SELF-MANAGEMENT EDUCATION

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Objectives

After completing this module the participant

will be able to
Discuss the value of education in helping women have
healthy pregnancies
Implement all components of the teaching process, that
is assessment, planning, implementation and evaluation
Discuss ways to make communication more effective
Define what is meant by a patient centered approach to
care.
Discuss the impact of gestational diabetes and
psychological needs of women and their families

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Diabetes Self-Management Education

Purpose
To prepare those affected by GDM to
Make informed decisions
Cope with the demands of a pregnancy complicated by
GDM
Make changes in their behaviour that support their
self-management efforts

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Evidence for diabetes education

Traditional knowledge-based diabetes

education is essential but not sufficient for
sustained behaviour change.
(Piette, Weinberger, McPhee, 2000)

While no single strategy or programme shows

any clear advantage, interventions that
incorporate behavioural and affective
components are more effective.
Barlow, Wright, Sheasby, Turner, Hainsworth, 2002
Roter, Hall, Merisca, Nordstrom, Cretin, Svarstad, 1998

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Evidence for diabetes education

Diabetes self-management education (DSME)

is effective for improving psychosocial and
health outcomes, particularly in the short-term.
Barlow, Wright, Sheasby, Turner, Hainsworth, 2002
Brown, 1999
Norris, Lau, Smith, Schmid, Engelgau, 2002
Roter, Hall, Merisca, Nordstrom, Cretin, Svarstard, 1998

On-going support is critical to sustain

progress made by participants during the
DSME program.
Norris, Lau, Smith, Schmid, Engelgau, 2002
Skinner, Cradock, Arundel, Graham, 2003

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Why is self-management important?

People want to be healthy and have healthy babies.

Gestational diabetes needs to be self-managed.
Person is responsible for their day-to-day care.
24-hours-a-day management is necessary.
Active, informed self-management leads to better long-term
outcomes.

Funnell, Brown, Childs, Haas, Hosey, Jensen, et al., 2007

Norris, Lau, Smith, 2002
Gary, Genkinger, Guallar, Peyrot, Brancati, 2003
Duncan, Birkmeyer, Coughlin, Ouijan, Sherr, Boren, 2009

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What do people need to understand?

Their own personal goals, values and feelings

Diabetes care and treatment (advantages/
disadvantages)
Behaviour change and problem-solving strategies
Who is the decision-maker the woman, the
husband, the mother-in-law?
How to assume day-to-day responsibility

Funnell, Anderson, 2004

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Self-management abilities

The ability to self-manage is enhanced by

Considering the individuals need(s)
Teaching skills to optimise outcomes
Facilitating behaviour change
Providing emotional support

Von Kroff, Gruman, Schaefer, 1997

Fisher, Brownson, OToole, Shetty, et al., 2005

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A change in philosophy

Teacher knows all, makes

Didactive decisions

Teacher and patient learn and

Collaborative work together

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So what should we do?

Tell the person

Medical Cover the basics
Judge compliance
Model
Teach to the person

Patient centered
Self- Ask the person
Management Learn with the person
Education Partnership approach

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Reframe our attitudes and behaviours

Educate for informed, self-directed decisions

and problem-solving
Ask questions
Identify problems
Address concerns

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Teaching

Deliberate interventions that involve sharing

information and experiences to meet intended
learner outcomes.

Bastable, 2008

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Teaching does not necessarily result in
learning

When was the last time someone

taught you?

Did you learn anything?

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Learning

Active, ongoing process that results in

changes in insight, behaviour, perception or
motivation
Change may be positive or negative

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Who is the Learner
and
Who is the Teacher?

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16
Communication Skills

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Communicating feelings or attitudes

Verbal 7%
Vocal 38%
Visual 55%
Mehrabian, 1999

"What you do speaks so loudly that I cannot hear

what you say."
Ralph Waldo Emerson

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Watch your body language!

Avoid looking like a school teacher!

