Helping Patients Succeed in Meeting the Challenges of Effective Diabetes Self-Management

Diabetes is a chronic disease that incurs significant health, disability, and financial cost in the United States. Diabetes has become increasingly prevalent with rising morbidity and mortality. It is estimated that approximately 7% of the US population has diabetes. In 2005, 1.5 million people over the age of 20 were diagnosed with diabetes. An additional 41 million have prediabetes. Diabetes stands as a leading cause for end-stage renal disease, blindness, and amputations in the US.1 In 2002, the estimated total financial cost (direct and indirect) of diabetes in the US was $132 billion per year.2 The average annual health care expenditures per person with diabetes are $13,243 compared with $2,560 for a person without diabetes.3 Diabetes also adversely affects patient quality of life4 and depression is twice as frequent in those with diabetes.5 Much of the excess costs associated with diabetes are related to the care for the preventable complications of diabetes. Intensive treatment of diabetes along with improved self-management can substantially reduce the risk of developing these complications. Despite evidence from well-designed clinical trials detailing interventions that can markedly reduce morbidity and mortality, 6-9 the majority of patients in the US do not reach these goals.
10

THE ROLE OF SELF-MANAGEMENT IN DIABETES CARE

Diabetes is primarily a self-managed illness. Thus, self-management is the foundation for achieving the tight glucose control needed to avoid the debilitating complications of diabetes. Self-management relies on patients' willingness and ability to alter their nutritional intake, exercise regularly, manage stress, take medications appropriately, and monitor their blood glucose on a regular basis. In addition to day-to-day self-management behaviors, patients are advised to seek diabetes-related preventive health care on a regular basis, including retinopathy screening, foot examinations, glycosylated hemoglobin (A1c) testing, lipid testing, and blood pressure monitoring.11 However, patients find many of the selfmanagement recommendations they are given difficult to sustain over the long term, especially those related to weight loss and increased physical activity.12 One of the most comprehensive examinations of diabetes self-management and related psychosocial issues to date is the Diabetes Attitudes Wishes and Needs (DAWN) study. This study queried over 5,000 patients with type 1 and type 2 diabetes as well as 3,827 providers, including primary care physicians, diabetes specialists physicians, and nurses from 13 countries.13 The DAWN study reported that only 46% (2% to 63% range by countries) of patients with type 1 diabetes and 39% (2% to 54% range by countries) of patients with type 2 diabetes reported achieving success in two-thirds of their selfmanagement domains, ie, diet, exercise, medications, self-monitoring of blood glucose (SMBG), and appointment keeping. Patient reports of self-management success for medication adherence (overall range 78% to 83%) and glucose monitoring (64% to 70%) were much higher than for diet (37% to 39%) and exercise (35% to 37%). Both patients and providers reported that a majority of patients suffer from psychosocial problems that interfere with their diabetes self-management. The difficulty patients have making and sustaining lifestyle changes involving diet and exercise puts increased emphasis on the importance of SMBG and medication adherence. A recent review of the research related to medication adherence reported that adherence rates for blood-glucose lowering therapy ranged from 65% to 85% with lower rates (36% to 54%) reported for certain populations (eg, Medicaid recipients) and regimens requiring

more frequent dosing.14 There were a number of reasons cited in these studies for lower adherence rates, including patients' inadequate understanding of the regimen, medication side effects, lack of perceived regimen benefits, medication costs, and regimen complexity. Although diabetes self-management is fundamental to controlling diabetes, it can be demanding, complex, and difficult to sustain, and requires ongoing support and education.

DIABETES SELF-MANAGEMENT EDUCATION INTERVENTIONS

Given both the importance of self-management and its often complex and demanding nature, it is not surprising that diabetes self-management education (DSME) has been recognized as instrumental in diabetes care.11 The goal of DSME is to arm patients with the knowledge, information, self-care practices, coping skills, and positive attitudes that promote effective diabetes care and improve long-term health outcomes. Several reviews and meta-analyses have found DSME interventions to have a positive impact on diabetes-related health and psychosocial outcomes, specifically increasing diabetes-related knowledge and improving blood glucose monitoring, dietary and exercise habits, foot care, medication adherence, coping, and glycemic control. 15-19 Although the evidence supports the efficacy of DSME programs as a whole, variability in program goals, outcome measures, length of intervention, frequency of session, learning format, and demographic make-up of participants means that it is not possible to define an optimal "prototype" for a DSME program.15-19 Furthermore, many studies that have reported successful outcomes have not articulated a detailed description of the intervention itself or the educational process, mechanism of behavioral changes, or specific technique and strategies utilized.20,21Substantial gaps remain in the body of knowledge related to DSME. Starting in 1998, the American Diabetes Association (ADA) commissioned a task force to identify the core content areas to be included in DSME, as well as establish the National Standards for Diabetes Self-Management Education Programs.22 This task force outlined 10 content areas including the diabetes disease process, nutritional management, physical activity, medication, monitoring blood glucose, acute complications, risk reduction related to chronic complications, goal setting, psychosocial adjustment, and preconception care/pregnancy. While a large body of evidence supports the efficacy of DSME interventions in improving diabetes-related health outcomes, few studies to date have investigated the impact of DSME delivery format on diabetes-health related outcomes. For example, there is insufficient data to determine with certainty whether individual-based DSME programs are more effective than group-based interventions or vice versa. However, compared to individual-based approaches, group-based DSME programs typically invite greater interaction and interpersonal dynamics.23 Moreover, the group setting can better foster certain educational activities such as social modeling or problem-based learning than the individual setting. Although the scientific evidence is incomplete, some providers believe group-based DSME is most preferable for improving diabetes health-related outcomes.24 Group education is also less costly than individual education. 24,25 In fact, the Balanced Budget Act of 1997 provided further economic incentive as this legislation specifically recognized diabetes education via group learning format for uniform reimbursement by the Health Care Financing Administration.24 Although the evidence for the efficacy of DSME is unequivocal and it is supposed to be reimbursed by Medicare, many DSME programs have been forced to close because of difficulty in receiving reimbursement. In an era of cost cutting, the efficacy of

