Education, like charity, begins at home – in this case, in the patient’s home where the patient becomes the teacher and the health professional the learner. Turning the norm upside down seemed a good place to start in improving nursing staff ’s perception of diabetes and its management. Generally ward staff deal with people with diabetes as a disease process that should be treated ‘by the book’. There is little understanding of the individuality within it, nor the areas of diabetes that impact so powerfully on peoples’ lives (McHoy, 2003). This article describes a method that appears to successfully redress the balance.
The diabetes nursing staff were receiving increasing numbers of referrals from the surgical wards, often due to nurses’ uncertainty about day-to-day management of diabetes and compounded by junior house officers’ equally minimal knowledge and infrequent consultant supervision. A recent study day had been attended almost solely by staff from the medical wards and I wanted to identify reasons for the poor surgical staff attendance, and to find a method of education that was both suitable and effective.
Reasons for staff non-attendance
I provided a questionnaire to identify both the staff ’s reasons for non-attendance and their perceived needs regarding diabetes education. The results of the questionnaire indicated that:
- releasing more than one member of staff at a time was extremely difficult
- infrequent study days do not suit ward needs
- general communication about study days appears to be poor
- the topics requested are basic understanding of diabetes and its day-to- day management, as one would expect.
As I already had some doubts about the efficacy of ‘lecture-type’ study days from the lack of resultant change in nursing practice, I discussed with the charge nurses and nurse manager the possibility of taking two trained staff from different wards on ‘home visits’, which I undertake as part of my job as a DSN. Ward nurses generally respond very positively to a trip out with the hospital. The experience seems to provide a paradigm shift in their perceptions of people with diabetes, enabling them to see the individuals as opposed to a ‘client group’. It also allows them to concentrate solely on diabetes without competing distractions.
I suggested a programme for the day. The nursing staff who agreed to participate were made aware that they would be asked to discuss their experience with their senior nurse and would be asked to cascade the resultant learning to their colleagues.
Following approval of the details, I contacted a number of patients of varying ages, conditions, medications, control levels and lifestyles to ask if they would be willing to give the nurses the benefit of their experience of living with diabetes. Everyone agreed without exception. All of the patients lived within a six-mile radius.
Dates and times were organised, and staff from all of the surgical wards were invited to attend, as suited ward staffing needs. All but one ward participated. The charge nurse of this ward felt they offered enough education on all topics within the ward area. Over a period of six months, 11 members of staff completed the whole study day and one did a half-day due to personal circumstances.
The day consisted of a short briefing about the patients to be visited (two in a typical morning), and any questions the staff had were answered, usually on the car journey to the patients’ homes. Once introductions had been completed I asked the hosting patient to start from their diagnosis, if possible, and explain to the nurses what diabetes management was like, what they coped with and how they felt about it (see Figure 1). They also described the impact their diagnosis had on their lifestyle, their relationships, and on their schooling or employment. If they had experienced hospital admission they were free to discuss this also. The nurses were encouraged to relate to the patient by asking questions so that they were able to clarify points and gain the particular pieces of information and knowledge they felt were relevant. Between visits and on the way back to the hospital there was time for a brief review and clarification from a DSN perspective.
On our return to the hospital we undertook a short tutorial-come- discussion, and handouts on basic diabetes knowledge were provided. Following a lunch-break the staff were introduced to the charge nurse in the clinic and she guided them through a patient’s journey. They also had the opportunity to accompany the diabetologist, the dietitian and the podiatrist during their patient consultations.
Eight wards participated. At the end of the study day participating staff were asked to complete and return an evaluation form, which they did without exception. Their evaluations and comments are summarised in Table 1.
The day was well evaluated and there was nothing highlighted that the staff wanted to have changed, except for more time with us. The day by no means addresses all the educational needs of the staff. It was intended to be – and served solely as – an introduction to diabetes, its impact, its individuality in terms of the ways people deal with it and manage it, and the basics required to manage it more effectively in the ward situation, e.g. dealing with hypos, hyperglycaemia, diet and patient autonomy. It gave the nurses more of a ‘feel’ for people with diabetes, resulting in greater patience and understanding for the individual. This is by no means the only effective education programme but it suited my working practice and resulted in changes in ward practice.
Effect of the education day on practice
Outcomes included more appropriate referrals that were more tailored to DSNs as opposed to medics, dietitians or podiatrists. In this area, the DSNs work mainly with insulin management and educational issues. Oral hypoglycaemic agents, etc, were generally dealt with by the ward medical staff.
When patients were referred from the wards, I was able to ask how the staff felt about their diabetes management. Ward staff almost unfailingly reported they had greater understanding, increased confidence in advising their patients, or in asking advice when they were unsure. From my personal observations of their practice, they were much more relaxed with their patients with diabetes, allowing greater flexibility in the individuality of their treatment.
There was no formal questionnaire for inpatients, unfortunately, so reports were anecdotal. Inpatients reported what appeared to be a change in nursing staff attitude, expressed in reduced conflict between themselves and the staff regarding having access to their own insulin and some control over their insulin doses. Action on random abnormal blood glucose readings and the foods patients were and were not allowed to eat had also been a cause of some disagreement. These issues were more readily resolved when the staff began to appreciate how individualised diabetes management is, and the flexibility there can be in the ‘diabetic diet’ (Lorig et al, 2000). Patients also reported feeling more confident about the staff’s ability in dealing with emergencies related to diabetes, such as hypoglycaemia.
The patients involved in providing the education to the staff members reported feeling needed, respected and appreciated. They felt they were able to give something back to the system from which they so often only receive. Patients appreciated being able to impart knowledge and information to those who were usually considered to be ‘the experts’. They also felt it put a value on their experiences with diabetes, many of which had not been easy and had often seemed to be unappreciated by health professionals. The home visits promoted patient and carer involvement, as family members often joined in the relating of experiences of living with diabetes (Scottish Executive, 2002). This gave the visiting nursing staff a much more holistic understanding of diabetes management and had a profound effect on their respect for people with diabetes and their family members.
On a personal level, I found the day demanding as I was either directly teaching or facilitating until the afternoon, when I then had a full clinic of patients. However, the advantages outweigh the fatigue as I now have considerably more rapport with the wards generally and the nursing staff in particular. Nursing staff now have an understanding not only of the diabetic patient’s challenges, but also of my role and theirs in dealing with diabetes as it presents itself (Scottish Executive, 2004).
Anecdotally, and as I can find no other reference to this method of staff education, I assume that it is infrequently used – perhaps as it appears to be labour intensive. However, the end results have been very positive for us all, staff and patients alike. The staff and patients involved have enjoyed the sessions together and I now have calls from people with diabetes in the community asking when I will be bringing more nurses with whom they can share their experiences.
We have recently reintroduced the programme and my colleague has undertaken to continue it in the meantime with a view to covering most of the wards in the hospital over the next year. She has introduced a pre- and post- programme knowledge questionnaire, which is a much-reduced version of the Diabetes Basic Knowledge Test. She also has a pharmaceutical representative providing lunch for the nurses whilst she and the representative provide further education about injections, mature-onset diabetes of the young (MODY), differences in type 1 and type 2 patients and their treatment needs, complications and diabetic ketoacidosis and referral guidelines. Following their session in the clinic they complete the same knowledge questionnaire as they did in the morning and an evaluation form.
For a half day per month of DSN time, the education day seems to me to have been a worthwhile investment.