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Old dog, new tricks

Lorraine Avery

Some of you will be aware that I am moving on ‘to pastures new’ and, consequently, this will be my last editorial for the educational supplement of the Journal of Diabetes Nursing. My new role will be at a national level working in diabetes care for a pharmaceutical company, so I’m sure I will see some of you whilst wearing my new hat. This will be an exciting opportunity and a new challenge for me: they say you can’t teach an old dog new tricks; well, watch this space. My tail will still be wagging!

I also think this change represents a great opportunity for the journal. I have held this position since the inception of the supplement in 2003. I genuinely believe that a new person taking on this editorship will keep the supplement fresh and offer new perspectives.

I thought I would use this occasion to reflect on the supplement to date. Initially, the supplement was entitled Patient education. This was subsequently changed owing to the fact that, in order to provide optimal patient education, it is important to consider the education of healthcare professionals. Thus, the supplement became more embracing of all aspects of education in 2005.

During my time as the Supplement’s Editor I have, with your help, filled its pages with the development of structured education programmes both for type 1 and type 2 diabetes. Nationally, a number of centres are now running the DAFNE programme and an increasing number of centres are developing their own programmes, some of which have been published in this supplement. The launch of the Type 1 Education Network has proved invaluable in supporting those of us delivering such programmes.

In terms of type 2 diabetes, DESMOND was conceived as a national initiative to demonstrate that structured education does lead to better outcomes for people with diabetes (Skinner et al, 2006). Using DESMOND led myself and my team to reflect considerably on how we delivered the type 2 diabetes education programmes we had been delivering for years. While the content was the same, the processes were different: delivering DESMOND has been a more rewarding experience for the healthcare professionals than our old type 2 education groups.

When NICE guidance on patient education was published, to begin with, it was not compulsory and, as a result, there was a scarcity of funding to support initiatives (NICE, 2003). National support was eventually provided by the DoH and this has, at last, seen some funding released for education programmes to be developed. The subsequent publication of the self-assessment tool to ensure local programmes are meeting NICE guidance has, in my opinion, enhanced patient education and the growth of diabetes teams’ expertise in this area (NDST, 2006).

One of the rewarding aspects of being a DSN or consultant nurse is the longevity of the relationship between ourselves and the person with diabetes. However, sometimes this relationship can be unproductive for all involved, for reasons that are not always clear. There is a multitude of evidence to support the notion that a collaborative relationship between healthcare professional and patient is associated with better outcomes.

For many years, we have sought to ‘educate’ people with diabetes to ensure they have the knowledge, skills and attitude to self manage their diabetes; unfortunately, if I look at my initial years as a diabetes nurse, this meant a rather didactic approach and frustration on my part as patients frequently failed to do as I asked! I believe the concept of empowerment has facilitated a change in our relationship with people with diabetes in that now there is an increasing number of healthcare professionals who are striving to increase their knowledge, skills, attitudes and, probably most importantly, their self awareness in order to enhance their relationship with the people they see in clinic. At last, education checklists seem to be a thing of the past!

Meanwhile, on a less positive note, I do have some reservations that the QOF targets are driving a medical model of diabetes consultation (the expert-led approach). While practice nurses strive to ensure that all the QOF indicators are addressed, there is little time left for an empowering consultation – something I know my local practice nurses find frustrating. 

The experience of education of the person with diabetes was highlighted in articles by Gill Kester and William Graham in 2004, in which they wrote about their experiences of being diagnosed with diabetes and their subsequent education around the condition. Despite a degree in physiology and having taught glucose homeostasis on a diabetes diploma course, Gill still struggled with some of the education she was provided with when she was diagnosed with type 2 diabetes.

Patient narratives, such as those listed above, offer powerful insights into the individuals’ responses to diabetes. I was reminded of this during a conference last year when Natalia Piana gave a brilliant presentation on using this approach. I have occasionally asked people with diabetes to write their story about living with diabetes. This task appears to be a very cathartic experience: individuals can write as much or as little as they wish and it is up to them whether or not they wish to share what they have written with me.

As a result, I have a collection of patients’ narratives that can be used to work cooperatively with the writers to understand the difficulties they face with the condition and to identify strategies to deal with these. For those of you who have not heard Natalia speak on the topic of patient narratives, I suggest you read the literature around this subject and look out for the piece that Natalia will be writing for a future issue of the Journal of Diabetes Nursing.

A wealth of literature supports education as a vital component of diabetes care and the evidence base is gradually becoming more robust in terms of providing us with evidence about what actually works. However, while this is an important tool for those involved in diabetes care, we all need to reflect on what makes a consultation successful. Individuals who continue to struggle to meet their negotiated targets and cope with the condition may be telling us something about our role as nurses and may provide us with an opportunity for reflection. 

This supplement comprises an article on patients’ knowledge about diabetes medication, a subject I also looked into a number of years ago and subsequently followed up by working with Marie Clark. Marie’s research involves patients’ health beliefs related to their medications and what it is that actually leads patients to take their medications (or not, as so often is the case; Clark et al, 2007). 

Finally, I would like to thank the current and previous contributors to this supplement. I wish the journal continued success.

Some of you will be aware that I am moving on ‘to pastures new’ and, consequently, this will be my last editorial for the educational supplement of the Journal of Diabetes Nursing. My new role will be at a national level working in diabetes care for a pharmaceutical company, so I’m sure I will see some of you whilst wearing my new hat. This will be an exciting opportunity and a new challenge for me: they say you can’t teach an old dog new tricks; well, watch this space. My tail will still be wagging!