DSME is necessary but not sufficient to ensure program survival. In a qualitative review by Norris and colleagues,26 individual versus group approaches to DSME were examined. This review found that patients in both settings demonstrated equal success in acquiring and honing self-care practices. The only self-management area in which group-based learning led to slightly better self-management outcomes than individual-based learning was nutritional management and physical activity. Norris and colleagues concluded that each intervention approach offered unique features and benefits. In another review paper one year later, Norris found no differential impact between individual versus group-based interventions in improving glycemic control.18 Although not conclusive, there are some data to support that group-based DSME can be more costeffective, lead to greater treatment satisfaction, and be slightly more responsive to lifestyle behavioral changes such as diet and physical activity. While research to date has not found group formats to be unequivocally superior to individual or vice versa, group-based interventions have been found to be clearly more effective than usual care or control conditions. Deakin and colleagues27 conducted a systematic review of randomized controlled trials in which group-based DSME interventions were compared to usual care/waiting list control/no intervention groups. Health endpoints for group-based DSME programs included improvement in self-management skills, selfefficacy or empowerment, metabolic control, patient satisfaction, and quality of life. Based on the eligibility criteria, meta-analyses of the 11 studies demonstrated the efficacy of group DSME program in improving A1c in the short term (4 to 6 months), intermediate term (12 to 14 months), and long term (2 years) (P <0.00001). Also found were significant improvements in fasting blood glucose at 12 months, decreased weight at 12 to 14 months, greater diabetes knowledge at 12 to 14 months, and lower systolic blood pressure at 4 to 6 months (range of P values; P <0.00001 to P <0.03). Finally patients in group-based interventions (versus usual care controls) were found to have a reduced need for diabetes medication (P <0.00001) than their control counterparts. Overall, this review found groupbased training to be definitely more effective than usual care control groups.27 In summary, numerous studies and meta-analyses have established that DSME programs, using a variety of designs and strategies, delivered in diverse settings, using group and/or individual formats, and targeting specific patient groups, have been consistently successful in producing improved metabolic, self-management, and psychosocial outcomes. The answer to the question of whether DSME is effective is a resounding yes. Future DSME research will need to focus on questions related to cost effectiveness, long-term sustainability of gains made in DSME programs, and the relative merits of different theoretical approaches to DSME.

THE COLLABORATIVE APPROACH TO DIABETES CARE AND DSME

The care of diabetes is becoming a priority for health and managed care organizations, as health care costs and health outcomes are being closely scrutinized.28,29 Reducing the incidence of acute and long-term complications of diabetes requires that patients be afforded the opportunity to receive DSME in order to develop competencies in selfmanagement, lifestyle change, and decision-making. Because the traditional health care system is designed to provide a symptom-driven response to acute illnesses, it is poorly configured to meet the needs of patients with diabetes.30,31 Collaborative approaches that are focused on both outcomes and prevention have been

developed and proposed as viable alternatives to our current acute approach to diabetes care and education.32-34 These collaborative approaches differ from the traditional acute care approach in that they emphasize DSME and counseling that is focused on the following: addressing psychosocial issues, promoting interactive communication between professionals and patients, assisting patients in becoming effective problem solvers, reducing barriers to self-management, supporting patients' role as the primary selfmanagement decision maker, and providing support and follow-up. 34-38 Provider/patient interactions that promote assertive communication and collaboration have been shown to result in better metabolic control and functional status, more positive self-evaluation of health, and greater patient satisfaction.39,40 In a recent study, 41 certified diabetes educators (CDE) were asked to indicate which theoretical approaches (respondents were allowed to endorse more than one approach) had most influenced the way they provide DSME. The theoretical approach most frequently chosen (98%) was empowerment. The empowerment approach to collaborative diabetes care and DSME is described in the next section.

THE EMPOWERMENT APPROACH TO DIABETES CARE AND DSME

Diabetes is a self-managed, chronic illness and differs from acute illnesses in such fundamental ways that it requires a completely different approach to care and DSME.42,43 Patients are completely responsible for the self-management of their diabetes and their responsibility cannot be negotiated, assigned, or diminished. 44 While that may sound like a strong assertion, in reality it is a straightforward description of the nature of diabetes care. The immutable responsibility that patients have for diabetes self-management is derived from three characteristics of this chronic disease. First, the most important choices affecting the health and well being of patients with diabetes are made by patients, not providers. Each day, patients make decisions about eating, physical activity, stress management, monitoring, etc., that are the major determinants of their diabetes control and, subsequently, their longterm health.44 Second, patients are in control. No matter what providers do or say, patients are in control of the important, daily self-management decisions. When patients leave the clinic or office they can and do veto recommendations made by their providers, no matter how important or relevant the provider believed those recommendations to be. 44 Third, the consequences of the choices patients make about their diabetes selfmanagement accrue first and foremost to the patients themselves. Health care providers cannot share in the risk of developing retinopathy, neuropathy, or cardiovascular disease, nor can providers share the cost to the patient's quality of life by making a commitment to rigorous blood glucose control. Diabetes, including its self-management, belongs to the person with the illness.44