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Tips for plain speaking

Introduce your subject and state a purpose

Paint a picture, make it visual
Keep it organised
Move from simple to complex
Repetition is important three times
Summarise
Evaluate
Belton, Simpson, 2010

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Tips for plain speaking

Use the active voice

The person should be the subject of the
message
You may require medication to achieve target
blood glucose levels
Vs
Some women may require medication to
achieve target blood glucose levels

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Communication

Open-ended question
At what time do you take your medication at home?

Closed question
Do you take your medication on time at home?

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Develop listening skills

You cant talk when you listen

Listen dont plan your response
Give the person your full attention
Paraphrase and ask if you heard correctly
So, you are saying.
It sounds like..
You are wondering if....
I hear you saying.

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Reflective listening

The words
the speaker
says

What the The words

speaker the listener
means hears
How the
listener
interprets
the words

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The teaching process

Assessment
Planning
Implementation
Evaluation

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Assessment

Goals
Establish trust
Determine priorities
Assess current health status, knowledge and self-
care practices
Determine family role or other support
Identify available resources
Identify barriers to learning and self-management

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There is a difference

Health professionals and women with GDM

may have different opinions on what is
important
Ask the woman what is important to her.

Suhonen, Nenonen, Laukka, Valimaki, 2005

Timmins, 2005

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Giving the diagnosis

Will my baby be ok? 1st question often asked

Is this temporary? 2nd question
Questions provide an opportunity for teaching
Must answer truthfully
Must convey importance of management during
pregnancy for healthy outcome but also for future
health of baby and mother
Risk of type 2
Risk of obesity
Assessment

Considerations
Should be non-threatening and non-judgemental
Consider the cultural and health beliefs of the
person
Consider physical environment
Building rapport takes time

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Planning

Develop together
What do you want to know?
What must you know?

Offer choices
Individual
Classes

Write learning objectives together

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Planning

Objectives for each topic

Reviewed and updated regularly
Objectives should be
Measurable
Timely
Specific
Mutually agreed

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Implementation

Communication is the key

Simple words
Open-ended questions
Encouragement
Positive feedback
Positive, caring attitude
Active listening
Repetition

Belton, Simpson, 2010

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Implementation

Determine priorities
Begin with the learners wishes
Most important topics first and last

Conducive environment
Simple to complex
Be specific
Repeat! Repeat! Repeat!
Belton, Simpson, 2010

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Evaluation

Integral part of programme management

Through all phases
Plans should include how and when to
evaluate
Not an afterthought!

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Evaluation

Clear description
Objectives that are
- Measurable
- Specific
- Centered on the person
- Timed

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Evaluation

Individual evaluation
Have objectives been met?
Open-ended questions
How are skills used?
Do you understand? is not a valid question
Ask the person with diabetes to explain information to
you teach-back

Belton, Simpson, 2010

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5 steps to self directed goal
setting for behaviour change

1. Identify the problem

2. Explore feelings
3. Set goals
4. Make a plan
5. Evaluate the results

Funnell, Anderson, 2004

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What is the problem?

What do you find the easiest thing to manage

in your diabetes?
What is the most difficult/worst thing about
caring for your diabetes?
What are your greatest concerns/fears/
worries?
What makes this so hard for you?
Why is that happening?

Funnell, Anderson, 2004

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How do you feel?

What are your thoughts and feelings about?

How will you feel if this doesnt change?
Do you feel ________ about _______?

Funnell, Anderson, 2004

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What do you want?

How does this need to change for you to feel

better about it?
What will you gain/give-up?
What can you do?
What do you want to do?
On a scale of 1-10, how important is this?

Funnell, Anderson, 2004

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What will you do?

Can you/do you want to/will you?

What might work?
What has/hasnt worked?
What do you need to do to get started?
What one step can you take this week?

Funnell, Anderson, 2004

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SMART behavioural goals

Eat three meals

I will eat three meals every day starting tomorrow.

