Michigan Diabetes Research and Training Center
1331 E. Ann St., Room 5111, Box 0580
Ann Arbor, MI 48109-0580, USA
Review
Received: June 3, 2001
Patient education continues to be an integral part of care for the person with diabetes. Reviews of the diabetes literature and other studies support the efficacy of self-management training for people with diabetes, however, the patients' success is often judged by their ability to adhere to a prescribed therapeutic regimen. A great deal of effort has been spent in developing methods for measuring compliance, and techniques and strategies to promote adherence.
Unfortunately, this approach does not match the reality of diabetes care. The chronic nature of diabetes, the complexity of its management and the multiple daily self-care decisions that diabetes requires mean that being adherent to a predetermined care program is generally not adequate over the course of a person's life with diabetes. In order to manage diabetes successfully, patients must be able to set goals and make decisions that are both effective and fit their values and lifestyles, all the while taking into account multiple physiological and personal psychosocial factors. Intervention strategies that enable patients to make decisions about goals, therapeutic options and self-care behaviors, and to assume responsibility for daily diabetes care are effective in helping patients better manage their diabetes.
Most health professional training is based on a medical model developed to treat acute health care problems. In this model, the health professional is the authority and is responsible for the diagnosis, treatment and outcome of the treatment. Patient education is generally prescriptive and goals are established by the health professional.
As chronic illnesses became more prevalent, the medical model was adapted for those patients and became the compliance or adherence model. This model promoted the idea that health professionals know best, but because chronic illness care is largely provided by the patient, efforts where made to convince patients to follow the recommendations of the professional. The compliance/adherence model is based on the belief that patients have an obligation to follow the direction of professionals and that the benefits of compliance outweigh the impact on the patient’s life. Education is designed to promote compliance or adherence. Motivational and behavioral strategies are applied to patients in an effort to get them to change.
As the large literature in non-compliance indicates, neither of the medical or compliance/adherence models is effective in diabetes care. A new paradigm is needed that recognizes the right of patients to be the primary decision-makers in their own care and facilitates their taking on this responsibility. Empowerment is a philosophy that is in keeping with this model. Patient empowerment is defined as helping patients discover and develop the inherent capacity to be responsible for one’s own life. In diabetes, this means the recognition that while health professionals are experts on diabetes care, patients are experts on their own lives. The role of patients is to be a well-informed active partner or collaborator in their care. The role of the professional is to help patients achieve goals and overcome barriers through education, appropriate care recommendations and support. It recognizes that knowing about an illness is not the same as knowing about a person’s life, and that because patients reap the benefits and consequences of their care efforts, they are the primary decision-makers.
In this model, patient education is designed to help patients make informed decisions about their care and obtain clarity about their goals, values and motivations. Patients need to know about diabetes and how to effectively care for it on a daily basis. They also need information about various treatment options, the benefits and negatives of each of these strategies, how to make changes in their behaviors and solve-problems. They also need to understand their role as a decision-maker and how to assume responsibility for their care.
Part of the educational process includes setting goals with patients. This is a three step process that provides patients with the information and clarity that they need to develop and reach their diabetes-related goals. The first step is to define the problem and ascertain the patients’ feelings that may support or hinder their efforts. The second is to identify long- and short-term goals that the patient will work towards in an effort to reach his or her goals. The final step is for patients to evaluate their efforts and identify what has been learned in the process. Helping patients view this process as behavioral experiments eliminates the concepts of success and failure. Instead, all efforts are opportunities to learn more about the true nature of the problem, related feelings and effective strategies. The role of the provider is to provide information, collaborate during the goal-setting process and support the patient’s efforts.
Health professionals face several challenges in making this shift to the empowerment model of care. Change is never easy and it is often difficult for professionals to give up their role as the authority and develop an equal partnership with patients. They may be concerned that it will take more time or that patients will be unwilling to make changes in their behavior unless professionals tell them to do so. Some are also uncomfortable with the power this gives to the patient and the fact that they can refuse to carry out provider’s recommendations.
Setting collaborative goals can also be difficult for some providers. This is particularly difficult if patients set goals that are different than providers would choose, or choose issues that the health professional views as a low priority. Many of us struggle to facilitate patient’s problem solving abilities and prefer to offer solutions and try to help patients feel better by ignoring or neutralizing negative feelings expressed by patients. While these may seem to be effective because they often shorten the encounter with the patient, they are rarely effective in helping patients make meaningful changes they can sustain.
There are also benefits to this model. The first is that it is patient-centered, which increases the satisfaction of the patients and effectiveness of the interventions. Outcomes improve in this model. In addition, it is less frustrating for patients and professionals. Professionals no longer have to spend time trying to motivate patients because the desire to achieve self-selected goals is intrinsic. Once health professionals no longer view their job as getting patients to comply, they no longer judge their efforts by how many changes patients make or how adherent they are to the regimen. They can instead focus their efforts on creating positive relationships with patients, helping them identify and achieve their own goals and creating a positive environment for growth and change.
Our models of care both guide and are reflected in the way that we practice and interact with patients. Empowerment provides a vision that allows us to be more effective and facilitates patients to achieve better outcomes.