When patients make self-management choices that differ from the recommendations of their providers, it is a source of concern and frustration for those providers. This issue has been primarily described in the literature as patient noncompliance or nonadherence and has resulted in approximately 1500 citations related to diabetes alone. Over the past 15 years, diabetes care providers and researchers have questioned the usefulness of compliance or adherence as a conceptual framework to understand and influence the selfmanagement behavior of patients with diabetes.45-49 Research in this area has led to the realization that the problem defined as nonadherence in diabetes is largely the result of defining the roles, responsibilities, and expectations of patients and health care providers in

diabetes care as they are defined in the treatment of acute illness.50 It also assumes the recommendation was right for the patient and feasible for the provider. Diabetes care requires a collaborative approach in which health care professionals are responsible to patients rather than responsible for them. Assuming that patients with diabetes will or even should make substantial changes in their daily lives because such changes have been recommended by health care providers is based on the traditional acute care approach where patients are passively cared for by experts and often do not participate in decision-making. The empowerment approach to DSME is based on the recognition that diabetes and its self-management essentially belong to the patient. Therefore, to be effective, a diabetes self-management plan must be developed cooperatively and be consistent with the patient's needs, resources, and goals. The empowerment approach to DSME seeks to provide information, resources, and psychological and social support to patients so that they can make informed, personally meaningful, and realistic self-management decisions.51 The knowledge needed to make informed decisions about daily diabetes selfmanagement falls into two global domains.51The first domain is expertise about diabetes. This expertise is generally provided by DSME either during one-to-one visits or group programs. The second and equally important domain is self-awareness and psychosocial skills. Because diabetes and its treatment affect the physical, emotional, mental, and spiritual domains of a patient's life, DSME needs to address the impact of diabetes on the totality of that person's life.52 The empowerment philosophy is based on the assumption that to live with and care for diabetes successfully, patients need to have the psychosocial skills necessary to recognize the need for and bring about changes in their personal behavior, their social situations, and the institutions that influence their lives.53

INTEGRATING PSYCHOSOCIAL AND SELF-MANAGEMENT CONCERNS IN DSME

Two recent studies have evaluated the efficacy of collaborative, problem-based DSME interventions in which clinical and psychosocial concerns were addressed in an integrated fashion.54,55 These studies evaluated a program consisting of six weekly group sessions (90 minutes in length) with follow-up for one year, as well as a 26-session program held each week for six months. In the latter program, patients were encouraged to attend the weekly group sessions as frequently as they felt they needed. One could think of the weekly sessions as a resource that patients could use to create an unique education and support program tailored to their specific needs. The design and conduct of the group sessions in both programs were essentially the same. Lectures were completely eliminated and the curriculum consisted of the concerns, problems, and questions introduced by patients in the program. No attempt was made to separate the clinical and psychosocial aspects of living with diabetes. The program emphasized a patient-centered approach supportive of and responsive to patient-specific needs, lifestyle, and goals. The program instructors helped patients identify personally relevant and meaningful issues, answered their questions, and endeavored to ensure that the patients' self-management goals and plans truly reflected their concerns. The five core components of the program were:

1. Reflect on diabetes self-management experiments. At the beginning of each session, patients are invited to reflect on the results of a selfmanagement experiment chosen at the end of the previous group session (see step 5 below). The self-management experiments are designed to help patients achieve selfselected short-term goals (eg, changing from whole milk to skim milk). 2. Discuss the emotional impact of living with diabetes. Living with diabetes raises emotional issues related to relationships, work, family, economic circumstances, overall health, physical functioning, and other life events. Emotions often have a strong influence on patients' self-management decisions. Discussing the emotional aspects of living with diabetes is usually therapeutic in and of itself. During group sessions patients were encouraged to discuss the emotional impact of living with diabetes. 3. Engage the group in systematic problem-solving. The fundamental principle in forming the structure and process of this DSME program was that the questions and concerns of patients were the focus of the program. The topics and issues discussed during the group sessions were ones introduced by patients. The problems addressed include interacting with health care providers as well as selfmanagement and psychosocial issues. The flow of each session was determined by the questions and concerns introduced by participants during that session. 4. Ask diabetes self-management questions. This component provided the opportunity for patients to inquire about diabetes selfmanagement-related issues. The question-and-answer (Q&A) component provided patients with the diabetes self-management information usually contained in the lectures presented in traditional programs. Often a particular topic area was identified by the educator for a Q&A session to ensure a coherent discussion. 5. Choose a self-management experiment. This component provided patients with an opportunity to identify a self-management experiment to help them achieve one of their short-term goals. However, patients were not pressured to conduct an experiment if they did not wish to. They were then given the opportunity to share their goal and experiment. Sometimes patients revised their plan based on the discussion, but it was made clear that the individuals carrying out the experiment were the best judge of what would work for them. This list of the five core components is intended to provide a conceptual framework for the sessions, not a literal agenda. Living with diabetes is a holistic experience; therefore, in practice, the five core components were usually dealt with in a fluid, dynamic, and integrated fashion. The group process was based on, and therefore bears great fidelity to, the patients' experiences of living with diabetes. Careful records were kept to ensure that all of the content areas required by the national standard for DSME were addressed over the course of the program.22 Table 1 contains questions and strategies for use in each of the five components. These group DSME interventions resulted in significant (P <0.0001 to P <0.01) improvements in metabolic status, self-management behavior, and psychosocial adaptation to diabetes that, with follow-up, were sustained for one year. However, it must be noted that in the study of the six-week program, patients in the six-week wait listed control group started making changes in their self-management behavior as soon as they enrolled in the study.55 After conducting almost 250 of these collaborative, patient-centered group sessions, it is clear that patient participation is lively, enthusiastic, and sustained. These DSME interventions have demonstrated that patients are not interested in diabetes; rather, they are interested in their own diabetes.

