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A diabetes education initiative for residential care home staff

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Marilyn Gallichan, MSc, RN, Cert Ed.

Diabetes Specialist Nurse, East Cornwall Hospital, Bodmin, Cornwall

This paper describes a district diabetes education programme for care home staff that was established through inter-agency and inter-professional collaboration, and has been running monthly since January 2000. Although there have been other initiatives in this field, we are, as far as we are aware, the only team to have developed a multidisciplinary, county-wide, rolling programme.
This paper describes a district diabetes education programme for care home staff that was established through inter-agency and inter-professional collaboration, and has been running monthly since January 2000. Although there have been other initiatives in this field, we are, as far as we are aware, the only team to have developed a multidisciplinary, county-wide, rolling programme.

The prevalence of known diabetes within residential homes is approximately 12% (Sinclair et al, 2001), but it is recognised that large numbers currently remain undiagnosed, so that this is likely to be a gross underestimate of the true prevalence. A more realistic estimate is that one in four residents has diabetes (Sinclair et al, 2001). Compared with other older people with diabetes, residents in institutionalised settings suffer a higher prevalence of macrovascular complications, tremendous susceptibility to infections, increased hospitalisation rates, and high levels of physical and cognitive disability (Sinclair et al, 1997a).

One of the important barriers to providing improved care for this large, highly vulnerable and often neglected group is the lack of appropriate training for care home staff (Sinclair et al, 1997b), who are mainly unqualified and inexperienced. Staff turnover is often high, and most managers have no budget for staff training.

The need to establish district diabetes education and training programmes for carers was endorsed by a 1999 British Diabetic Association (now Diabetes UK) report (BDA, 1999).

In the past, the diabetes specialist nurses in our district have delivered ad hoc educational presentations to care home staff at various locations, including the district diabetes centre and a number of residential homes. We sometimes initiated these ourselves, and on other occasions were invited by care home managers or by the joint inspection unit (county council and district health authority). However, our efforts were uncoordinated, and we realised that we were reaching only a very small proportion of the staff of the 282 residential homes scattered across our rural district. It was not a cost-effective use of our time to travel to a distant care home to deliver education to a handful of staff, but it was usually difficult for care home staff from rural areas to reach the diabetes centre.

In our health district, there is no diabetes specialist nurse (DSN) with special responsibility for older adults, but there are seven (whole-time equivalent) DSNs for adults, four employed by the community NHS trust and three by the acute services NHS trust, each providing a service to a different locality. DSNs from both trusts decided to embark upon a shared project to improve our educational provision for care homes.

Aims and objectives
We agreed that our aim should be to improve the health and well-being of residents with diabetes through an educational programme that would be:

- Ongoing: we wanted to replace our one-off ad hoc training sessions with a rolling programme of repeated sessions, planned at regular intervals

- Accessible: training should be equally accessible to staff from large or small institutions, whether in towns or villages

- County-wide

- Low cost

- Appropriate: the educational content would be basic, and designed specifically to meet the needs of participants

- Multidisciplinary: we agreed to seek the support of the dietetics and chiropody teams.

Development process
Collaboration with the joint inspection unit
The collaborative network for this project is shown in Figure 1. Our first step was to seek advice from the principal officer of the joint inspection unit whose remit is to promote and monitor standards in care homes and services. In one of its mailings to every residential home, the joint inspection unit included a letter outlining our plan to provide free diabetes education, and invited offers from managers of homes with accommodation suitable for training who would be willing to open their doors to staff from neighbouring homes.

The response was enthusiastic. Thirty-eight homes offered the use of their premises, and those who lacked the space to accommodate the training indicated their keenness to participate. We devised a programme, commencing in January 2000, in which each DSN would be responsible for arranging one or two two-hour sessions within his or her locality per year. This would spread the training evenly across the whole district and distribute sessions regularly throughout the year. The joint inspection unit circulated this schedule to all residential homes, and applicants were invited to book their place by contacting the training venue directly.

Involvement of the multidisciplinary team in planning and preparation At a multidisciplinary meeting of diabetes care professionals, the DSNs' plan was enthusiastically embraced by the dietitians and chiropodists, who were keen to assist both with the development of an information pack and with delivery of the training itself.

Because of the need to supply local information and the prohibitive cost of providing educational literature published by the British Diabetic Association at that time, we compiled an in-house information folder. This included a general introduction, together with sections on diet and foot care, which were written by the district dietitians and a regional group of chiropodists. At first, the loose-leaf pages of the information pack were photocopied and presented in a plastic folder supplied by a pharmaceutical company. However, we have since received funding from the health authority's health promotion department to publish sufficient bound copies for distribution of one to each residential home. The Diabetes UK guide for managers and staff in care homes is now available free of charge (Diabetes UK, 2000).

Together we developed a teaching plan, so that the programme would be standardised across the district and, as suggested in feedback from the participants of previous training sessions, we devised a basic diabetes knowledge quiz to suit the specific requirements of this group.

This multiple-choice quiz is a teaching and assessment tool, which we have modified several times to reduce ambiguities and to clarify its principle teaching messages. We also printed answer sheets, so that each participant would be able to take home a copy of the correct answers. Box 1 provides examples of quiz questions.

The training sessions
Our learning objectives are that, following this training, staff should be able to:

- List, recognise and report the symptoms of high blood sugar

- Recognise and treat hypoglycaemia

- Offer an appropriate diet for residents with diabetes

- Offer suitable foods and drinks when residents with diabetes are unwell

- Provide basic foot care

- Appreciate the importance of regular health checks, especially eye checks

- Know when and where to seek professional help.

