Self-monitoring for long term conditions like diabetes is all the rage in the new NHS. To be fair, it has long been advocated, but it is, happily, really centre stage at the moment. The idea that looking after your own health, taking responsibility and being personally involved in decisions about treatment, is central to the NHS reforms, summed up by the phrase ‘no decision about me, without me’.
It’s a welcome change from historical services for people with long term conditions, (which, incidentally, they have always managed themselves for the most part, so the idea is not new, just reality being acknowledged). The previous approach was based on following ‘doctor’s orders’ and woe betide you if you got it wrong as this would lead to a ‘telling off’ appointment with a penance of more rules to follow until the next time. For many, ‘getting it wrong’ was most of the time because doctor’s orders (often without explanation) is one thing, but having the tools to do the job, such as information, testing equipment and discussions with others, is quite another. There used to be way too much of the former ‘rules’ and not nearly enough of the latter ‘means’. Thankfully that has all changed now, or at least is in the process of changing, as we have discussed regularly on this blog.
But have new rules replaced the old ones, bringing their own difficulties in applying them? For example, Diabetes UK have an admirable website, which includes a great deal of information for all ages and types of diabetes. On there is a page called ‘monitoring your health’, which sets out the need for ‘knowing your blood glucose, your blood pressure and blood fat levels, as well as the condition of your feet and getting your eyes screened for retinopathy’. While this may be accurate, it is a pretty tall order to hold in your mind every day whilst trying to juggle the usual demands of family, work and social life. It’s possible that someone could get it equally ‘wrong’ with knowledge as they may previously have done without it!
It was with these thoughts in mind that our latest ebook was born. Trying to address the question ‘how do I remember what’s important about managing my diabetes whilst getting on with my life?’, one answer has come in the form of ‘Diabetes ‘Forget-Me-Nots’, a bright and friendly little ebook with a mission to act as a spare diabetes memory! We hope it’s going to live on people’s ebook reader, tablet or computer so that when it comes to following the ‘rules’ of the moment, it can offer that extra bit of help and confidence to get it right - for a change.
References
Diabetes UK: Monitoring Your Health
Diabetes 'Forget-Me-Nots'
Showing posts with label communication. Show all posts
Showing posts with label communication. Show all posts
Tuesday, 3 September 2013
Friday, 31 May 2013
Help with Hurdling: Getting over the Barriers to Self Management
A recent review article in the journal 'Diabetic Medicine' described in detail the kind of barriers that get in the way of people with diabetes from being able to successfully self manage their condition, that is, taking the actions that are likely to promote and maintain health, such as measuring blood glucose, taking and adjusting medication, looking after feet, eating healthily being physically active and taking steps to prevent or deal promptly with hypoglycaemia and high blood glucose levels.
While a review article doesn’t aim to make recommendations for changes in practice, in describing the evidence for each of the barriers, it does reveal what is effective or less effective. This is helpful because, ideally, it gives the chance for diabetes services and health professionals to use the evidence base to implement effective strategies for promoting and supporting self management and ‘lose’ the less effective ones.
Unfortunately this is not always what happens. Translating knowledge into action in relation to living with diabetes is in fact cited as one of the barriers. For example, the knowledge that persistent high blood glucose levels can lead to long term complications does not lead most people to keep their blood glucose levels within recommended ranges all the time. And it is exactly the same with health professionals – the knowledge that telling people what to do, advice giving and ‘warnings’ about complications is not effective in helping people manage their diabetes, does not stop them doing it regularly. There are other factors involved in effectively taking action and some of these are illuminated in this review article.
In keeping with previous blogs, I would like to suggest that in the evidence for effectiveness cited for each of the factors, there are as many messages for people working with diabetes as there are for those living with it, and reflecting and taking action on these could potentially help us all to feel more successful and satisfied in our efforts.
So, to make it easier than reading the whole paper in a lofty journal – who has time for that?! - here’s an SD 'key points' guide for both health professionals AND people with diabetes, along with some of the strategies that really work to promote and prize self management of diabetes, based on the evidence in this review. Think of it as your ‘hurdling guide’ - ideas for getting over the barriers when they arise!
‘Your SD Hurdling Guide’
Knowledge is important in self management. Unless someone knows what to do, why and when, they are unlikely to take useful action. However, Knowledge delivered once, or in a didactic or authoritarian way is not effective. Knowledge given in the context of an opportunity to use it, for example as part of an activity or as a result of someone's questions is much more helpful and likely to be remembered. Also, information given at diagnosis, is particularly likely to be forgotten, so must be revisited and checked. So, health professionals need to provide education and ask if it has been received, and for people learning about diabetes, they need to generate questions they need the answers to, and also check from time to time, to ensure their knowledge is accurate.