STRATEGIES FOR INTERACTIVE, COLLABORATIVE DSME

This section contains a set of interactive teaching/learning strategies suitable for patientcentered, collaborative DSME. It has been adapted from material contained in The Art of Empowerment: Stories and Strategies for Diabetes Educators. 51 Interactive learning strategies help patients develop the skill of thinking critically, so they can make appropriate decisions about the self-management of their diabetes. People learn to think critically by practicing. Learning this way requires an environment that both challenges and nurtures patients. Patients need an environment that feels psychologically safe and supportive, so they are comfortable thinking out loud, making mistakes, and taking intellectual and emotional risks. Patients also need opportunities to identify, prioritize, analyze, and solve problems related to the self-management of their diabetes. The following strategies can be used in both group and/or one-to-one DSME. Many of these activities can be used in combination with one another.

Questions
Asking appropriate questions is one of the most effective techniques for promoting critical thinking in patients with diabetes. Questions should not focus on the recall of information (an oral quiz), but rather on helping patients identify and solve problems. For many providers, teaching equals telling, ie, the transfer of information. While providing information is certainly a part of teaching, the creative use of questions is a far more powerful stimulus for learning. Whenever a question is asked, whether it is of an individual patient or a group of patients, that question focuses the attention of the patients on the subject manner contained within the question. For example, imagine that a giant mural painted on a wall represents a patient's life with diabetes, portraying numerous people, events, and locations. Standing in front of the mural the provider turns to the patient and asks, "Who is this person?" or "What does this event mean to you?" These questions focus the attention of the patient on a particular aspect of living with diabetes.

Table 1. Structure of the DSME Group Sessions 51

Component 1: Reflect on diabetes selfmanagement experiments Component 2: Discuss the emotional impact of living with diabetes What feelin gs does havin g diabe tes bring Component 3: Engage the group in systemic problem solving Component 4: Ask diabetes self-management questions Component 5: Choose a selfmanagement experiment

Invite patient s to describ e what they did and what happen

Invite patient(s) to identify a problem or concern to address Use the group to

Answer diabetesrelated clinical and health questions raised by participant s

What will you do? When and where will you do it? Who will

ed Did it help them reach their shortterm goals? What did they learn about themse lves from this experie nce? What did they learn about their diabete s selfmanag ement? How can they incorpo rate what they learned into their diabete s selfmanag ement?

up for patie nts? How do they feel when they get a negat ive test result ? How do these feelin gs influe nce their selfmana geme nt decisi ons? How do they feel about how other s react to their diabe tes?

generate possible solutions to the problem Invite the patient to identify facilitators and barriers to implement ing possible solutions Invite the patient to chose one of the solutions based on its "goodnes s of fit" with his/her situation

Encourage participant s to share knowledge within the group Encourage participant s to seek consultatio n with health care providers when necessary Address psychosoc ial, behavioral and clinical issues in an integrated holistic fashion, ie, the way patients experienc e living with and managing diabetes

be involved ? How will you evaluate the outcome of your experim ent?

Asking "just the right question" can prompt an important insights and/or disclosure by a patient. Developing the skill of asking productive questions requires listening attentively to what is being said and then making a judgment about what should come next. The ability to use questions to nurture and challenge patients is an art that can be refined continuously over the course of one's career.

Facilitating Self-Directed Behavior Change The following section details questions for facilitating self-directed behavior change during individual DSME. A. What part of living with diabetes is most difficult or unsatisfying? Would you tell me more about that? Would you give me some specific examples? The purpose of these questions is to focus the discussion on the patient's concerns about living with and caring for diabetes. Providers and patients often have different priorities about the most important issues related to diabetes care. Patients are most likely to make changes that will solve problems that are personally meaningful and relevant to them. B. How does that (the situation described above) make you feel? Are you feeling (insert the feeling, eg, angry, sad, confused, etc.)? Are you feeling this because of (insert the reason)? As mentioned earlier, patients seldom make and sustain changes in situations unless they care deeply about solving the problem or improving the situation. It is common for people to repress uncomfortable emotions, and repressed emotions reduce the energy and clarity necessary for effective problem solving. Discussing the feelings associated with a particular diabetes care situation can energize patients. When patients experience the depth of their anger, sadness, or dissatisfaction by talking about their feelings, they are much more likely to take action. C. How would this situation have to change for you to feel better about it? Where would you like to be regarding this situation in (insert specific time, eg, one month, three months)? What will happen if you don't do anything to change this situation? How will you feel if things don't change? The purpose of these questions is to help patients concretely identify how the situation would appear if it were improved. This means imagining the particulars of the situation if they were to be changed and imagining how the patients would feel if the situation improved. It is also useful to help patients imagine how they would feel if things did not improve. This question helps patients focus on tangible elements in the situation that must change for them to feel better. D. Are you willing to take action to improve the situation for yourself? How important is it to you for this situation to improve? These questions help patients develop clarity about whether or not they are fully committed to changing the situation, which is crucial. However, for the questions to have an impact, patients should feel free to make or not make a commitment to change. It is important that patients do not feel pressured to change to please the provider, because changes made in response to such pressure seldom last. E. What are some steps that you could take to bring you closer to where you want to be? What could you do to help solve this problem? Are there any barriers you would have to overcome? Are there other people who could help you? These questions help patients develop a specific plan that will make their commitment to change more tangible. It is useful to consider the various actions that could be taken,

