and culture) • Dynamic energy and motivation • Visual and written resources • Use of different teaching methods • Person centred :- • “Tell me I forget, show me I remember, involve me and I understand”

15. Example of curriculum headings-for each session • Specific aspects of theory • Learning outcomes • Facilitator activity • Participant activity • Resources

16. Acknowledgements to :- Philip, Frances, Wendy, Julie, Jane, Carol, Caroline & Mel • Carole.gelder@leedsth.nhs.uk • Frances.robson@leedsth.nhs.uk • Fiona.campbell@leedsth.nhs.uk • www.diabetes-education.net • www.leedsth.nhs.uk/sites/diabetes