Implementing empowerment group education in diabetes

https://doi.org/10.1016/j.pec.2003.07.009Get rights and content

Abstract

The overall aim was to gain insight into and understand how physicians and nurses view the implementation of empowerment group education (EGE) in diabetes. Prior to the study the physicians and nurses attended a 2-day empowerment workshop. Further, they had implemented the empowerment approach in two groups of patients with type II diabetes. Three to 9 months later they (five physicians and 11 nurses from six family practices) participated in focus group interviews to evaluate the implementation of the EGE. The interviews were audio-taped, transcribed and analysed using the constant comparative method. The main result showed a conflict in roles. The physicians and nurses knew their role in the traditional approach but not with respect to the empowerment approach, which they needed to grow into. At the same time as they started a new way of working, their role had changed from being an expert to being a facilitator. As experts they felt secure; as facilitators they needed support in their educational process. To implement EGE they required support both from the family practice and from a supervisor in direct connection with the EGE.

Introduction

Patient education has long been an important part of the treatment of diabetic patients. In the 1980s it was considered that traditional education did not correspond to the needs of patients with chronic conditions such as diabetes [1]. During this decade the need to improve diabetes care and education was highlighted to meet targets for “Healthy People 2000” [2].

In traditional education, providers acted as experts who gave advice and recommendations they expected that patients required in their self-management [3]. Discussions concerned how the providers’ attitudes and behaviours could affect patients’ acceptance and attitude to their disease [4]. Patients wanted to be listened to, be given opportunities to explain their problems and get information that was suitable in their daily life. They also wanted to be supported and trusted as responsible human beings [3]. A change in the providers’ role was needed, from being controllers to becoming helpers or enablers [4].

In the 1990s empowerment was introduced as an approach in patient education [5], [6], [7]. At the individual level, empowerment is defined as a process where people gain mastery and take control of their own lives [8], [9]. The empowerment approach implies other roles than the traditional. The providers’ tasks are to enable patients to express their feelings, explore problems and to develop solutions to their problems. The providers’ enable patients to make informed choices and to discover their own capacity to take control and responsibility for their diabetes and its management. Patients select their learning needs, as well as identifying problems, strengths and barriers to making behavioural changes and setting their goals. A plan to reach these goals is established with the assistance of the providers [5]. This approach requires a change in the health care system to a culture where the patients are treated as experts in living with diabetes and the providers act as facilitators [10], [11].

Studies in behavioural change strategy [12], empowerment [6] and patient-centred approach [13], [14] have shown barriers to providers’ ability to change behaviour and apply a new approach. Implementation barriers included providers’ ability to respond to emotional issues and to allow patients to solve their own problems [6], lack of competence in method [12] and choosing not to use the method [15] or some parts of the method [16]. Other barriers were time constraints [12], [16] and the predominance of other clinical issues [12]. These studies showed that it is necessary to go further and highlight providers’ ability to apply the new approach in order to increase the understanding of how to implement this approach in patient education.

The overall aim of this study was to gain insight into and understanding of the physicians’ and nurses’ view of implementing empowerment group education (EGE) in diabetes and to explore opportunities and barriers for its implementation.

Section snippets

Methods

The study design was approved by the research ethics committee at Uppsala University.

Results

A central theme in the focus group discussions was the conflicting roles that might occur when introducing the empowerment approach and implementing the approach in group education. These conflicts can be seen as tensions between two different roles—the traditional role as a physician or a nurse in individual counselling and the role the empowerment approach required in the group education. These conflicts will be presented more in detail.

Discussion and conclusion

Considering the conflict between the traditional and empowerment approaches it was not easy for the physicians and nurses to implement the empowerment approach. As facilitators they should give the patients knowledge when required, as well as help and support in their change process and goal-setting. At the same time they needed support and feedback in their own educational process. This can be compared to the patients’ and their need for feedback about their changing habits [3], [19]. It might

Acknowledgements

First, we wish to thank the physicians and nurses from the family practices who gave us their time. Special thanks to Dr Peter Tilly and the Director of Primary Care in the county council of Västmanland, Christina Hjulström, for supporting the study; Dr Åke Tenerz, Västerås for his co-operation in the interview questions; and Professor Bengt Starrin, Karlstad University, for sharing his valuable knowledge about qualitative research.

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