barriers to those actions, and potential resources (personal and otherwise) that patients could use to help themselves. F. What is one thing that you will do when you leave here to improve things for yourself? This question helps patients focus on the first thing they will do to begin improving the situation. It is useful to end the session by having identified at least one immediate step the patient will take to begin the behavior change process. It is helpful, in many situations, to write down the action so that subsequent visits can include a discussion of how the problem-solving process proceeded and new strategies that can be made if the process was not successful. Patients may wish to take a written copy of their plan home with them. Commitments tend to be more binding when they are expressed publicly and/or documented: "I (the patient), will do (what, when, where, and with whom)." Table 2 contains questions that can be used during group DSME sessions. The following are suggestions for ways to use questions effectively to stimulate learning. 1) Wait for answers. Most teachers wait about one second after asking a question before either answering that question or asking another. However, it takes most people three to five seconds to formulate an answer. One way to develop the habit of waiting an appropriate amount of time after asking a question is to recite a short nursery rhyme silently to yourself. For example, "Baa baa black sheep, have you any wool? Yes sir, yes sir, three bags full." Please feel free to substitute a different nursery rhyme, song, or poem. 2) Use open-ended questions. Open-ended questions usually encourage discussion more effectively than closed-ended questions. Closed-ended questions can be answered yes or no; open-ended questions require a more detailed response. Closed-ended question. Provider: "Have you ever had a low blood sugar reaction?" Open-ended question. Provider: "How do you feel when you have a low blood sugar reaction?" 3) Match questions to patients' knowledge. Most diabetes education focuses on the lower three levels of Bloom's Taxonomy of Educational Objectives: 56 1) knowledge, 2) understanding, and 3) application. If patients are unable to answer questions, it may be that the questions being asked are at a level that is too high for them. A simpler question at a lower level will usually help. For example, if patients seemed unable to discuss how to prevent hypoglycemia, then a question at the understanding (application) level would be appropriate. For example, "What have you learned about low blood sugar reactions?" Conversely, if patients can answer questions too easily, then more complex questions at a higher level of the taxonomy are appropriate. 4) Use questions to move back and forth between principles and applications. Learning can be stimulated continually, shifting the patient's attention back and forth between principles and applications. For example, a discussion about the principles of insulin action could be followed by a question that will prompt a discussion about a specific insulin injection regimen that illustrates those principles. After a discussion has focused on either the applications or the principles, it helps to use questions to shift attention to the other domain to stimulate and reinforce learning.

5) Avoid oral quizzes. Quizzes, disguised as discussions, are usually negative experiences for patients. If it is necessary to test knowledge levels publicly, inform the patients that you are going to ask a few questions to determine their level of knowledge so that you can tailor your instruction. Most people are uncomfortable answering questions incorrectly in a group setting, unless the group has been together for a while and has a very high level of trust. Questions that encourage critical thinking and/or the sharing of personal experiences are more effective in stimulating learning than oral quizzes. 6) Use appropriate tone. The tone of questions can be crucial to their success. Questions that are used to interrogate patients or to try to persuade them to reach preordained conclusions are usually received unfavorably. Patients often resent directed questioning (pointed toward a particular conclusion) because it is manipulative. If you have a point you want to make and are unwilling to accept an alternative point of view, it would be better to make your point as a statement rather than asking questions, hoping that the patients will come up with the "correct" point of view. 7) Use more questions and discussions and fewer lectures. Appropriate use of questions stimulates critical thinking, sharing of personal experiences, problem solving, and reflection. Many providers do not make use of questioning as a learning strategy because they have been conditioned to believe that teaching equals telling. Limit presentations to 10 to 15 minutes because the attention of most patients wanders after that length of time. Long lectures can be broken into short presentations interspersed with question-stimulated discussion sessions. This approach works especially well with adult learners. Educators can use questions to focus the attention of patients on particular topics, thus ensuring required content areas are covered.

Table 2. Questions That Can Be Used During Group Sessions51 1. 2. 3. 4. 5. 6. 7.

Why did you join this class? What do you expect to have at the end of this program? What part of having diabetes is most worrisome or confusing? We have handed out a form with your (A1c, blood pressure, cholesterol) lab results. Next to your value is the normal value. What questions do you have? Today's topic is _______ (eg, complications of diabetes). What complications are you aware of? What have you heard, seen, or experienced personally about _______ (eg, vision problems)? Do you believe that you will get the complications of diabetes no matter what you do?

8. What one thing could you change between now and our next class that might
make things better for you?

Listening Attentively
Obtaining the maximum value from asking questions requires that providers listen attentively to their patients' answers; this is especially true of questions that encourage patients to share personal experiences.51 Listening attentively means that providers strive to focus their attention on the patient while using their senses, mind, and heart to perceive, understand, and appreciate their patient's experience. This is done by listening to the meaning of the patient's words, explicit and implicit, and tuning in to the fears, hopes, and

anxieties of the patient. Being listened to this way helps patients feel accepted and understood. It is rare for most patients to be listened to without being judged, criticized, or persuaded. Listening to patients without judgment conveys respect and reaffirms the validity of their experience. It also allows patients to lower their defenses and explore more candidly their experience of living with diabetes. Withholding advice, solutions, and provider insights allows patients to see, feel, and express more deeply what is true for them. When provided with this kind of opportunity for personal reflection, patients often realize how deeply they care about the issues related to their diabetes. Problems, goals, barriers, and strategies for change often emerge naturally during the discussion. Free from blame, patients can begin to see and communicate on a deeper and more authentic level, and that communication leads naturally to the identification of the next steps to take. Providers can help patients ask themselves, "What do I really want? What would I have to do to achieve my goals?" To be able to explore and address such questions truthfully can be a wonderful experience. Attentive listening also provides patients with the opportunity to listen to themselves. Asking questions for clarity and summarizing the patients responses not only helps providers better understand the problem, but also helps patients gain insight and clarity. Insight often leads to change. Table 3 contains an attentive listening experiment that providers can use to explore the challenges and benefits of listing attentively to patients.51 This experiment can result in important and useful insights whether done individually or by group of providers who after completing the experiment follow-up with a discussion. Although it is important to listen attentively in any educational setting, one-to-one sessions usually allow for greater degrees of psychological safety, intimacy, and self-disclosure.

