Therapeutic Patient Education

Therapeutic Patient Education
Marg McGill RN MSc (Med)
IDF Vice President
Chair, IDF Consultative Section On
Diabetes Education
Manager, Royal Prince Alfred Hospital ,
Sydney Australia

The Burden Of Diabetes

Too Many Patients for Number of Staff
• Keep working in the “old way”
• High patient throughput ---> > poor quality care
• Blood glucose focus rather than comprehensive
care
• Information focus rather than motivation and
behaviour change
• Staff burnout and high turnover

Sharing The Burden – Pulling Together

“Helping others is good, teaching
them to help themselves is better”
George Orwell

Why Is Patient Education So Important?
1. It improves quality of life
2. People want information
3. Chronic disease and lifestyle related illnesses are
common
4. Health education helps us use resources more
efficiently

The Role Of The Educator
• The diabetes educator promotes
– self care
– self responsibility
– informed decision making
• through information and behaviour change
strategies

Staff Selection
• Select Staff Who:
– Intelligent, non-judgemental and flexible
– Keen to Go Beyond Traditional Training and Role
– If educator has diabetes need to respect others’
ways of coping with their diabetes

Skills Needed
• An effective educator :
– Patience and Commitment
– Knows principles of diabetes management
– The education process
– Good communicator
– Presentation skills
– Writing skills
– Counselling/interviewing

Educating the Educator
• “Think outside the square you live
in”, have an open mind and learn
from
– Advertising/Marketing
– Negotiators
– Media presenters
– PATIENTS

Myths About Education
• Education is a process of giving people information
and telling them what to do
• If people come to see you, they want to learn or
change
• Knowledge changes behaviour

Knowledge to Behaviour Change
• “you must walk every day”
• this is NOT diabetes education …….rather
• help patient consider strategies that allow them to
integrate exercise into their day
– Use pedometer to motivate

Case Study 1
New Patient Clinic
• Mr Mankov, , newly diagnosed type 2, overweight
– Smoker
– Ischaemic heart disease
– Hba1c 11.1%
– ↑ Serum cholesterol
– ↑ Blood pressure

Case Study 1 - Strategies
• Select most important issue
• Address one at a time
• Use high dosage medication

Designing A Diabetes Education Program
• Assess
• Plan
• Implement
• Evaluate

Content for Education Program
life Content Life Content

Assess, , Plan, Implement, Evaluate
• Why?
– Establish rapport and trust with the person
– Determines what the role for family will be
– Identifies barriers to learning
– Encourages participation

Do We Know What Our Patient’s Want?
• A significant difference exists among the problems
identified by the patient and those identified by the
caregiver.
Genev, 1992, Woodcock & Kinmonth, 2001

Assess, , Plan, Implement, Evaluate
• Goals of assessment
– find out the person’s most pressing concerns
– prior knowledge
– current status of disease
– current self-care practices
– determine cultural and health beliefs

Assess, , Plan, Implement, Evaluate
• Vital information
– what information does the person need to be
safe?
– what skills does the person need to perform?
– May call these ‘survival skills’

Communication
• Words 7%
• Verbal
– Tone, volume etc 38%
• Non-verbal
55%
– Facial expression,
– Eye contact,
– Gestures and posture
– Physical contact
– Appearance

Tips for Plain Speaking
• Use simple non-medical language
• it’s not “clever” or “more intelligent” to use words
people cannot understand

Assess, Plan, , Implement, Evaluate
• Develop with the person with diabetes
– what do you want to know?
– what must you know?
• Offer choices
– individual
– classes
• Write objectives or goals together

Assess, Plan, Implement, Evaluate
• Communication is the key
– simple words
– open ended questions
– encourage feedback
– give positive feedback
– attitude
– listen, listen
– repetition

Assess, Plan, Implement, , Evaluate
• Determine priorities from the objectives
– begin with what the learner wants to know
– most important first and last
• Conducive environment
• Move from simple to complex
• Be specific
• Repeat, repeat, repeat
– Patients only recall 25% of a 20 minute
consultation

I Need Resources!
• All you need is good understanding of diabetes,
your voice, your ears and a kind heart

Developing Written Resources
• Often too high a literacy level
• Tabloid newspaper (~ 11years)
• Short sentences
• Use informal language
• Meaningful pictures

Original Text
One of the vital aspects of
your care is the adherence to
a dietary regimen. Each
patients dietary prescription
varies, depending on the
degree of obesity and
hyperglycaemia.
Accommodations to your
eating habits will be of prime
importance as adherence to
dietary management will
enhance your overall quality
of life.
Rewritten Text
Your diet is an important
part of your care.
Everyone is different so
your diet will need to be
planned just for you.
Following your diet is one
way of helping you feel
well.

What Can I Eat?
• Carbohydrate counting/exchange system confusing
Deck of cards = 1 serving
of meat, poultry of fish
Tennis ball = 1 medium
size vegetable or fruit

The Hand Method
• Hand is proportional to the size of the person
Thumb-tip = teaspoon
2 thumbs=serving of cheese
Palm=serving of meat,chicken or poultry
Fist = cup

What Are The Different
Strategies/Formats For Patient
Education?

Individual Instruction
• Advantages
– personalized
– based on needs
– actively involves the
learner
– allows for personalized
goal setting
– allows for questioning
and ongoing evaluation
• Disadvantages
– no opportunity to share
with others
– educator runs the risk of
teaching too much
– ?? more costly

Watch your body language

Group Instruction
• Advantages
– opportunity to share
– cost effective
– members gain support
from each other
• Disadvantages
– need a skilled facilitator
to keep things on track
– some may not be
comfortable speaking up
in a group
– some people do not
participate actively
– some topics may be too
sensitive to discuss in a
group

Watch Your Body Language!
• “avoid looking like a school teacher”

Lecture
• Advantages
– learners have some
opportunity to share
– teacher has control of
material discussed
– cost effective??
• Disadvantages
– minimal exchange
between students
– not tailored to the
individual
– passive learning
experience

• Works in all cultures
Use Role Play

Use Drawing/Art

Targeting Education
• Do not mix type 1 and type 2
• Special groups
– children …look at how schools divide them into
infant, primary, high, college/university
– Elderly...targets may be modified,
• Not everyone requires the same level of education
– “take your tablets every day, walk around the
block and come and see me in 3 months”
– footcare education,

Footcare Education
• Low Risk
– Simple advice
– No change in lifestyle
– Annual foot assessment
• High Risk
– Intensive education,
– Practical demonstration
– Significant behaviour changes
– Concentrate on precipitating events
• Shoes cause 58% of ulceration

Evaluate the Outcome
• Concerned with measurement of :
– patient performance
– educator effectiveness
– quality of programme

Evaluating Education
• Do not test knowledge only
– eg You should check your shoes everyday
– yes
no
• Test behaviour change
– How many days in the last 7 did you check your
shoes
– 1 2 3 4 5 6 7

Other Evaluation Processes
• Ask patient about educators performance
• Skill demonstration
• Videotape session
• Have an observer
– watch body language
– chart communication flow
• Note the number and type of questions asked

Summary
• Select the best person for the job
• Do needs assessment
• Plan your program
• Target education to patient’s needs
• Use interactive, cooperative teaching style
• Provide good learning environment
– Avoid being judgmental and creating guilt
Don’t overload the patient with information
• Evaluate

Be Brave And Try New Things