This article follows the progress of a project to support DSNs in meeting Standard 3 of the NSF for Diabetes. The workshop format provided the delegates with the opportunity to discuss shared issues and concerns

Brady, L

Bushby, P

Clarke, P

Clay, T

Dromgoole, P

Dudding, S

Hicks, D

Kadis, T

Richardson, E

Smith, F

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attendance. The meetings were chaired andfacilitated by the DSN organising group. Eachmeeting commenced with a pre-dinnerdebate about whether empowerment works. This debate set the scene for the followingday. The motion was ‘I believe self care andempowerment are essential for people withdiabetes’. Pat Clarke argued for the motionand Paul Dromgoole argued against.Pat Clarke stated that Standard 3 from theNSF for Diabetes centres on patientempowerment and that there should be apartnership in care and decision making. Sheposed the question ‘how long, on average,does a person with diabetes spend with ahealth professional?’ The answer isapproximately 3h per year, which leaves8757h of the year for patients to managetheir own condition. For this reason, we oweit to our patients to understand and takeresponsibility if outcomes are to beoptimised. Effective education is required,providing information in an acceptable form,so that patients develop the knowledge toself-manage their diabetes. Another issue iscompliance leading to concordance, forexample, only one in three people withdiabetes take all of their tablets; these aredecisions which have a major impact on long-term health (Morris, 2002).There has been much emphasis placedon nurses to help deliver thestandards within the National ServiceFramework for Diabetes (DoH, 2001),however, little guidance has been offered onhow to achieve the outcomes detailed withinthe document.With this issue in mind, a group of 13 DSNsfrom across the Yorkshire, Trent andNorthampton regions were brought togetherby a pharmaceutical company to explore howDSNs could be assisted to achieve thestandards. Empowerment (of the person withdiabetes) is mentioned strongly within Standard3 of the National Service Framework forDiabetes. The group of DSNs who organised the meetings identifiedempowerment as a crucial issue, and wanted togain an insight into how we could influence andpromote strategies to help fulfil Standard 3.Educational programme onempowermentAn educational programme entitled Standard 3:Making it work was developed by the organisingDSNs, which addressed components ofStandard 3. Two meetings were held in Mayand October 2003 which followed the sameprogramme. Figure 1 shows the group at oneof the venues.The diversity of diabetes carewas addressed by considering which strategiescould be used to achieve Standard 3 in thefollowing groups: people with type 2 diabetesand older people with diabetes, people withtype 1 diabetes and young people withdiabetes and ethnic minority groups.Over 50 DSNs and PDSNs, who attendedand participated in the meetings, were givenprereading material and shared the same aimsand objectives to achieve on the day ofSmall steps towards a large framework: a workshop approachLesley Brady, Phyllis Bushby, Pat Clarke, Tracey Clay, Paul Dromgoole,Sandra Dudding, Debbie Hicks, Tara Kadis, Eileen Richardson, Fiona SmithIntroductionThis article follows the progress of a project to support DSNs in meetingStandard 3 of the NSF for Diabetes. The workshop format provided thedelegates with the opportunity to discuss shared issues and concerns.Lesley Brady is a DiabetesSpecialist Research Nurse atSheffield, Phyllis Bushby is aSenior DSN at Manfield, PatClarke is a Senior DSN atNottingham, Tracey Clay is aDSN at Scunthorpe, PaulDromgoole is a Lecturer/practitioner - diabetes at York,Sandra Dudding is a DSN atBradford, Debbie Hicks is aSenior DSN at Hull, Tara Kadis isa DSN at Leeds, EileenRichardson is a Senior DSN atNorthampton, and Fiona Smith isa DSN at RotherhamDSN educationARTICLE POINTS1Empowerment (of theperson with diabetes)is mentioned stronglywithin Standard 3 of theNational ServiceFramework for Diabetes.2Effective education isrequired so thatpeople with diabetesdevelop the knowledgeand understanding to self-manage their condition.3The consultationbetween the healthcare professionaland the person withdiabetes should be ameeting of equals.4There is often amismatch betweenwhat the healthcareprofessional and theperson with diabetesperceive happens during a consultation.KEY WORDS Empowerment Effective education Partnership Goal settingJournal of Diabetes Nursing Vol 8 No 5 2004192Figure 1. Woodhall hotel meeting7c.p192-95_hicks.sbd.aq  20/5/04  4:56 pm  Page 1SMALL STEPS TOWARDS A LARGE FRAMEWORK: A WORKSHOP APPROACHEmpowerment is a two-way street; theempowerment model of diabetes care andeducation where the patient becomes thecentral player is