THE DIABETES SELF-MANAGEMENT EXPERIMENT WORKBOOK

The Diabetes Self-Management Experiment Workbook (Figure 1) can be used in one-toone and/or group education.51 It works equally well in both settings. This workbook is based on the concept of experimenting with self-management behavior changes. It eliminates the idea of success or failure associated with achieving goals. The purpose of an experiment is to learn. Whether a plan to make a self-management change works or not, the learning associated with that experiment can be used to help the patient develop a more realistic and effective diabetes self-management plan. One way to think of the Self-Management Experiment Workbook is as a continuous cycle of examining four questions with patients, which are: 1) what does the patient want to change?; 2) what did the patient try out?; 3) what was the result of what the patient did?; and 4) what will the patient try out next? This approach entirely eliminates the notion of success or failure, good or bad, cheating, or any of the other emotionally laden judgmental concepts that have been traditionally been associated with diabetes education. Figure 1 shows a sample page from the workbook. In actual use, the workbook has pages with empty boxes following the sample entries. Directions on how to use the self-management workbook are described in the next section.

Table 3. Attentive Listening Experiment: Diabetes Through the Eyes of the Patient
51

1) Ask

"What is the most difficult part of having diabetes for you?" 2) Listen Listen to the patient's story for at least five minutes without interrupting to redirect, offer advice, or express an opinion. The goal of the experiment is to learn about the most difficult part of living with diabetes from the patient's point of view. 3) Encourage If there is a pause, encourage the patient to tell you more of his or her story. You can use an empathic response, eg, "It sounds like you have had a rough time of it," or you can ask an exploratory question, eg, "What's that been like for you?" or "How does that make you feel?" The crucial element of the experiment is to continue to ask open-ended questions (and only questions) for at least five minutes. 4) After the Experiment Continue talking with the patient. Respond as you would naturally. The following questions can be useful for continuing a dialogue with the patient. "How would things have to change for you to feel better about this situation?" "Have you tried to deal with this situation in the past? If so what happened?" "Can you think of any steps that you could take that might bring you closer to where you want to be?" "What can I do to help you?"

Attentive Listening Experiment Results What was the most important thing that you learned about the patient? What was it like for you to listen for five minutes without offering advice or problem solving? How can you incorporate what you learned into the patient's care?

Self-Management Experiment Workbook Directions The workbook is designed to help patients take steps toward better health. It is set up so they can try out changes in their eating, physical activity, responses to stress, or other aspects of their diabetes self-management. A self-management change that fits one person's life will not necessarily fit another's. The final choice about what self-management plan works has to be made individually by each patient.

Figure 1. Sample Page in the Self-Management Workbook

SelfManagement Experiment Start Date Stop Date Result Commments

1. Change from 2/2/06 whole milk to 2% milk 2. Substitute regular French 2/16/06

2/13/06

It works.

Took a few days but tastes fine now. This works fine.

2/28/06

OK.

dressing with reduced-calorie French dressing on salads 3. 10 oz steak in restaurant to 6 oz steak in restaurant 4. Trim all the fat from my steak in a restaurant 5. Vegetables with margarine to vegetables plain. 6. Put low-fat spread on vegetables instead of margarine. 3/4/06 3/9/06 No way! I hate feeling hungry after a meal, especially in an expensive restaurant. No problem.

3/9/06

3/15/06

Fine.

3/17/06

3/21/06

No way!

Vegetables with all the taste sucked out. This isn't heaven, but I can get used to it. After being late twice, I almost gave up on this one, but now that I am used to the walk, I enjoy it. I almost died the first time. Now I climb as many flights as I can and take the elevator the rest of the way.

3/21/06

3/29/06

OK.

7. Park in the 4/3/06 outer lot and walk 1/4 mile to office

4/14/06

OK.

8. Walk upstairs 6 flights to cafeteria at lunch

4/18/06

4/26/06

Sometimes.

Because it is impossible to know ahead of time which self-management changes will work for each person, this workbook has been set up as a series of experiments. The purpose of an experiment is to learn. Each time patients experiment with a self-management change they learn something. They learn whether it works and whether they want to make it a permanent part of their self-management. Or they may find that it is not a change they are willing or able to fit into their self-management plan. They can then use what they learn to plan (and try) future self-management experiments. There is no failure in this type of program. Whether patients make a permanent change or not, they know a little bit more about themselves and can make a wiser decision about their next self-management experiment.

TIPS TO HELP ACHIEVE LONG-TERM BEHAVIOR CHANGES

The following is a set of tips for helping patients succeed in making long-lasting behavior changes. 51 A. One step at a time. Make one change at a time. Changes are easier to make and more likely to last if patients make them one at a time. Before too long, a series of small changes can result in a major alteration in patients' self-management and lifestyle. B. Easy does it. Focus on changes that your patients believe will work. Changes that are likely to work are ones that your patients feel enthusiastic about and believe strongly that they can carry out. Save tougher changes for later&mdashafter patients have succeeded in making some less demanding changes. C. Take small steps. For example, if you have patients who drink whole milk and want to try drinking fat-free milk, advise them to do it in a series of small changes (eg, switching from whole to 2% milk, then from 2% to 1%, and finally 1% to skim milk). Making changes like these in small steps is a way to help your patients gradually adapt to a larger change later. D. Don't go it alone. Advise your patients to ask for support when they need it. It is hard to make long-lasting lifestyle changes without the support of other people. Often patients think those close to them should know what they want in the way of support without having to be told. If your patients are making changes for their health and want the help of their friends, family, or co-workers, advise them to ask for it. Have them tell the people from whom they want support what they are doing, why it is important, and specifically what they want in the way of help. E. Play to win. Help your patients identify the behavior changes that will be the most meaningful to them personally. Start with these changes even if, as a health care provider, you believe different changes would have a greater positive impact on your patients' health. Patients are more likely to succeed in making changes that are important to them personally than they are with changes that the provider thinks are important. After patients have succeeded in making some personally meaningful changes is the time to discuss the changes the provider thinks are important.