Motivation to take care of diabetes is influenced by how severe someone thinks their condition is, and how likely they believe themselves to be at risk of problems from it. Also, taking a particular action, for example starting insulin or taking up a new activity, will have benefits and barriers which will also determine whether it happens. So, health professionals need to explore with people what their perceptions are of severity, personal risk and benefits and barriers, rather than just dictate what actions they should take. For people with diabetes, being aware of the pros and cons for them of taking a particular action, and being prepared to discuss these in a consultation is very useful.
A higher level of confidence in self management makes it more likely that someone will do this effectively. Confidence can be measured on a simple 0-10 (high) scale, with discussion of the number given and working out what the barriers are if confidence is low. Discussions about confidence are vital, to shed light on what a person feels more or less able to achieve. For health professionals, this means giving people an opportunity to consider and assess their confidence and discuss it with them. For people with diabetes, it means being able to work out what they feel less confident about and why and what might improve their score in these areas.
Day to day problem solving is associated with better self management. Problem solving involves first acknowledging a problem, then working out what would improve the situation (a goal) and what action needs to be taken to achieve this. For health professionals, this means that consultations need to be based around what problems the person with diabetes is currently troubled by, then working together to set a goal and action plan. For the person with diabetes, reflection on their key problems and their preferred ways to solve them, and actively practising problem solving is helpful, to make it become an everyday habit.
Finally, social support, that is the availability of help from others, is an important factor in self managing diabetes. Support refers not only to practical, but emotional and informational help as well. People with more support seem to be more successful at taking care of their diabetes. This means that health professionals need to explore with people what kind of support they have and ways they could access more if they need it. For people with diabetes, the implication of this is to consider who and how they receive support and affirmation in managing their condition, and where there are gaps. Also, to recognise that they may need to ask for, or set up support rather than feeling like they have to 'soldier on' alone or ignore their condition for fear of what others may think.
Reference
Ahola, AJ., Groop, P-H. (2013). Barriers to self management of diabetes. Diabetic Medicine, 30, 413-420
While a review article doesn’t aim to make recommendations for changes in practice, in describing the evidence for each of the barriers, it does reveal what is effective or less effective. This is helpful because, ideally, it gives the chance for diabetes services and health professionals to use the evidence base to implement effective strategies for promoting and supporting self management and ‘lose’ the less effective ones.
Unfortunately this is not always what happens. Translating knowledge into action in relation to living with diabetes is in fact cited as one of the barriers. For example, the knowledge that persistent high blood glucose levels can lead to long term complications does not lead most people to keep their blood glucose levels within recommended ranges all the time. And it is exactly the same with health professionals – the knowledge that telling people what to do, advice giving and ‘warnings’ about complications is not effective in helping people manage their diabetes, does not stop them doing it regularly. There are other factors involved in effectively taking action and some of these are illuminated in this review article.
In keeping with previous blogs, I would like to suggest that in the evidence for effectiveness cited for each of the factors, there are as many messages for people working with diabetes as there are for those living with it, and reflecting and taking action on these could potentially help us all to feel more successful and satisfied in our efforts.
So, to make it easier than reading the whole paper in a lofty journal – who has time for that?! - here’s an SD 'key points' guide for both health professionals AND people with diabetes, along with some of the strategies that really work to promote and prize self management of diabetes, based on the evidence in this review. Think of it as your ‘hurdling guide’ - ideas for getting over the barriers when they arise!
‘Your SD Hurdling Guide’
Knowledge is important in self management. Unless someone knows what to do, why and when, they are unlikely to take useful action. However, Knowledge delivered once, or in a didactic or authoritarian way is not effective. Knowledge given in the context of an opportunity to use it, for example as part of an activity or as a result of someone's questions is much more helpful and likely to be remembered. Also, information given at diagnosis, is particularly likely to be forgotten, so must be revisited and checked. So, health professionals need to provide education and ask if it has been received, and for people learning about diabetes, they need to generate questions they need the answers to, and also check from time to time, to ensure their knowledge is accurate.
Motivation to take care of diabetes is influenced by how severe someone thinks their condition is, and how likely they believe themselves to be at risk of problems from it. Also, taking a particular action, for example starting insulin or taking up a new activity, will have benefits and barriers which will also determine whether it happens. So, health professionals need to explore with people what their perceptions are of severity, personal risk and benefits and barriers, rather than just dictate what actions they should take. For people with diabetes, being aware of the pros and cons for them of taking a particular action, and being prepared to discuss these in a consultation is very useful.