recognised as a good model tohelp patients successfully manage their diabetes.Paul argued against the motion thathealthcare professionals believe that they canforce empowerment even when people donot want to be empowered. Patients havespent many years under a paternalisticmedically focused healthcare system andactually go to their healthcare professional forinstruction and advice; they do not want to bepushed into decision making (McKinstry,2000). Empowerment is often talked about interms of something we do to people, that it isexpected of our patients to play an active rolewithout appreciating that some people chooseto be passive recipients of information.Empowerment takes time and we need toconsider this in our busy clinic systems. Thedebate generated much discussion but it wasagreed that self care and empowerment areessential for people with diabetes. The following morning began with keynotespeaker, Chas Skinner, Health Psychologist,presenting differing views on empowerment.Empowerment strategiesChas opened his presentation by putting theconcept of empowerment, or the healthcareprofessionals’ view that you can empower,into context: Nearly all the decisions that affectoutcomes for the individual are made bythe individual. They have the responsibility. Nearly all the consequences of thesedecisions rest with the individual with thecondition. They have the complications. Nearly all the barriers to achieving effectiveself-management lie in the individual’spersonal and social world. They have theproblems. People will make the best decisions forthemselves given their perception of thesituation they are in. They have a lifebeyond their condition.Chas suggested that instead ofempowerment being imposed, it should beabout checking and exploring people’s valuesabout themselves and their real world. Itshould be about supporting the individual inmaking an informed choice that matches theirunderstanding and values.ARCH and SMARTIt was considered that health professionalsmight benefit from the following strategy:Accept that the consultation is a meeting ofequals, with different roles, expertise andresponsibilities.Respect the individual’s decision and that theconsultation should be about supporting theindividual in making a truly informed decision.Curious. Be curious. Not confrontational orchallenging but curious in trying to discoverwhat patients believe to be true, their valuesor understanding.Honest. Be honest concerning risk, optionsfor change and consequences of theirdecisions.In supporting the individual in their deci-sion making and action planning process, itis important for health professionals toremember some of the principles of goalsetting (Bauman et al, 2003). Goals shouldbe: Specific Measurable Actionable Realistic Time-limitedPlanning and decision makingOften there is little agreement duringconsultation as to what was discussed andperhaps agreed. Chas drew on a recent studywhich considered levels of agreement post-consultation between the nurse or dietitianand the patient (Parkin and Skinner, 2003)After 20% of the consultations there wascomplete disagreement between the nurse ordietitian and the patient on what issues werediscussed. Following 21% of the consultationsthere was complete disagreement as todecisions made. Complete agreement withwhat was discussed occurred in only 28% ofcases and complete agreement regardingdecisions made in only 47%. This study shouldmake us all conscious of mechanisms thatmight improve clarity of thought betweenourselves and our patient during andfollowing consultation.This was an enlightening presentation andone that allowed the listener to focus on theirown attitudes and beliefs, consultational styleand methods of agreeing and developingaction plans with their patients. Syndicatesessions followed the presentation. EachPAGE POINTS1Nearly all thedecisions that affectoutcomes for theindividual are made bythe individual. They havethe responsibility.2People will make thebest decisions forthemselves given theirperception of thesituation they are in.They have a life beyondtheir condition.3Often there is littleagreement duringconsultation as to whatwas discussed andperhaps agreed.Journal of Diabetes Nursing Vol 8 No 5 2004 1937c.p192-95_hicks.sbd.aq  20/5/04  4:56 pm  Page 2SMALL STEPS TOWARDS A LARGE FRAMEWORK: A WORKSHOP APPROACHthey would like to discuss with thedoctor/nurse during the consultation sothe clinic is led by the young person, i.e.their agenda not the health professional’s. Many DSNs are now using other forms ofcommunication to reach their patients,including email and texting. Some centres offer social events for youngpeople to meet and discuss issues in aninformal environment. These are acommon approach. Transition clinics for young people, whereboth paediatric and adult diabetes teamswork together are a common