CONCLUSION
The human and financial costs associated with diabetes and its complications have been increasing, yet much of this is preventable. Because patients are responsible for the daily management of their illness, diabetes self-

management education is essential to help patients obtain the knowledge, skills, and attitudes they need to improve their metabolic status, self-management skills, and overall quality of life. The role of health care providers as educators, behavior change coaches, and sources of psychosocial support and encouragement is a vital component of their patients' ongoing efforts to succeed as diabetes self-managers. This monograph provides resources that will allow health care professionals to help their patients succeed in the daily self-management of their diabetes.

TIPS FOR PHARMACISTS AND PHYSICIANS FOR SUPPORTING DIABETES SELF-MANAGEMENT

All diabetes care providers can and should include patient education each time they interact with patients. However, physicians and pharmacists are less likely than nurses and dietitians to teach in group settings or in extended one-to-one visits devoted to diabetes education. Although their time with patients may be limited, there are several ways they can support patients' self-management, which include: 1. Reinforce the importance of diabetes education. Know the names and locations of diabetes programs and diabetes educators in your area and have this information in writing to give to your patients. 2. Use your limited time to deliver core messages. a) "Diabetes is a serious disease even if you don't feel sick." b) "You are in control. The choices you make every day will influence your health more than any other single factor." c) "We know for certain that keeping your blood glucose well controlled will reduce your risk of complications." d) "With diabetes knowledge comes power. The more you know, the better you can manage your diabetes." e) "Support from your friends and family is crucial for many patients, but you may need to tell them what you need in the way of support. Just because they care about you doesn't make them mind readers." f) "Do you know others who have or had diabetes?" A patient whose grandmother lost her eyesight 25 years ago may believe that blindness is an inevitable outcome of diabetes. Such a belief provides the opportunity to inform the patient that we now have the knowledge and technology to prevent such outcomes. 3. Change "you should" messages into "something to think about" messages. Adults often resist being told what to do even if they are being given good advice. For example, "I had a patient that decided to write down every thing she ate. She told me that just looking over the list each day helped her make changes. It might be something to think about." Another way to use this approach is to end the interaction by giving the patient a question to ponder: "What do you think would happen if you tried parking further away from the office each morning to get in some walking?" Finally, the core messages mentioned in #2 can all be delivered as "something to think about" messages. 4. Develop a handout with credible diabetes-related web sites. This will reduce the time spent correcting misinformation patients find on the internet and should include: The American Diabetes Association

The Centers for Disease Control

The National Institutes of Health

The National Diabetes Education Program

5. Take advantage of "teachable" moments. Diagnosis is usually a teachable moment. Patients are trying to determine what it means to have diabetes. This is an excellent time to deliver the core messages listed in #2. For a physician, a new finding presents an opportunity. For the pharmacist, a change in the medication regime is another example, especially if patients are starting insulin. In this instance, the provider may have an opportunity to correct common myths about insulin. 6. Dispel common myths patients may have regarding taking insulin, which include: a) It leads to long-term complications. b) It means patients have failed and their diabetes is now much worse. c) It means a very restricted lifestyle. d) It will make managing their diabetes very difficult.

REFERENCES
1. American Diabetes Association. Diabetes statistics. Total prevalence of diabetes & pre-diabetes. Available at http://www.diabetes.org/diabetes-statistics/prevalence.jsp. Accessed February 6, 2006. 2. CDC. National Diabetes Fact Sheet. United States, 2005. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf. Accessed February 6, 2006. 3. Hogan P, Dall T, Nikolov P. Economic costs of diabetes in the US in 2002. Diabetes Care. 2003;26:917932. 4. Rubin RR, Peyrot M. Quality of life and diabetes. Diabetes Metab Res Rev. 1999;15:205-218. 5. Lustman PJ, Griffith LS, Clouse RE. Depression in adults with diabetes. Results of 5-yr follow-up study. Diabetes Care. 1988;11:605-612. 6. DeGroot M, Jacobson AM, Samson JA, Welch G. Glycemic control and major depression in patients with type 1 and type 2 diabetes mellitus. J Psychosom Res. 1999;46:425-435. 7. Centers for Disease Control Cost Effectiveness Group. Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. JAMA. 2002. 287:2542-2551. 8. Pyorala K, Pedersen TR, Kjekshus J, et al. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. A subgroup analysis of the Scandinavian Simvastatin Survival Study (4S). Diabetes Care. 1997;20:614-620. 9. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomized trial. Lancet. 1998;351:1755-1762. 10. Saaddine JB, Engelgau MM, Beckles GL, et al. A diabetes report card for the United States: quality of care in the 1990s. Ann Intern Med. 2002;136:565-574. 11. Clinical Practice Recommendations 2006. Diabetes Care. 2006;29(suppl 1):S5-S13. 12. Lutfey KE, Wishner WJ. Beyond "compliance" is "adherence." Diabetes Care. 1999;22:635-639. 13. Peyrot M, Rubin RR, Lauritzen T, et al. Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study. Diabetes Med. 2005;22:1379-1385. 14. Rubin RR. Adherence to pharmacologic therapy in patients with type 2 diabetes. Am J Med. 2005;118:275-345. 15. Norris SL, Lau J, Smith SJ, et al. Self-management education for adults with type 2 diabetes: a metaanalysis of the effect on glycemic control. Diabetes Care. 2002;25:1159-1171. 16. Norris SL, Engelgau MM, Venkat Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized control trials. Diabetes Care. 2001;24:561-587. 17. Brown S. Studies of educational interventions and outcomes in diabetes adults: a meta-analysis