Training takes place at a different residential home each month, for about 20 care staff from 5-10 neighbouring homes. The facilitator is the DSN from the locality, supported by a dietitian and a chiropodist. To encourage participation by the learners, the atmosphere is as informal as possible. The programme covers the main topics outlined in the information pack, and teaching methods include group work, questions and answers, and explanations from the teachers, supported by a small number of projected slides.

We use the quiz in a variety of ways, according to the number of learners, the room layout, the time available and the preferences of the teacher. It is not used as a test of an individual's knowledge, as this could be perceived as threatening. However, using it for group work at the beginning of the training session (while the teacher sets up the portable projector and screen), focuses attention, and provides an indication of the learners' baseline knowledge. Used at the end of the session, it serves as a summary of the main teaching messages, and provides an indication of the knowledge gained.

In the first two years of our programme, staff from more than 40% of the county's residential homes have participated in this training. Two hundred-and-seven care staff from 71 residential homes attended during 2000 and 157 from 67 homes in 2001, including staff from 46 homes not represented in the first year (Table 1).

Knowledge Participants' quiz answers have shown that, before training, most carers are aware that diabetes is a condition in which there is too much sugar in the blood, and that people with diabetes need regular meals and snacks. However, they have little awareness of the complications of diabetes and their own role in reducing the risks, and have confused ideas about hypoglycaemia and hyperglycaemia. Most carers are unsure about suitable foods and drinks, especially during illness, and many believe that special 'diabetic foods' are essential.

The first time the quiz was used at the beginning and end of the same training session proved a valuable learning experience for the facilitators. Although there were significantly more correct answers after the training, the responses showed that there was still some confusion concerning the management of 'sick days', and hypoglycaemia and its treatment. Several respondents thought that an insulin injection was a treatment for hypoglycaemia. We realised that we had been too ambitious, and attempted to deliver too much information in a short space of time. In subsequent sessions we have aimed to simplify the teaching to increase the emphasis on the principle messages.

Evaluation by participants Participants are asked to complete an evaluation form at the end of the training sessions. This information is used, together with analysis of their quiz answers, as a basis for reflective discussion among the teachers, allowing continuous modification and development of our programme. These forms have demonstrated that participants find the training helpful, relevant and enjoyable.

They reported that the most helpful aspects of the training were:

- Dietary advice (the most common response)

- Written information

- The quiz

- The way things were explained.

Most replies reported no unhelpful aspects, but one participant commented that the talks seemed rushed. Extending the session, and simplifying our talks, have helped to create a more relaxed, unhurried atmosphere. Several people responded that they felt some of the foot-care advice was either too basic or not relevant. This has been addressed by changing the format of the foot-care component to include slides of common foot problems and discussion of appropriate action by carers.

When replying to the question 'What would you have liked done differently?' the most common response in 2000 was that participants felt the two-hour training session was too short. In the second year we extended the sessions by half an hour. One or two participants at each session have stated that they would have liked training in blood glucose monitoring. However, it is not possible to incorporate a practical session on blood glucose monitoring within our current time schedule, or within such a large group. We therefore encourage care home staff to liaise with local district nursing teams who may be able to organise glucose monitoring workshops for a small group.

Eight individuals (less than 0.5%) stated that they would have liked more in-depth explanations of the physiology of diabetes, but we have chosen not to modify our programme in this respect because we feel it is important to keep the information as clear and simple as possible, to ensure that the principle messages are understood by as many as possible.

We had originally invited care staff to contact their chosen training venue to book their place, but this booking method proved impossible to implement, as the homes' telephones were frequently manned by staff with no knowledge of the planned training sessions. Central bookings made via the district diabetes centre have proved a much more reliable method. In 2000 we found that attendance was less good when bookings were made too far in advance. In 2001 we advertised the training more frequently and, as an experiment, introduced a £5 fee per participant to help with administration costs, and to serve as an incentive not to forget to attend. Interestingly, we have found that the £5 fee made no difference. Attendance was still poor unless the homes received a telephone reminder a few days before the session.

We have explored the possibility of seeking National Vocational Qualification (NVQ) accreditation for this diabetes training pro-gramme but, unfortunately, this would require extensive and prohibitively time-consuming individual assessment of participants. This would very severely restrict the numbers of places we could offer, and would detract from our aim of providing an easily accessible county-wide training programme.

This initiative has been received with great enthusiasm both by diabetes care professionals and by the care home staff.

Participants' post-training evaluation demonstrates an increased awareness of the special needs of elderly residents with diabetes, which we hope will be reflected in improved care and a better quality of life for this large group of vulnerable people. With teamwork and collaboration, this service development could be replicated at very low cost in other areas, using existing resources.

Useful contact
Diabetes UK (formerly British Diabetic Association), 10 Queen Anne Street, London W1M 0BD. Tel: 020-7323 1531. Email: Website:

British Diabetic Association. (1999) Guidelines of Practice for Residents with Diabetes in Care Homes: A British Diabetic Association report. London: BDA (now Diabetes UK). Also available at: www.

Diabetes UK. (2000) Diabetes Care Today: A guide for managers and staff working in residential and nursing homes. London: Diabetes UK. Also available at: www.

Sinclair, A.J., Allard, I., Bayer, A.J. (1997a) Observations of diabetes care in long-term institutional settings with measures of cognitive function and dependency. Diabetes Care 20: 5, 778-784.

Sinclair, A.J., Turnbull, C.J., Croxson, S.C.M. (1997b) Document of diabetes care for residential and nursing homes. Postgraduate Medical Journal 73: 864, 611-612.

Sinclair, A.J., Croxson, S.C.M., Gadsby, R. et al (2001) Prevalence of diabetes in care home residents. Diabetes Care 24: 6, 1066-1068.
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