approach.We concluded that there is still further togo and our ‘wish list’ for the future would be: Psychological support present in clinic An up and running ‘Buddy’ scheme which ispatient led and nurse facilitated. Current and relevant patient informationthat is designed specifically for the youngperson, in a format relevant to the group,for example, CD rom.People from ethnic minorities. Themajority of DSNs who chose this group wereworking with people of south Asian origin.We firstly discussed what we mean byempowering people from ethnic minorities.The main points were that we need to be ableto understand culture and beliefs. We alsodiscussed whose agenda empowerment was,and came to the conclusion that not allpatients wish to be empowered. Therefore itmust be patient choice and we as nursesshould respect their wish.We progressed to discussing what we dowell when working with people from ethnicminorities. Health promotion was high on theagenda. As a group we were all able to shareideas of different approaches. We alsorealised that many of us were working onsimilar projects, which we hope that we willbe able to share with each other so that weare able to implement best practice.For the future, we discussed the possibilityof using the ‘expert patient’ approach,particularly in a primary care group situation.On reflection, the group highlightedpossible ways in which we may be able toempower people from ethnic minorities intheir own diabetes care, such as single sexeducation sessions, education programmeson local radio stations, multilingualeducational leaflets and videos of patientssyndicate group explored how their chosenclient/patient group could be empowered andwhat the difficulties or barriers might be. Thegroups then presented their findings to themain group in a feedback session.Feedback from syndicate groupsPeople with type 2 diabetes and elderly people with diabetes. Thediscussions in this group highlighted issues thatmay need to be addressed in relation to thisgroup of patients, such as the paternalisticattitude to healthcare delivery and the wayeducation programmes are delivered, whichvery often do not take into account the specialrequirements of the elderly population. Tosupport empowerment it was suggested that achange in the culture and perceptions of healthdelivery by both the person with diabetes andthe healthcare professional was required toallow individual wants and needs to be takeninto account. The issue of management planswas highlighted and whether there was theneed for generic plans that would need to beadapted to support this particular group ofpatients.The use of group education and how thiscan support empowerment was discussed,but questions were raised regarding the lackof and length of follow up, and whether bysupporting more structured follow-up wouldlead to better outcomes. It was suggestedthat self-help groups could also facilitate this.There was a great deal of discussion onwhether nurses have the skills to empowerpatients; it was decided after some debatethat nurses have the skills but these are oftenare used unconsciously. Barriers identified bythe group to empowerment included aperceived lack of time and training, the lack ofconfidence by the professional to let go and insome cases health professional having the ‘Iknow best mentality’.People with type 1 diabetes and youngpeople with diabetes. All the delegates inthe group for type 1 diabetes/young peopleagreed that this group is a very difficult groupto empower. They have very specificproblems not only in relation to theirdiabetes but also in the transition fromchildhood to adulthood. Some examples ofgood practice are highlighted here: One centre gives all young people attendingthe clinic a tick list for them to tick whatPAGE POINTS1To supportempowerment it wassuggested that a changein the culture andperceptions of healthdelivery by both theperson with diabetes andthe healthcareprofessional wasrequired to allowindividual wants andneeds to be taken intoaccount.2All the delegates inthe group for type 1diabetes/young peopleagreed that this group isa very difficult group toempower. They havevery specific problemsnot only in relation totheir diabetes but also inthe transition fromchildhood to adulthood.3We firstly discussedwhat we mean byempowering people fromethnic minorities. Themain points were that weneed to be able tounderstand culture andbeliefs.Journal of Diabetes Nursing Vol 8 No 5 20041947c.p192-95_hicks.sbd.aq  20/5/04  4:56 pm  Page 3SMALL STEPS TOWARDS A LARGE FRAMEWORK: A WORKSHOP APPROACHdiscussing their own experiences of diabetes.Motivational interviewingThe afternoon session began in acontroversial manner with keynote speaker,Dr Yvonne Doherty, ConsultantPsychologist, Northumbria Health Care NHSTrust, stating how DSNs should be motivatingpatients with diabetes. She