Despite advancements in recent years in the treatment of diabetes, patients continue to develop the chronic complications of diabetes leading to a reduced quality of life and an increase in mortality. Health professionals often toil to engage patients in effective diabetes self-management and find it frustrating when their advice is not followed. 

The chronic, non-curable and complex nature of the condition means that patients have to make multiple decisions on a daily basis about its management. A patient being expected to adhere to a pre-determined care plan is not an acceptable way for them to manage the condition. In order for patients to self-manage their diabetes they need to be able to think critically and make informed, autonomous decisions.¹

Health professionals are comfortable in their role providing education and information to their patients, but many struggle, particularly in a busy clinical setting, to provide the type of support that helps facilitate the behaviour change that is necessary for diabetes self-management. 

Although acquiring knowledge is essential, it is not sufficient to engage patients in effective diabetes self-management. Techniques such as persuasion and offering advice have proven to have limited value in the management of diabetes and also cause resistance among patients, leading to frustration among clinicians and patients alike.²

Health professionals need to adopt more interactive methods that help to motivate their patients by ensuring that they are involved in identifying their barriers to change and in the negotiation of realistic goals. These methods do not necessarily guarantee patient empowerment in managing their diabetes but they provide a good starting point.

Identifying barriers to effective diabetes self-management

Diabetes self-management refers to patients engaging in a number of tasks in order to effectively look after their diabetes and health. It involves patients managing their diabetes but at the same time maintaining all the aspects of daily life and coping with the emotions that go with living with a chronic illness.³

When identifying the barriers to effective diabetes self-management, one of the problems, as highlighted by Wiltshire 2013,⁴ may be that health professionals and patients have conflicting agendas. 

Health professionals see the patients’ world through their own eyes; they feel responsible for the patient but are not in control as the majority of diabetes care is provided by the patient and not the healthcare professional. 

Health professionals have the medical experience and the professional qualifications and are familiar with the evidence and research. Patients, on the other hand, understand their priorities and are aware of how diabetes self-management tasks will fit into their lives. They know what might work and what will not work, as they are aware of their own lifestyle and priorities. In fact, both health professionals and patients are experts and, therefore, should work together.⁴

Robert Anderson, a well-known diabetes educator, identified that one of the reasons for non-compliance is when the health professional and the patient are pursuing different goals.⁵ As such, knowledge between the healthcare professional and the patient should be exchanged and the responsibility shared. 

Collaborative communication between patients and healthcare professionals results in greater adherence to treatment plans and enhanced patient satisfaction. If patients and health professionals agree on goals it leads to more effective diabetes self-management.²

As diabetes is managed by the patient, a degree of motivation is required by them to carry out self-management tasks. In order for health professionals to support patients in breaking down the barriers to effective diabetes self-management, it is necessary for them to assess the motivational status of the patient and help to motivate them. The use of motivational interviewing techniques is an effective way of doing this.⁶

Motivational interviewing

As early as the 1600s, it was recognised that “we are usually convinced more easily by reasons we have found ourselves than by those that have occurred to others”.⁷ Motivational interviewing is built on this insight. It was first described as a “directive, client-centred counselling style for eliciting behaviour change that helps clients to explore and resolve ambivalence”.⁶

Motivational interviewing has been shown in a number of randomised control trials to be more effective than the practice of providing traditional advice and education in engaging patients in diabetes self-management.^8,9,10 Evidence surrounding motivational interviewing techniques suggests that practitioners elicit from their patients increased expressions in support of change and less talk of resistance, both of which are predictive of behaviour change.¹¹

Patients are only weakly motivated by what others say to them; they may respond with ambivalence or resistance and do not follow through with the plan given to them by the health professional. They respond more to what they hear themselves say. The use of motivational interviewing techniques addresses this, as it is a patient-centred approach where the health professional uses reflective listening skills and empathy, and the patient does most of the talking. 

Patients have the opportunity to assess for themselves what is important and how their goals may be achieved. They identify inconsistencies between their behaviours and their goals and this increases their intrinsic motivation to change. The health professional helps to elicit solutions from the patient instead of just prescribing solutions without the agreement of the patient. Collaboration between healthcare professionals and the patient is promoted and dual expertise is acknowledged.¹¹

Health professionals already practise essential communication skills that are necessary to evoke motivation. These include the use of open-ended questions, expressing empathy and the use of non-verbal communication skills. Other basic principles necessary for motivational interviewing can be learned and applied successfully in ways that reduce the frustrations of both patients and health professionals. 

Health professionals may perceive that using motivational interviewing techniques is time consuming. However, those experienced in motivational interviewing have found that patients only require a few minutes of active listening to discuss their self-care behaviours. Motivational interviewing is a teachable, evidence-based approach to behaviour change suitable even when working within the constraints of a busy clinical setting.¹²

Conclusion

One of the factors influencing diabetes outcomes is how patients manage their diabetes in between hospital appointments. The choices that patients make on a daily basis in caring for their diabetes have a greater impact on their outcomes than the choices made by health professionals. Improving our communication skills with our patients will improve the quality of care we provide and their clinical outcomes. 

The annual Multidisciplinary Diabetes Study Day in Croke Park, Dublin, will take place on March 21, 2014. Lyndi Wiltshire, who is head of diabetes care at Birmingham and Solihull Mental Health Foundation Trust, will speak on ‘The barriers to effective diabetes self-management’. 

In addition to this, Rev Eugene Curran, a lecturer from All Hallows College in Dublin, will discuss how motivational interviewing can help to engage patients in their own self-care. 

References

1. Funnell M, Anderson R. Empowerment and self-management of Diabetes. Clinical Diabetes 2004; 22(3): 123-127
2. Heisler M, Bouknight RR, Hayward RA, et al. The relative importance of physician communication, participatory decision-making, and patient understanding in diabetes self-management. J Gen Intern Medicine 1002; 17: 234-252
3. Lorig KR, Holman H. Self-management education: History, definition, outcomes and mechanism. Annals of Behaviour medicine 2003; 26: 1-7
4. Wiltshite L. Barriers to effective self-management. The Diabetes Education Network 2013 Annual Conference (workshop presentation, 9 May 2013). Available from: www.diabetes-education.net <http://www.diabetes-education.net> accessed 24/10/2013
5. Anderson RM, Funnell MM. Compliance and adherence are dysfunctional concepts in diabetes care. Diabetes Educator 2000; 26: 597-604 
6. Miller WR, Rollnick S. Motivational Interviewing: Preparing people for change. 2nd edition. New York Guilford press, 2002
7. Pascal B, Genet C. Pensees. Paris, Hatier, 1670
8. Resnicow K, Baskin M, Rahotep S, et al. Motivational interviewing in health promotion and behavioural medicine settings. Health Psychology 2003; 21: 444-541
9. Rubak S, Sandboek A, Lauritzen T, et al. Motivational Interviewing: a systematic review and meta-analysis. British Journal of General Practitioners 2005; 55: 305-312
10. Britt E, Hudson SM, Blampied NM. Motivational interviewing in health settings: a review. Patient Education Counselling 2004; 53: 147-155
11. Welsh G. Motivational interviewing and diabetes: What is it, how is it used and does it work? Diabetes Spectrum 2006; 19(1): 5-11
12. Hettema J, Steel J, Miller WR. Motivational interviewing. Annual Review of Clinical Psychology 2005; 1: 91-111