Introduction

The day-to-day management of diabetes includes appropriate use of medication, monitoring of blood or urine glucose levels and lifestyle issues such as exercise and diet. These self-care behaviours are all determined by the patient. Effectiveness of treatment will therefore be limited by the patient's actions.

The current culture of patient training tends to be strongly influenced by the medical model, an issue that was first raised in dietetic training in 1987. Evidence highlighted dissatisfaction with this method and non-compliance (1). This predominant style is still often used by both dietitians and other health professionals to advise patients on diet. This model assumes that patients are ready and motivated to change because a credible professional has told them to. The traditional educational strategies employed have relied on the health professional's perception of what the patient with diabetes needs to know. A didactic process of persuasion is then entered into, in which the health professional attempts to persuade the patient to change his or her diet. The conversation is one-sided and based on information gathering to help the health care professional determine what the patient needs to be told to do. In practice this method of communication is only likely to work for a small number of patients, and this type of expert-led, confrontational counselling style could lead to resistance and a poor outcome (2,3).

Information overload is another common practice, and relates to the fear that the patient may not attend another session and hence must be given all the information necessary in case this occurs. By doing this however there is a real danger of overloading the patient with information and thus demotivating them with the sheer volume of change that is required (4). It also carries the risk that the health care professional's own health beliefs and priorities will be involved in the changes dictated. This is unrealistic and counterproductive as patients' concerns are very different from those of health professionals, and unless we take these into account we will fail to meet their needs (5). The end result is frustration both on the part of the health care professional, who labels the patient as non-compliant or a failure, and on the part of the patient, who feels their needs are not being met (6).

The way we deliver our message therefore needs to change. If something is not working it is clearly ineffective to continue to practise in the same way. Most studies tend to review knowledge as an outcome, but there is ample evidence to indicate that although essential, knowledge alone is not sufficient to change behaviour or establish healthy eating (2,7-9). The information-giving and instructional aspects of dietary counselling must therefore be extended to incorporate motivational and behavioural components (9,10).

Reviews of available data on educational and psychosocial interventions for adults with diabetes, and other chronic illnesses, indicate that a 'patient-centred' approach is more effective in enhancing patient communication and their subsequent health (11-13). For example, interventions designed to increase patient participation and autonomy have resulted in improvements in self-care behaviour and glycosolated haemoglobin (HbA1c) (14,15). Some studies however fail to clearly define what is meant by 'patient-centredness'. In diabetes care we can take the definition of 'patient-centredness' to mean a process that involves the health care professional being open and responsive to the concerns and needs of patients, including needs for information and participation in decision making (16). This definition encompasses the basis of the majority of counselling models currently used in behaviour change for diabetes care.

It has long been recognised that changing behaviour takes more than a directive approach of telling people what to do. Whole person care is important, and this involves identifying psychological issues which may influence how patients respond to the disease and its treatment. By identifying these issues we can help patients to find ways of coping more effectively with their diabetes. The ultimate aim is to improve the level of knowledge and health locus of control of the patient, as well as trying to help develop a positive attitude to active self-care (17). Not everyone with diabetes will require formal counselling, but exposure to the theories and ideas behind counselling can help everyday diabetes education (18,19).

To practise, we require a range of skills, which involve being able to give information where appropriate, teaching, counselling and advising (20). To practise effectively we must also review our basic skills in communication,

Establish rapport

Set agenda

Single behaviour

Assess importance and confidence (and readiness)

Build confidence

Figure 3.1 Key stages in the consultation Reproduced from Rollnick etal. (21), p.12.

although this would appear to be fundamental as it underpins the majority of the work that we do.

Key stages in the consultation are outlined in Figure 3.1.

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