A higher level of confidence in self management makes it more likely that someone will do this effectively. Confidence can be measured on a simple 0-10 (high) scale, with discussion of the number given and working out what the barriers are if confidence is low. Discussions about confidence are vital, to shed light on what a person feels more or less able to achieve. For health professionals, this means giving people an opportunity to consider and assess their confidence and discuss it with them. For people with diabetes, it means being able to work out what they feel less confident about and why and what might improve their score in these areas.
Day to day problem solving is associated with better self management. Problem solving involves first acknowledging a problem, then working out what would improve the situation (a goal) and what action needs to be taken to achieve this. For health professionals, this means that consultations need to be based around what problems the person with diabetes is currently troubled by, then working together to set a goal and action plan. For the person with diabetes, reflection on their key problems and their preferred ways to solve them, and actively practising problem solving is helpful, to make it become an everyday habit.
Finally, social support, that is the availability of help from others, is an important factor in self managing diabetes. Support refers not only to practical, but emotional and informational help as well. People with more support seem to be more successful at taking care of their diabetes. This means that health professionals need to explore with people what kind of support they have and ways they could access more if they need it. For people with diabetes, the implication of this is to consider who and how they receive support and affirmation in managing their condition, and where there are gaps. Also, to recognise that they may need to ask for, or set up support rather than feeling like they have to 'soldier on' alone or ignore their condition for fear of what others may think.
Reference
Ahola, AJ., Groop, P-H. (2013). Barriers to self management of diabetes. Diabetic Medicine, 30, 413-420
Tuesday, 29 January 2013
‘Difficult Patients’ – How to Manage
At a recent workshop for health professionals, a couple of the participants mentioned that some of their patients were ‘really difficult’. On exploring what they meant by this, they were frustrated by people who seemed not to contribute in consultations, or didn’t attend regularly, or when they did attend, they didn’t seem particularly interested in doing what they were asked to manage their diabetes. One also mentioned that such ‘difficult patients’ also often attended with their own agenda and questions that weren’t always relevant to the consultation.
This made me reflect on how often I hear this kind of point made and also on what a powerful, emotionally charged exclamation it is, to say that you have ‘difficult patients’. What is perhaps really being said is ‘I find it really hard to meet these peoples’ needs, so I am categorising them as difficult’.
I have heard of ‘difficult patients’ in all sorts of guises – someone with Type 2 diabetes who feels nothing the health professional suggests is worth trying, a teenager with Type 1 diabetes who sits surly and unresponsive throughout the consultation or what has been described by a fellow blogger Alison Finney as ‘a nightmare patient’ in her blog shoot up or put up , referring to someone who wants to know everything about everything and discuss the pros and cons of all advice given.
I venture the view that actually, there is no such thing as a ‘difficult patient’ but there are difficult encounters between people with diabetes and health professionals. These are characterised, in my view, by strong feelings on the part of each and yes, competing agendas, which are often only partly fulfilled.
It’s often about roles. Having diabetes certainly doesn’t make you keen to adopt or adopt unquestioningly, the behaviours recommended for keeping well. Neither does being a health professional make you all – knowing or even all-powerful. However, these are frequently the roles assigned, albeit unconsciously, in a typical consultation. Herein lies where agendas can clash.
There is also the question of expectations, if not judgements. Often, thoughts that precede the ‘difficult encounter’ will be “oh no, it’s the difficult/uncompliant/badly controlled/intense/obsessional person coming in next (health professional) or ‘I hate going to this consultation, I’m fed up of never getting anything right/not having my questions answered/not being able to get a word in edgeways/being told stuff I already know’ (person with diabetes). Hence the stage is set for a tricky, unfulfilling, and most sadly of all, ultimately pointless meeting.
