I was gutted when I read Professor Leitch’s blog – the idea of asking people “what matters to you?” was exactly what I planned for my Blog. I now had to convey my own pathway into this area in such a persuasive way
My journey (unlike Professor Leitch’s) did not begin in a formal Quality Improvement class with international experts in the USA but began in a more slow burning fashion right here in Dumfries and Galloway.
I arrived in Dumfries in the spring of 2004 –a newly trained consultant. My head was full of evidence-based treatments and guidelines combined with naivety and a genuine enthusiasm to improve diabetes care.
At that time empowerment, self-management and structured education were emerging as factors to improve outcomes in people with diabetes and other long-term conditions. Shortly after my appointment we were fortunate enough to be given funding from the Scottish Diabetes Group to pilot DAFNE. For those of you unfamiliar with the diabetes world DAFNE is not a person but stands for Dose Adjustment For Normal Eating and is an evidence based weeklong structured educated programme for people with type1 diabetes. Structured education means that there is a defined curriculum delivered using adult education theory and delivered by trained and peer-reviewed educators.
6-8 people with diabetes participate in each course and bring with them years of experience of diabetes – on a recent course within the room we had amassed 254 years of experience of diabetes
DAFNE didn’t just empower, educate and motivate those individuals with diabetes who attended but also provided our local diabetes team (myself in particular) a unique insight in what it was really like to live with diabetes. I listened with interest and a growing sense of shame as people with diabetes described their experiences of diabetes in hospital , the sense of foreboding they felt when they attended clinics – they felt chastised, felt failures and felt that they were not always listened to. They told us how seeing high blood sugars despite trying to balance food, exercise and insulin was frustrating and many said that they simply didn’t bother to test as the results made them anxious.
I listened and I learned and I reflected.
I learnt that our interactions with people were often more powerful than we realised but not always in the ways we hoped. I realised that we were often ineffective in promoting improvements in diabetes self-management.
I reflected on my own training -despite my knowledge of trials and guidelines I had little training in consultation technique and promoting behaviour change.
Somewhat shamefully over the years I had become very skilled at moving people away from topics that were important to them to focus on the topic of blood sugar which was what was important to me.
I realised if we were to achieve continued engagement of our newly educated and empowered cohort of DAFNE graduates that this traditional medical model of diabetes clinics had to change
Alongside this realisation we became involved with our local psychology department who took on the task of teaching us the theory of behaviour change and demonstrating the use of motivational interviewing, Socratic questioning, functional analysis and other tools to help change unhelpful health behaviours. This training was further complimented and developed by the “Doing Diabetes Better” programme and PIDPAD (Psychology in Diabetes, Psychology and Diabetes) project funded by the Scottish Diabetes Group
The heart of the training was active listening and in particular listening to what was important to people.
Initially I struggled to use the tools- I worried about the time factor involved; I worried about opening up emotions that I was uncomfortable dealing with and it often seemed easier to stay in a traditional role but as I practiced more and began to see people with diabetes begin to successfully generate their own goals and solutions I knew that this was a way forward
Behaviour change is difficult not just for people with diabetes but for all of us in all aspects of our lives and just like the people I see in clinic I have found that old habits die hard and I know that when I am tired, stressed or running late I don’t always listen as well as I should or apply the tools I have learnt as effectively as I should. In these circumstances I find myself slipping back into my comfort zone of focussing on blood sugars, targets and guidelines but through the increased self- awareness I recognise these factors and try to avoid dictating care plans
Finally I suppose it is important to know whether it has made a difference-I now have a better understanding of the reasons why people find it difficult to implement and sustain changes to improve health and wellbeing. I know that I now find clinics more tiring -exploring thoughts and feelings in relation to diabetes is emotionally exhausting but the things I hear and results I see encourage me to continue.
By changing from what from “what’s the matter?” to “what matters to you?” patient satisfaction scores have increased significantly as has HbA1c (a marker of blood sugar control)-both of these improvements matter to me.
Now when a consultation takes a diversion into areas unrelated to diabetes I stick with the diversion as I realise what I hear matters to us both
Dr Fiona Green is a Consultant Endocrinologist and Diabetologist at NHS Dumfries and Galloway
Next week we will have a joint blog from myself (@kendonaldson) and Peter Bryden (@peterbryden1) summarising the recent Enhanced Patient Experience Event.