I also think this change represents a great opportunity for the journal. I have held this position since the inception of the supplement in 2003. I genuinely believe that a new person taking on this editorship will keep the supplement fresh and offer new perspectives.

I thought I would use this occasion to reflect on the supplement to date. Initially, the supplement was entitled Patient education. This was subsequently changed owing to the fact that, in order to provide optimal patient education, it is important to consider the education of healthcare professionals. Thus, the supplement became more embracing of all aspects of education in 2005.

During my time as the Supplement’s Editor I have, with your help, filled its pages with the development of structured education programmes both for type 1 and type 2 diabetes. Nationally, a number of centres are now running the DAFNE programme and an increasing number of centres are developing their own programmes, some of which have been published in this supplement. The launch of the Type 1 Education Network has proved invaluable in supporting those of us delivering such programmes.

In terms of type 2 diabetes, DESMOND was conceived as a national initiative to demonstrate that structured education does lead to better outcomes for people with diabetes (Skinner et al, 2006). Using DESMOND led myself and my team to reflect considerably on how we delivered the type 2 diabetes education programmes we had been delivering for years. While the content was the same, the processes were different: delivering DESMOND has been a more rewarding experience for the healthcare professionals than our old type 2 education groups.

When NICE guidance on patient education was published, to begin with, it was not compulsory and, as a result, there was a scarcity of funding to support initiatives (NICE, 2003). National support was eventually provided by the DoH and this has, at last, seen some funding released for education programmes to be developed. The subsequent publication of the self-assessment tool to ensure local programmes are meeting NICE guidance has, in my opinion, enhanced patient education and the growth of diabetes teams’ expertise in this area (NDST, 2006).

One of the rewarding aspects of being a DSN or consultant nurse is the longevity of the relationship between ourselves and the person with diabetes. However, sometimes this relationship can be unproductive for all involved, for reasons that are not always clear. There is a multitude of evidence to support the notion that a collaborative relationship between healthcare professional and patient is associated with better outcomes.

For many years, we have sought to ‘educate’ people with diabetes to ensure they have the knowledge, skills and attitude to self manage their diabetes; unfortunately, if I look at my initial years as a diabetes nurse, this meant a rather didactic approach and frustration on my part as patients frequently failed to do as I asked! I believe the concept of empowerment has facilitated a change in our relationship with people with diabetes in that now there is an increasing number of healthcare professionals who are striving to increase their knowledge, skills, attitudes and, probably most importantly, their self awareness in order to enhance their relationship with the people they see in clinic. At last, education checklists seem to be a thing of the past!

Meanwhile, on a less positive note, I do have some reservations that the QOF targets are driving a medical model of diabetes consultation (the expert-led approach). While practice nurses strive to ensure that all the QOF indicators are addressed, there is little time left for an empowering consultation – something I know my local practice nurses find frustrating. 

The experience of education of the person with diabetes was highlighted in articles by Gill Kester and William Graham in 2004, in which they wrote about their experiences of being diagnosed with diabetes and their subsequent education around the condition. Despite a degree in physiology and having taught glucose homeostasis on a diabetes diploma course, Gill still struggled with some of the education she was provided with when she was diagnosed with type 2 diabetes.

Patient narratives, such as those listed above, offer powerful insights into the individuals’ responses to diabetes. I was reminded of this during a conference last year when Natalia Piana gave a brilliant presentation on using this approach. I have occasionally asked people with diabetes to write their story about living with diabetes. This task appears to be a very cathartic experience: individuals can write as much or as little as they wish and it is up to them whether or not they wish to share what they have written with me.

As a result, I have a collection of patients’ narratives that can be used to work cooperatively with the writers to understand the difficulties they face with the condition and to identify strategies to deal with these. For those of you who have not heard Natalia speak on the topic of patient narratives, I suggest you read the literature around this subject and look out for the piece that Natalia will be writing for a future issue of the Journal of Diabetes Nursing.

A wealth of literature supports education as a vital component of diabetes care and the evidence base is gradually becoming more robust in terms of providing us with evidence about what actually works. However, while this is an important tool for those involved in diabetes care, we all need to reflect on what makes a consultation successful. Individuals who continue to struggle to meet their negotiated targets and cope with the condition may be telling us something about our role as nurses and may provide us with an opportunity for reflection. 

This supplement comprises an article on patients’ knowledge about diabetes medication, a subject I also looked into a number of years ago and subsequently followed up by working with Marie Clark. Marie’s research involves patients’ health beliefs related to their medications and what it is that actually leads patients to take their medications (or not, as so often is the case; Clark et al, 2007). 

Finally, I would like to thank the current and previous contributors to this supplement. I wish the journal continued success.

REFERENCES:

Clark M, Avery L, Hampson S (2007) Beliefs about medicines and personal models of diabetes in relation to adherence to medication in patients with Type 2 diabetes. Diabetic Medicine 24(suppl. 1): P248
Graham W (2004) Evaluation of a formal education programme by an expert patient. Journal of Diabetes Nursing 8: 62–4 
Kester G (2004) Taking control of diabetes through education. Journal of Diabetes Nursing 8: 59–61
NDST (2006) NDST network guide supplement. Structured Patient Education: Role of Diabetes Networks. NDST, Leicester
NICE (2003) Guidance on the use of patient-education models for diabetes. Technology Appraisal 60. NICE, London
Skinner TC, Carey ME, Cradock S et al (2006) Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND): process modelling of pilot study. Patient Education and Counselling 64: 369–77

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