The Uk Story

In the UK, since the early 1970s, diabetes education strove to teach people the principles of how to do the 'right things' to get their diabetes 'right'. This was based on the assumption that if people performed the 'right' number of blood tests, ate the 'right' diet, took the 'right' amount of insulin and undertook the 'right' amount of exercise, that good diabetes control would ensue. Diabetes education was therefore directed towards getting people to do the right tasks, in the right amount at the right time. The job of providing this diabetes education initially formed the basis of a major component of the diabetes nurse specialist role. The role of the diabetes nurse was to teach people how to be skilled at undertaking these tasks.

Until the 1970s there was limited technology to aid the health care professionals in determining the how, what, when and where of these diabetes management tasks. This changed with the development of self-blood glucose monitoring and the recognition that people could learn to adjust their own insulin dosage. These technological advances supported this model of diabetes education, as health care professionals now saw good control as feasible and achievable by everyone. However, during the 1980s diabetes health care professionals began to experience the outcome of this approach to diabetes education. Rather than basking in the glow of unremitting success, health care professionals kept finding out what did not work. This led to increasing levels of frustration for everyone involved in diabetes care, with everyone blaming themselves and everyone else for the 'failures' of diabetes care:

Patients 'Why can't I get this right?'; 'I do everything you tell me and it's still no better'

Nurses 'What am I doing wrong?'; 'What else don't I know?'; 'This patient just can't learn this'; 'This patient has got difficult diabetes'; 'I am not a good enough teacher' Medics 'If only they would comply?'; 'This patient isn't intelligent enough?'; 'This patient has brittle diabetes'

As a result, the training of diabetes clinicians focused on how to be a better teacher, how to be better provider of information. The fault was being squarely laid at the feet of teaching methodology, i.e. health care professionals were not enabling successful transfer of knowledge and skills to persons with diabetes. Where patients were clearly able to demonstrate expert knowledge and diabetes management skills (doing the right thing), they were then deemed to be poorly motivated and still not getting it 'right'. These lessons led to the development of innovative ways of delivering diabetes education, such as group work, development of audio-visual teaching materials and computer-based knowledge assessment tools. Diabetes specialists acknowledged that this improved educational method was successful for some individuals, but not the majority.

However, the 1990s has seen a shift to a consideration of the psychological and social aspects of diabetes. It has become increasingly acknowledged that these factors have a significant, but unclear role in determining the outcomes of diabetes education, care and management. This led to the appearance of the counselling model to diabetes care, as advocated by Shillitoe17 and the development of the still popular Northampton Diabetes Counselling Course. Despite the obvious benefits of using counselling skills to enable health care professionals to gain insight into the perceptions of people with diabetes, a new dilemma was created for many. How could this approach be incorporated into everyday diabetes health care? A chance meeting with members of the LUCD team led to discussion of these issues, as a result of which two nurses (Sue Cradock and Jil Rodgers) sought out the funding to attend the empowerment workshops in Stockholm.

The experience of participating in the workshop taught us two key things. First, that counselling skills could be integrated into clinical care. The model advocated at this workshop made use of the counselling skills to enable patients to learn about themselves and their diabetes and potentially to enable behaviour change. Second, this model enabled the diabetes clinicians to explore the emotional aspects of diabetes management. Experience tells us that emotions are probably the biggest motivator of change, the biggest barrier to change and often the biggest reward of change. However, discussing emotional issues is often the most difficult part of the process for medically-trained health care professionals. Health care professionals have been disempowered to explore the emotional aspects of diabetes. They have been encouraged to believe that discussing emotional issues with patients would lead to 'opening a can of worms'. Once the can is open, and the patient is freely expressing his/her emotions, it has been has assumed that, as health care professionals lack the skills to 'heal or solve' these emotional issues, they may harm the patient by exploring them. This is clearly not the case—just having the opportunity to discuss issues in a safe, honest, non-judgemental environment is experienced as beneficial by the patient.

Experience of using this approach in clinical practice convinced us of two things. This approach allowed us to trust our developing belief that there was no need to blame anyone for failure. In fact that act of blaming gets in the way of helping, and the concept of failure is just another barrier to overcome. It also became apparent that this model can be incorporated into clinical care, resulting in the consultation becoming:

• A more positive experience for the patient.

• A more positive experience for the health care professional.

• More focused on active problem solving.

• More likely to result in meaningful and lasting behaviour change.

• More likely to result in improved emotional well-being for the patient.

• Reductions in the level of frustration experienced by the health care professional.

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