Giving people with diabetes greater control over their treatment empowers them and can improve outcomes. A study of…
VOL: 103, ISSUE: 09, PAGE NO: 28
Jill Hill, BSc, RGN, is diabetes nurse consultant at Birmingham East and North PCT
Giving people with diabetes greater control over their treatment empowers them and can improve outcomes. A study of patients with type 2 diabetes starting insulin found that those who titrated their own insulin experienced significantly better glycaemic control than those whose titration was physician-controlled (Davies et al, 2005).
Structured patient education (SPE) supports self-management and is essential to achieve standard 3 of the National Service Framework (NSF) for diabetes, which advocates supporting people in managing their diabetes and engaging them in decision-making (DH, 2001). NICE guidance recommends that: ‘Structured patient education is made available to all people with diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need’ (NICE, 2003).
The Department of Health directed PCTs to provide funds for patients for this from January 2006 (NDST, 2005a) and the Patient Education Working Group (PEWG), a joint initiative between the DH and Diabetes UK (DUK), was set up in May 2004 to support development and implementation of structured patient education (DUK and DH, 2005).
RECOMMENDATIONS ON DESIGN
NICE’s review of education programmes found insufficient evidence to recommend a specific type or frequency of sessions because of the practical limitation of the studies, small numbers of participants and high drop-out rates. However, it emphasised that programmes should uphold the following principles of good practice:
- Reflect established principles of adult learning;
- Be provided by an appropriately trained multidisciplinary team, including a diabetes specialist nurse or practice nurse with experience in diabetes, and input from other disciplines such as podiatry;
- Be accessible to the broadest range of people taking into account culture, ethnicity, disability and geographical issues;
- Use a variety of techniques to promote active learning.
The only structured programme NICE recommended was Dose Adjustment for Normal Eating (DAFNE) for people with type 1 diabetes. It also found that education at the time of diagnosis varied enormously in length, content and style and that the Expert Patient Programme complemented but was not an alternative to specific diabetes education because it was for people with a variety of long-term conditions and focused on generic skills, such as developing confidence to access services (NICE, 2003).
The Scottish Executive is funding training for professionals in Scotland who are delivering education programmes to people with diabetes. It is also developing an effective portal for patient and carer information, improving patient access to their own electronic medical records and developing a patient-led buddy service.
A PEWG report states that local diabetes teams’ programmes should: involve a structured, written curriculum; be run by trained educators; be quality assured; and be audited. The report says that the curriculum should be evidence-based, flexible, dynamic, person-centred and able to use different teaching media. The programme should be reviewed by trained, independent assessors who assess against agreed criteria, including course structure, process, content, use of materials and evaluation. Outcomes from the programme must be audited and might include quality of life, patient experience and level of self-management achieved following the course (DUK et al, 2006). The report upholds DUK’s guidance on topics that education programmes should cover:
- The nature of diabetes, including the significance and implications of diagnosis, aims and types of treatment, the relationship between blood glucose, diet and physical activity, and consequences of poor control, complications and how to prevent them;
- Day-to-day management of diabetes, including healthy lifestyle, foot care, oral hygiene, self-monitoring, storing insulin and adjusting doses and rotating injection sites;
- Specific issues such as hypoglycaemia, illness, immunisation and pregnancy;
- Living with diabetes, including the importance of personal identification, driving, holidays, employment, accessing benefits and making the best use of healthcare services;
- Sick-day rules, including maintaining medication, replacing food with carbohydrate drinks if necessary, testing urine and/or blood glucose more frequently and when to contact the doctor (DUK, 2005).
STRUCTURED PATIENT EDUCATION
PCTs can either adopt national structured patient education programmes, such as DAFNE and DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed), or refine or develop their own local programme.
DAFNE has been developed over 20 years and teaches people with type 1 diabetes during a five-day programme to adjust insulin to suit their choice of food, rather than adjusting their diet to insulin doses. DESMOND is a new programme, designed to meet NICE criteria. It provides six hours of structured education for groups of 6-10 people with type 2 diabetes. Until recently, much of the focus has been on education at diagnosis but both DAFNE and DESMOND are developing modules for ongoing education (NDST, 2005a).
The diabetes X-PERT programme for people with type 2 diabetes was developed locally and is based on theories of empowerment and discovery learning. It has been shown to impact positively on clinical, lifestyle and psychosocial outcomes (NDST, 2005a). Local programmes for adults with type 1 diabetes include Bournemouth Type 1 Intensive Education (BERTIE) programme 3 which, when audited, showed significant improvement in clinical and psychological outcomes (DUK and DH, 2005).
PCTs are not obliged to adopt national programmes provided local programmes meet NICE criteria for structured education and are effective. DESMOND is as yet unproven, so local teams may prefer to refine existing programmes, particularly if people are emotionally attached because they helped develop them. Establishing a high-quality programme can take three years or more, so starting from scratch or adapting an existing programme is not always cost-effective (DUK and DH, 2005).
IMPLEMENTING A PROGRAMME
Implementation of a structured education programme will place many local teams under financial pressure. A downloadable document from the National Diabetes Support Team (NDST) contains points that can be used to compile a business case to secure funding (NDST, 2005b). Responsibilities should be clearly defined and, once teams are established, they should review what is in place and where the gaps in service occur.
The PEWG report identifies gaps in education provision, such as children/adolescents whose educational needs change as they grow, insulin pump therapy, pregnancy, carers and ethnic groups. Group sessions will not be appropriate for some patients because of language, cultural or other barriers. Those with hearing problems, learning difficulties, poor literacy skills, psychiatric problems or who are hard to reach - such as travellers and refugees - may require one-to-one teaching.
The NSF delivery strategy suggests that local teams should initially focus on the newly diagnosed and those most at risk of complications (NDST, 2005b). If structured education is already in place, it should be assessed to see whether it can be adapted to meet criteria in the PEWG report or whether a nationally available programme might be more cost-effective. To ensure a local programme meets NICE criteria, teams should assess learning needs, train health professionals and develop quality assurance tools to test the programme’s validity.
Needs assessment compares ‘what is’ with ‘what should be’ and can clarify educational planning. Health professional training should include interprofessional education to enable students from different disciplines to learn from each other and promote collaborative practice. Any education programme needs to be monitored to ensure it is delivered to a high standard (DUK and DH, 2005). The importance of continual evaluation is illustrated by the BITES programme for people with type 1 diabetes, which showed increased patient satisfaction but no actual benefit in glycaemic control compared with the control group (NDST, 2005b).
Patient education is fundamental to successful diabetes self-management. Patient education programmes empower those with diabetes to manage their condition effectively, enabling them to ‘live with diabetes, not suffer from it’. We need to inform people with diabetes fully of the dangers so they can manage it appropriately and minimise the risk of complications, thereby extending their life and maximising quality of life.
- Understand the aims of diabetes treatment
- Be familiar with the types of structured patient education for diabetes
- Be aware of the challenges facing nurses developing SPE programmes
- Understand how to monitor the effectiveness of a programme so that it can be adapted or replaced as necessary
- Outline your place of work and why you were interested in this article
- Identify information in the article that could help improve patient education
- Outline how you would work with patients to improve self-management of diabetes
- Explain how you intend to share what you have learnt with colleagues
This article has been double-blind peer-reviewed.