I will walk more

I will walk for 10 minutes at my lunch hour for four days
next week

Funnell, Anderson, 2004

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How did it work?

What did you learn?

What barriers did you encounter?
What support did you have?
What did you learn about yourself?
What would you do the same or differently next
time?

Funnell, Anderson, 2004

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How to respond?

Avoid judgments
Avoid minimising negative experiences
Celebrate with - not for
Repeat process

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Patient-Centered education

Interventions are more effective when

Tailored to individual preferences
Tailored to the persons social/cultural environment
Actively engage the person in goal-setting
Incorporate coping skills
Provide follow-up support

Piette, Weinberger, McPhee, 2000

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Activity

Imagine you have just been told you have

gestational diabetes

Think of three things you would need to

change to manage your diabetes

Then ask yourself

What would be easiest for you?
What would be hardest?

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Activity

What do you feel is supportive behaviour from

close family, friends, or the health professional?
What is not supportive?
If you had gestational diabetes, what would you
expect from the people listed above?

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Summary

Be selective
Be specific
Prioritise
Categorise
Repeat
Reinforce

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References (1 of 2)
Anderson, R.M., Funnell, M.M., Arnold, M.S). Using the empowerment approach to help patients change behavior. In Anderson, B.J., Rubin,
R.R., eds. Practical Psychology for Diabetes Clinicians, 2nd edition. Alexandria: American Diabetes Association; 2002.
Anderson, R.M., Funnell, M.M. The Art of Empowerment: Stories and Strategies for Diabetes Educators. 2nd ed. Alexandria: American
Diabetes Association; 2005.
Bastable, S. Nurse as Educator. 3rd ed. Sudbury, MA: Jones & Bartlett Publishers; 2008.
Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Self-management approaches for people with chronic conditions: a review. Patient
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Belton AB, Simpson N. The How To of Patient Education. 2nd Ed. Streetsville, ON: RJ & Associates; 2010.
Brown SA. Interventions to promote diabetes self-management: State of the science. Diabetes Educ, 25(Suppl) 1999: 5261.
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. 2008 Clinical Practice Guidelines for the Prevention and
Management of Diabetes in Canada. Can J Diab. 32,(suppl 1); 2008 :S82-83.
Duncan, I., Birkmeyer, C., Coughlin, S., Qijuan, (E)L., Sherr, D., & Boren, S. Assessing the value of diabetes education. The Diabetes Educator
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Fisher EB, Brownson CA, OToole ML, Shetty G et al. Ecological Approaches to Self-Management: The Case of Diabetes, Am J Public Health
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References (2 of 2)
Gary, T.L., Genkinger, J.M., Guallar, E., Peyrot, M. & Brancati, F.L. Meta-analysis of randomized educational and behavioral interventions in
type 2 diabetes. The Diabetes Educator 2003;29:488-501.
Harvey, J.N., Lawson, V. L. The importance of health belief models in determining self-care behaviour in diabetes, Diabetic Medicine
2009;26:513.
International Diabetes Federation. Standards for Diabetes Education, 4th ed. Brussels: IDF; 2009.
International Diabetes Federation. Diabetes Atlas, 3rd ed. Brussels: IDF; 2009.
Knowles, M. The Adult Learner: a neglected species. Houston, Gulf Publishing Co; 1984.
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Norris, S.L., Lau, J., Smith, S.J., Schmid, C.H., Engelgau, M.M. Self-management education for adults with type 2 diabetes: A meta-analysis on
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Piette, J.D., Glasgow, R.E. Education and self-monitoring of blood glucose. In Gerstein HC, Haynes RB, eds. Evidence-based diabetes care.
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diabetes care: a randomized, controlled trial. Medical Care 2000;38:21830.
Roter, D.L., Hall, J.A., Merisca, R., Nordstrom, B., Cretin, D., Svarstad, B. Effectiveness of interventions to improve patient compliance: A meta-
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