I paint a dire picture, I know, but I’m guessing that it’s one you may recognise, at least in part, from your experiences of consultations. If you do recognise and would like to lessen the chances of being seen as or having a ‘difficult patient’, then I’d like to offer you a few ideas from research and experience – in no particular order of importance:
• Ask about feelings: sometimes anxiety manifests as anger and silence equals upset. Acknowledging that consultations are emotionally charged can remove a great deal of difficulty
• Plan for 1 thing – and 1 only – that you’d like to achieve from the consultation and share this with the other party, ideally before or at least at the start of the consultation
• Don’t expect your consultation to be 100% perfect or have 100% perfect outcomes. You are bound to be disappointed! Seeing this meeting as just one step on the journey of diabetes is fine
• Share your feelings – yes, both of you. Not in a ‘deep and meaningful’ way, but honestly: how about ‘I’m not sure we’re getting on so well: how can I best help you today?’ or ‘coming here always makes me feel a bit of a failure I’d like to talk about what I have been doing rather than what I’ve not done’
• Examine your motives for the consultation: are you expecting the health professional to solve or take over your diabetes? Do you want your patients to do what you tell them, unquestioningly? Either way, it’s unrealistic. Consider having a conversation about 1 thing that really matters to you both, instead
• Are you talking at cross purposes because you don’t both have the same facts at your fingertips, eg test results and their meaning? If so, would sharing test results in advance of the consultation help, so you can discuss them on equal footing?
It is certainly true that the more honesty and information sharing there is in consultations, the more worthwhile experience they seem to be. While writing this I’ve also been reminded of a comment made by a colleague, who once said ‘I see the HbA1c as an invitation to look at the person’s life with them’. Could this possibly be all that ‘difficult patient’ needs from their consultation?
This made me reflect on how often I hear this kind of point made and also on what a powerful, emotionally charged exclamation it is, to say that you have ‘difficult patients’. What is perhaps really being said is ‘I find it really hard to meet these peoples’ needs, so I am categorising them as difficult’.
I have heard of ‘difficult patients’ in all sorts of guises – someone with Type 2 diabetes who feels nothing the health professional suggests is worth trying, a teenager with Type 1 diabetes who sits surly and unresponsive throughout the consultation or what has been described by a fellow blogger Alison Finney as ‘a nightmare patient’ in her blog shoot up or put up , referring to someone who wants to know everything about everything and discuss the pros and cons of all advice given.
I venture the view that actually, there is no such thing as a ‘difficult patient’ but there are difficult encounters between people with diabetes and health professionals. These are characterised, in my view, by strong feelings on the part of each and yes, competing agendas, which are often only partly fulfilled.
It’s often about roles. Having diabetes certainly doesn’t make you keen to adopt or adopt unquestioningly, the behaviours recommended for keeping well. Neither does being a health professional make you all – knowing or even all-powerful. However, these are frequently the roles assigned, albeit unconsciously, in a typical consultation. Herein lies where agendas can clash.
There is also the question of expectations, if not judgements. Often, thoughts that precede the ‘difficult encounter’ will be “oh no, it’s the difficult/uncompliant/badly controlled/intense/obsessional person coming in next (health professional) or ‘I hate going to this consultation, I’m fed up of never getting anything right/not having my questions answered/not being able to get a word in edgeways/being told stuff I already know’ (person with diabetes). Hence the stage is set for a tricky, unfulfilling, and most sadly of all, ultimately pointless meeting.
I paint a dire picture, I know, but I’m guessing that it’s one you may recognise, at least in part, from your experiences of consultations. If you do recognise and would like to lessen the chances of being seen as or having a ‘difficult patient’, then I’d like to offer you a few ideas from research and experience – in no particular order of importance:
• Ask about feelings: sometimes anxiety manifests as anger and silence equals upset. Acknowledging that consultations are emotionally charged can remove a great deal of difficulty
• Plan for 1 thing – and 1 only – that you’d like to achieve from the consultation and share this with the other party, ideally before or at least at the start of the consultation
• Don’t expect your consultation to be 100% perfect or have 100% perfect outcomes. You are bound to be disappointed! Seeing this meeting as just one step on the journey of diabetes is fine
• Share your feelings – yes, both of you. Not in a ‘deep and meaningful’ way, but honestly: how about ‘I’m not sure we’re getting on so well: how can I best help you today?’ or ‘coming here always makes me feel a bit of a failure I’d like to talk about what I have been doing rather than what I’ve not done’
• Examine your motives for the consultation: are you expecting the health professional to solve or take over your diabetes? Do you want your patients to do what you tell them, unquestioningly? Either way, it’s unrealistic. Consider having a conversation about 1 thing that really matters to you both, instead
• Are you talking at cross purposes because you don’t both have the same facts at your fingertips, eg test results and their meaning? If so, would sharing test results in advance of the consultation help, so you can discuss them on equal footing?
It is certainly true that the more honesty and information sharing there is in consultations, the more worthwhile experience they seem to be. While writing this I’ve also been reminded of a comment made by a colleague, who once said ‘I see the HbA1c as an invitation to look at the person’s life with them’. Could this possibly be all that ‘difficult patient’ needs from their consultation?
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