revisited. Patient Educ Couns. 1990;16:189-215. 18. Norris SL, Nichols PJ, et al. Increasing diabetes self-management education in community settings. A systematic review. Am J Prev Med. 2002;22:39-43. 19. Gary TL, Genkinger JM, Guallar E, et al. Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes. Diabetes Educ. 2003;29:488-501. 20. Brown S. Interventions to promote diabetes self-management: state of the science. Diabetes Educ. 1999;25:52-61. 21. Fain JA, Nettles A, Funnell MM, Charron D. Diabetes patient education research: an integrative literature review. Diabetes Educ. 1999:25(suppl 6):7-15. 22. Mensing C, Boucher J, Cypress M, et al. National standards for diabetes self-management education. Diabetes Care. 2006;29(suppl 1):S78-S85. 23. Mensing CR, Norris SL. Group education in diabetes: Effectiveness and implementation. Diabetes Spectrum. 2003;16:96-103. 24. Rickheim PL, Weaver TW, Flader JL, Kendall DM. Assessment of group versus individual diabetes education. Diabetes Care. 2002;25:269-274. 25. Heller S, Clarke P, Daly H, et al. Group education for obese patients with type 2 diabetes: greater success at less cost. Diabetes Med. 1988:5;552-556. 26. Norris SL, Engelgau MM, Narayan KMV. Effectiveness of self-management training in type 2 diabetes. Diabetes Care. 2001;24:561-587. 27. Deakin T, McShane CE, Cade JE, Williams RD. Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2005;2:CD003417. 28. Chicoye L, Roethel CR, Hatch MH, Wesolowski W. Diabetes care management: a managed care approach. WMJ. 1998;97:32-34. 29. Ratner RE. Long-term health care outcomes in diabetes. Economic and political implications. Endocrinol Metab Clin North Am. 1997;26:487-498. 30. Fisher EB Jr, Heins JM, et al. Metabolic Control Matters: Nationwide Translation of the Diabetes Control and Complications Trial: Analysis and Recommendations. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases; 1993. 31. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Quarterly. 1996;74:511-544. 32. Anderson RM. Patient empowerment and the traditional medical model. Diabetes Care. 1995;18:412415. 33. Anderson RM, Funnell MM. Theory is the cart: vision is the horse: reflections on research in diabetes patient education. Diabetes Educ. 1999;25(suppl 6):43-51. 34. Funnell MM. Integrated approaches to the management of NIDDM patients. Diabetes Spectrum. 1996;9:55-59. 35. Glasgow RE. A practical model of diabetes management and education. Diabetes Care. 1995;18:117126. 36. Glasgow RE. Outcomes of and for diabetes education research. Diabetes Educ. 1999;25(suppl 6):7488. 37. McCulloch DK, Glasgow RE, Hampson SE, Wagner E. A systematic approach to diabetes management in the post-DCCT era. Diabetes Care. 1994;17:765-769. 38. Von Korff M, Gruman J, Schaefer J, et al. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-1102. 39. Kaplan SH, Greenfield S, Ware JE. Assessing the effects of physician-patient interactions on the outcome of chronic disease. Medical Care. 1989;27:110-127. 40. Street RL Jr, Piziak VK, Carpentier WS, et al. Provider-patient communication in metabolic control. Diabetes Care. 1993;16:714-721. 41. Funnell MM, Anderson RM, Fitzgerald JT, et al. Study of certified diabetes educators: influences and barriers. Diabetes Educ. 2006;(under review). 42. Anderson RM, Funnell MM, Arnold MS. Using the empowerment approach to help patients change behavior. In: Anderson B, Rubin R, eds. Practical Lessons from Psychology for Diabetes Clinicians. Alexandria, VA: The American Dietetic Association; 1996. 43. Etzwiler DD. Chronic care: a need in search of a system. Diabetes Educ . 1997;23:569-573. 44. American Diabetes Association: report of the task force on the delivery of diabetes self-management of education and medical nutrition therapy. Diabetes Spectrum. 1999;12:44-47. 45. Anderson RM. Is the problem of noncompliance all in our heads? Diabetes Educ. 1985;11:31-34. 46. Johnson SB. Methodological issues in diabetes research: measuring adherence. Diabetes Care. 1992;15(suppl 4):S1658-S1667. 47. Glasgow RE, Wilson W, McCaul KD. Regimen adherence: a problematic construct in diabetes research. Diabetes Care. 1985;8:300-301. 48. McNabb WL. Adherence in diabetes: can we define it and can we measure it? Diabetes Care. 1997;202:215-218. 49. Glasgow RE, Anderson RM. In diabetes care, moving from compliance to adherence is not enough: something entirely different is needed. Diabetes Care. 1999;22:2090-2091. 50. Funnell MM, Anderson RM, Arnold MS. Empowerment: a winning model for diabetes care. Practical Diabetology. 1991;10:15-18. 51. Anderson RM, Funnell MM. The Art of Empowerment: Stories and Strategies for Diabetes Educators.

2nd Edition. Alexandria, VA: American Diabetes Association; 2005. 52. Feste C, Anderson RM. Empowerment: from philosophy to practice. Patient Educ Couns. 1995;26:139144. 53. Funnell MM, Anderson RM, Arnold MS, et al. Empowerment: an idea whose time has come in diabetes education. Diabetes Educ. 1991;17:37-41. 54. Tang TS, Gillard ML, Funnell MM, et al. Developing a new generation of ongoing diabetes selfmanagement support interventions (DSMS): a preliminary report. Diabetes Educ. 2005;31:91-97. 55. Anderson RM, Funnell MM, Nwankwo R, et al. Evaluating a problem-based empowerment program for African Americans with diabetes: results of a randomized controlled trial. Ethn Dis. 2005;15:671-678. 56. Bloom BS, ed. Taxonomy of Educational Objectives: The Classification of Educational Goals. Handbook I: Cognitive Domain. New York, NY: Longmans, Green; 1956.

BACK to TOP

View Exam

Take Exam

Print Version

Copyright 1997 - 2007 Jobson Medical Information LLC / Power-Pak C.E. unless otherwise noted. All rights reserved. Reproduction in whole or in part without permissio