implied that wewere not doing things well, that we could dobetter and that her way was the expert way.This rapidly unfolded into a ploy for debateamongst the delegates which was followed byan electric interactive session on motivationalinterviewing of patients with diabetes.Yvonne offered theoretical and practicaladvice, highlighting the positives and negativesof putting MI into practice. Small groups wereencouraged to form, allowing role-play.Practical suggestions were made, such as tapeor video recording of consultations, so thatindividuals could establish how skilled theyare at MI. In essence, this was an exhilaratingsession filled with enthusiasm. The key benefitof motivational interviewing appears to bethe role of the health professional indeveloping the patients own decision-makingstrategies and assisting greater self-relianceand self-efficacy. The healthcare professionalis directive in helping the patient examine andresolve ambivalence. Health professionalsneed to accept that patients may not be readyfor change or may have made conscious andrational decisions to maintain the status quo.Consultation style is something that allhealthcare professionals should be consciousof, particularly in relation to moving awayfrom prescribed advice. EvaluationFeedback from the delegates confirmed thatthe both meetings were well delivered andenjoyed by all (Figure 2). Verbal feedback(Figure 3) and evaluation forms confirmed thatthe content was relevant and topical.Delegates felt that the keynote speakerswere excellent and it was appreciated thatboth speakers welcomed questions andcomments during and after theirpresentations.Overall it was felt that the groups werewell organised and well facilitated, wereappropriate in size numbers and that thedelegates themselves worked well together.Group sizing (smaller rather than large)featured positively on many of theevaluation forms. Members of theorganising group felt that in smaller groupsdelegates can share their views and make acontribution to groupwork activity,whereas in a larger group one or two morevocal delegates can alter dynamics of group.(We recognise that this can also happen ina smaller group, however, a good facilitatorwould deal with this appropriately).Feedback from each syndicate group to themain group was given by a nominateddelegate.  The format of the meeting alsoafforded delegates the time to networkand exchange good practice and ideas.Most delegates reported that they wereable to take back to their workplacesomething that would make a differencein their workplace. There isoverwhelming support and interest infurther meetings this year. Throughoutthe planning and delivery stages of thedays, the organising group of DSNs wereable to build on their own personaldevelopment in areas of chairing andfacilitation skills.                              Journal of Diabetes Nursing Vol 8 No 5 2004 195DELEGATES’ COMMENTS Fantastic – well organised Excellent venue Enjoyed workshops and found them mostuseful Both excellent speakers Makes you think about current practiceand possible improvement Helpful session on empowerment – buzzword Good networking Good feedback from other groups – veryhelpful Enthusiastic about changes we can make Feels like a treat – reflects how NovoNordisk value DSNs contribution Relaxing environment with ready availablerefreshmentsFigure 3. Delegates’ commentsVery PoorPoorAverageGoodVery GoodFigure 2. Woodhall meeting results; all participants rated the meeting as very good.How would you rate the meeting contentand speakers?Bauman AE, Fardy HJ, Harris PG(2003) Getting it right: whybother with patient-centredcare? Medical  Journal of Australia179(5): 253–56Department of Health (2001)National Service Framework forDiabetes: Standards. DoH:LondonMcKinstry B (2000) Do patientswish to be involved in decisionmaking in the consultation? Across sectional survey withvideo vignettes. British MedicalJournal 321: 867–71Morris AD (2002) Considerationsin assessing effectiveness andcosts of diabetes care: lessonsfrom DARTS. DiabetesMetabolism Research and Reviews18 (Suppl 3): S32–35Parkin T, Skinner TC (2003)Discrepancies between patientand professionals recall andperception of an outpatientconsultation. Diabetic Medicine20(11): 909–14 Very poor Poor Average Good  Very goodThe organising group of DSNswould like to thank AlanGourlay, Nicki Copeland andthe Region 2 team of NovoNordisk Limited not only forproviding the funding andorganisation for these meetingsbut also for the support theyprovided the organising groupduring the whole process.7c.p192-95_hicks.sbd.aq  20/5/04  4:56 pm  Page 4

Small steps towards a large framework: a workshop approach

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Small steps towards a large framework: a workshop approach

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