Diabetes Asia (1)

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Self-management education
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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

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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

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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
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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
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Self-management abilities

• The ability to self-manage is enhanced by
• Considering the individuals need(s)
• Teaching skills to optimise outcomes
• Facilitating behaviour change
• Providing emotional support

Von Kroff, Gruman, Schaefer, 1997 Fisher,
Brownson, OToole, Shetty, et al., 2005
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A change in philosophy
Teacher knows all, makes decisions
Didactive
Teacher and patient learn and work together
Collaborative
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So what should we do?
Tell the person Cover the basics Judge
compliance Teach to the person
Medical Model
Patient centered Ask the person Learn with the
person Partnership approach
Self- Management Education
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Reframe our attitudes and behaviours

• Educate for informed, self-directed decisions and
  problem-solving
• Ask questions
• Identify problems
• Address concerns

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Teaching

• Deliberate interventions that involve sharing
  information and experiences to meet intended
  learner outcomes.

Bastable, 2008
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Teaching does not necessarily result in learning

• When was the last time someone taught you?
• Did you learn anything?

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Learning

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

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• Who is the Learner and Who is the Teacher?

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(No Transcript)
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• Communication Skills

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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
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Watch your body language!

• Avoid looking like a school teacher!

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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

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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?

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Develop listening skills

• You cant talk when you listen
• Listen dont 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.

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Reflective listening
The words the speaker says
What the speaker means
The words the listener hears
How the listener interprets the words
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The teaching process

• Assessment
• Planning
• Implementation
• Evaluation

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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

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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
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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

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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

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Planning

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

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Planning

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

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Implementation

• Communication is the key
• Simple words
• Open-ended questions
• Encouragement
• Positive feedback
• Positive, caring attitude
• Active listening
• Repetition

Belton, Simpson, 2010
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Implementation

• Determine priorities
• Begin with the learners wishes
• Most important topics first and last
• Conducive environment
• Simple to complex
• Be specific
• Repeat! Repeat! Repeat!

Belton, Simpson, 2010
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Evaluation

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

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Evaluation

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

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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
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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
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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
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How do you feel?

• What are your thoughts and feelings about?
• How will you feel if this doesnt change?
• Do you feel ________ about _______?

Funnell, Anderson, 2004
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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
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What will you do?

• Can you/do you want to/will you?
• What might work?
• What has/hasnt worked?
• What do you need to do to get started?
• What one step can you take this week?

Funnell, Anderson, 2004
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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
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How to respond?

• Avoid judgments
• Avoid minimising negative experiences
• Celebrate with - not for
• Repeat process

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Patient-Centered education

• Interventions are more effective when
• Tailored to individual preferences
• Tailored to the persons 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?

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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?

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Summary

• Be selective
• Be specific
• Prioritise
• Categorise
• Repeat
• Reinforce

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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
  Educ Couns 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 5261.
• 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, OToole ML, Shetty G et
  al. Ecological Approaches to Self-Management The
  Case of Diabetes, Am J Public Health 2005
  9515231535.
• 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 Educ
  1991 17 37-41.
• Funnell MM, Anderson RM. Empowerment and
  self-management education. Clinical Diabetes 2004
  22123-127.
• 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 301630-1637.

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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
  200329488-501.
• Harvey, J.N., Lawson, V. L. The importance of
  health belief models in determining self-care
  behaviour in diabetes, Diabetic Medicine
  200926513.
• 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
  Group1999.
• 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
  2002251159?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 200038218?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 1998361138?61.
• Simmons, David. Personal barriers to diabetes
  care Is it me, them or us? Diabetes Spectrum
  200110-12.
• 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
  20031675-80.
• 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 1997127(12)1097-102.