Consultations: An opportunity for education

Every consultation in diabetes should present opportunities: an opportunity for discussing current issues, an opportunity for education, an opportunity for joint decision-making and an opportunity for forming a joint treatment plan. But what makes a good consultation? Walker (2000) suggests that a good consultation must:

‘aim to improve heath outcomes as well as to enable the patient to feel satisfied with the process.’

A consultation based on the medical model (the expert-led approach), I feel, is likely to simply address the healthcare professional’s agenda, and this contradicts a key theme in education. The root word of education is the Latin educare, which is related to educere, meaning ‘to lead forth’ (Simpson and Weiner, 1989). In my experience, education respects the capabilities, skills, beliefs and values which learners bring to the learning session, and importantly it also respects and often incorporates learners’ life experiences. Accordingly, it is implicit, I believe, that in a consultation we need to be drawing on the above if the consultation is to offer the most educational value for the person with diabetes.

The challenges
Great strides have been made in diabetes consultations towards a more patient-focused approach. Anderson and Funnell (2005) state that:

‘collaborative diabetes care requires a new empowerment paradigm that involves a fundamental redefinition of roles and relationships of health care professionals and patients.’

However, there are challenges in adopting this approach. This is reflected in the local experiences of my colleagues and me working alongside practice nurses in diabetes clinics, where the reality is somewhat different from the collaborative ideal. In the consultations, our observation is that there is a real pressure to tick all of the boxes and ensure that all of the Quality and Outcomes Framework (QOF) indicators are addressed. In this setting, practice nurses could be seen to be taking the responsibility for solving what they perceive as the problems of people with diabetes. They may then feel frustrated that their self-care advice is not being followed. The achievement of points could lead to practice nurses feeling that they, rather than people with diabetes, are responsible for achieving the targets in the QOF indicators.

While the majority of practice nurses recognise the empowerment approach, their consultations still largely reflect an acute care model. I feel that this may be because the acute care model is appropriate for their more general, task-orientated workload (such as immunisations, smears and dressings),  where  the average appointment is more like 10 minutes. When in this mode of consultation it may be difficult for the practice nurse to consider new approaches when dealing with long-term conditions. Given that diabetes care is shifting towards a community setting (Department of Health, 2006), I believe that it is essential to engage primary care staff, particularly practice nurses, in considering new ways of working. This requires a change from feeling responsible for patients to feeling responsible to patients (Anderson and Funnell, 2005).

Setting up specialist nurse clinics in primary care has been a challenge. The request from the diabetes nursing team for appointments to be a minimum of 30 minutes did raise a few concerns from senior practice staff along the lines of ‘you will only see six patients per clinic.’ It has been difficult for me at times to persuade staff that a patient-centred approach is not more time consuming when you have specifically requested double the amount of time for appointments! I hope that working alongside the specialist nursing team and seeing the empowerment approach in action will enable practice nurses to see the value of such an approach and ultimately facilitate a change in practice.

In the articles that follow, Elizabeth Kamps reflects on developments in diabetes education and the challenges that lie ahead in delivering effective interventions, while Jane Pennington describes an innovative project that led to the development of Agenda Cards. These cards may just be the sort of tools required to encourage healthcare professionals to reflect on their approach.