Training Health Care Professionals

Diabetes education designed to empower patients requires appropriate attitudes, knowledge, educational and counselling skills on the part of diabetes educators. This is especially true when diabetes patient education is directed at helping patients increase their self-awareness of their own values, needs and goals regarding diabetes care.

The MDRTC developed and evaluated a professional education programme for diabetes educators designed to enable them to apply the empowerment approach in their own settings. The programme was an intensive 3-day workshop, limited to 12 participants, each of whom was videotaped practising empowerment-based patient education and counselling skills each day. Each of the participants reviewed his/her videotapes each day as well. The programme was designed to provide participants with both the theoretical framework and the hands-on counselling skills necessary to apply the empowerment approach with a variety of patients. The evaluation of the programme demonstrated its efficacy in terms of changing attitudes, simulated and actual counselling skills, determined by blind ratings of audio-tapes with real patients13.

At LUCD, Stockholm, we have organized workshops for health professionals, lasting 2.5 days, with the content, methods and structure of the workshops based on the work at MDRTC. A four-step model of patient education is presented and trained. The four steps aim at supporting the patient in: (a) identifying and exploring his/her problem; (b) exploring feelings and values regarding diabetes, self-care behaviour or other problems; (c) identifying goals and behaviours leading to these goals; and (d) committing to and planning for action. The main task and responsibility of the educator in this model is to help the person with diabetes to explore and reflect upon his/her thoughts, feelings and actions; and further, to make sure that decisions about goals and behaviour changes are made by the patient him/herself and are based on a genuine wish for change.

Some structural issues and rules in these workshops are important for the participants to get a safe environment where they can experiment with new behaviours, and a deeper learning experience:

• The small format—no more than 12 participants.

• Video-recording and viewing in groups of four.

• 'Real play', as opposed to role play—when in the role of a patient, the participant brings up a problem of his/her own.

• A facilitator in each small group who is not allowed to criticize or give any 'right' answer, but should help participants reflect on their own behaviour and the motives behind it.

Workshops were evaluated using the Diabetes Attitude Scale (DAS)20, administered before the workshop, immediately afterwards and at follow-up. At the same points in time participants gave their responses to six statements made by people with diabetes—'What would be your first response to a patient who says: ...?'. At each stage these were currently analysed according to whether they included words or statements which were judgemental or prescribing (minus) and/or whether they encouraged the patient to explore problems or feelings (plus).

Results from these evaluations indicated that participants felt patients should have more autonomy with regard to making their own choices regarding diabetes treatment and self-care (Table 4.1). The answers to the statements from patients showed a strong move from judgemental, prescribing or neutral statements towards statements that encouraged the patient to explore and reflect upon his/her problems or feelings. Responses that

Table 4.1. Change in patient autonomy beliefs as assessed by the Diabetes

Attitude Scale


Agreement pre-workshop

Agreement post-workshop


Individuals with diabetes should 87 93 Non-significant be taught to choose their own management options (e.g. type of meal planning, type of glucose monitoring, type of insulin regimen)

Decisions about managing 56 68 Non-significant diabetes should be made by the physician

People with diabetes have the 81 93 0.035

right to decide how aggressively they will work to control their blood glucose

The important decisions 76 91 0.011

regarding daily diabetes care should be made by the individual with diabetes

People with diabetes should 70 91 0.008

choose their own goals for diabetes treatment

encourage the patient to explore the issue and/or express understanding and empathy were given +1 point. Responses that were irrelevant to the patient's statement or missing were given a zero. If more than two of the six statements were not responded to, the whole case was coded as missing. Finally, responses expressing information or advice not asked for, blame or praise, or efforts to hand the patient over to someone else, were given the value —1. The coding was done by the author and a co-worker not involved in the project, independently and blind regarding whether before or after workshop. Disagreements (a few) were discussed until consensus was reached. Before the workshop the mean sum of points was 0.6 ± 3.2 (M ± SD). Immediately afterwards this sum had increased to 3.0 ± 2.9 (M ± SD), p = 0.001. Table 4.2 shows some examples of responses from participants in the workshop and how they were coded.

In the last hour of the workshop, the participants are asked to give their comments on what they have experienced during the workshop. At a reunion after about 3 months they are asked to comment on experiences from having tried to apply the model in everyday work. A number of challenging and rewarding experiences have been reported which are fully in line with what has earlier been reported from the MDRTC:

Facilitating Self-care Through Empowerment 79

Table 4.2. Examples of responses to patient statements and how they were coded

Positive response (+1)

'I will never start taking insulin' 'What is stopping you?' 'Can you tell me why?'

'I hardly eat anything, and I still don't lose weight' 'What do you think is the reason for that?'

'I do hate my diabetes' 'Tell me how you feel'

Neutral response (0)

'Many patients do' 'For how long did you have diabetes?'

'What time of the day do you eat most?'

'I'm sure there are others who feel like you do'

Negative response (—1)

'Why not, you would feel much better and it would be easier to control your blood sugar'

'Sounds strange, perhaps you should document everything you eat for a week?'

'I don't like to hear that'

• Difficulties in exploring patients' feelings and values: the educator does not feel comfortable in asking questions in this area and/or is afraid to 'open Pandora's box' (What if I initiate something that I'm not competent to take care of?').

• Difficulties in holding back one's urge to give advice. In the traditional role as patient educator, much of the work has focused on finding solutions for the patient. Many participants feel that by 'just' helping the patient to find his/her own solutions, they have not done a good job. Also, when the patient's choice is not what the educator think is the 'best one', an internal conflict can be experienced which, if too strong, threatens the new behaviour.

• Patients prefer a passive role. Traditionally, the educator has been the active, giving, partner and the patient the passive, receiving, part in the encounter. Even if this has not been fruitful, resistance to change can be strong.

• Reported rewarding aspects of using the model are a greater capacity to see what is one's own responsibility and what is the responsibility of the patient; a greater capacity to hold back one's own ideas and wait for the patient to find his own solutions; and also less time spent on motivating or persuading patients.

In the UK, empowerment workshops for health care professionals— predominantly nurses based in primary and secondary care—have been run by a group of nurses (Sue Cradock, Jil Rodgers, Florence Brown and Rosie Walker), for 2 years and supported by a colleague from the MDRTC and LUCD. Based on the model already described, the workshops have two components. First, before actually attending the workshops, participants are asked to mimic having diabetes for a week. Then they attend a 2 day workshop, involving a brief lecture, group discussions and 'real play' rehearsal of an empowerment consultation, which was videotaped and discussed in the small groups. These workshops have been evaluated using the dame approach as in the USA and Sweden. Participants were asked to complete the Diabetes Attitude Scale before mimicking diabetes, immediately before the workshop and at the end of the workshop. In addition, at the start and at the end of the workshop, participants were asked to indicate their response to hypothetical patient statements (e.g. see Table 4.2).

One of the most emotional and challenging experiences of the workshop, as perceived by the facilitators, is the mimicking of diabetes. Participants were asked to follow a prescribed diabetic of lifestyle, a fixed diet, two injections a day, four blood glucose test a day and an exercise programme. At the beginning of the workshop participants are encouraged to share their experiences of living with diabetes for a week. At these workshops we have been constantly struck by the powerful emotions this experience generates:

• 'I felt really guilty, like I could not stick to this for a week, let alone a lifetime'.

• 'I felt angry at the programme organizers for putting me through this'.

• 'It got in the way of everything, and my husband wanted to know when it would be over'.

• 'It was not what I tell my patients to do, so I followed my own regimen'.

• 'I was embarrassed to tell people what I was doing'.

• 'I did not need to do it, I know about diabetes and I inject myself all the time to show patients how to do it'.

These responses highlight just some of the emotions and responses brought out by this discussion. They confirmed in our minds, and those of participants, the mass of emotions generated by living with diabetes, if only for a week. The value of this experience for any health care professional, in recognizing the power of the emotional experience of diabetes care, cannot be understated.

These experiences of life with diabetes, and the group work undertaken in the workshops, led to a number of changes in participants' attitudes. Using repeated measures analysis of variance, compared to their initial responses on the Diabetes Attitude Scale, at the end of the workshop participants reported a greater need for specialist training for health care professionals caring for people with diabetes (F = 4.32; df = 2; p < 0.02). Similarly, participants reported a stronger belief in the need for patients to have more autonomy (F = 5.40; df = 2; p < 0.007). Both of these effects appear to a result of the combination of mimicking diabetes and the workshop, see Figures 4.1 and 4.2. Participants also reported a more positive attitude to poor self-care at the end of the workshop (F = 9.08; df = 2; p < 0.001) than before mimicking diabetes. However, this effect appeared to be influenced largely by the workshop (t = —3.65; df = 37; p < 0.001) and not by mimicking diabetes (see Figure 4.3).

Figure 4.1. Change in need for specialist training
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