This HSJ Award-winning training and quality development programme for educators teaches a thoroughly patient-centred approach. Stuart Shepherd is keen to learn more

DESMOND provides an all-round education. The impact of the structured programme for people with type-2 diabetes goes far beyond the classrooms or clinics where it is delivered, not just showing improved outcomes for patients but also changing the way practitioners approach their work.

But what makes DESMOND – diabetes education and self management for ongoing and newly diagnosed – and its interventions so different from any other self-care programme delivered by health professionals? The answer lies in its training and quality development programme, winner of the 2007 HSJ Award for skills development.

The origins of the self-management education programme can be traced back to 2002, and the combined thoughts and ambitions of a multidisciplinary group working in diabetes.

“Several of us were at an international conference, talking about a forthcoming National Institute for Health and Clinical Excellence appraisal report on structured education in diabetes,” says the programme’s national director Marian Carey. “We knew it wasn’t going to recommend anything because all the existing programmes had failed to meet the criteria.”

Driven to do something about it, professionals from medicine, psychology, nursing and dietetics – many already developing programmes of their own – formed a collaborative. After extensive literature searches, design work, pilots and a randomised controlled trial funded by Diabetes UK, the national programme finally emerged in 2005.

Almost 400 healthcare professionals or “educators”, who deliver the courses for patients, have been trained to date. The educator register, resources, practitioner support, training and other activities are organised by the national programme team, based at University Hospitals of Leicester trust. The training strategy group, a core team of senior trainers, oversees the training and development programme.

DESMOND interventions bring together elements from theories of learning and a shared philosophy of care aimed at empowering individuals to make informed decisions and set priorities. The structured education course for patients lasts six hours and the curriculum content contains key messages.
Educators take a markedly different approach to more conventional programmes. Rather than focusing on simply getting facts and advice across, they help patients explore what having type-2 diabetes means to them, the choices they have and the actions they may choose to take to enjoy better health.

“That’s not to say that it isn’t the role of the programme to give information. What really matters is the way they are encouraged to make links and work out the things that are important to them,” says Dr Carey.

The trainers who prepare new educators also adopt or model that facilitative style, using open questions and empathic listening during the two-day residential training course for educators, encouraging the professionals to think about the methods they use.

“Both [the patient education and the trainer] programmes deal with skills change, which is a difficult area,” says Dr Carey. “You can send lots of people on training or education courses and they will acknowledge what they have heard and agree with it. But generally it doesn’t affect their practice or behaviour, and that is hard to achieve.”

With the patient, that process of change begins when they start putting together their personal “scaffold” – as one educator describes it – joining their own priorities to new information and understanding, building as they go in the direction they choose.

Role play
The opportunity to examine behaviour and to look at the options available for change for the educator begins with some self-reflection before training. Practitioners are encouraged to examine their own philosophy of care and attitudes to patients, why they think the way they do and what kinds of decisions this leads them to make. To help them with this, they get the chance to either watch educators taking patients through a six-hour programme or follow a session pre-recorded on a DVD.
During their two-day training, these potential educators observe the trainers modelling the programme and the philosophy that underpins the DESMOND interventions. At times they
also adopt the role of a person with diabetes taking part in a programme, at others the part
of an educator.

“Most of my working life in the health service has been with people socialised in institutions where work is based on an acute healthcare model,” says training strategy group member Lorraine Martin Stacey, who is a nurse specialist in diabetes at University Hospitals of Leicester trust. “But diabetes is a long-term condition and the approach needs to be different.

“When I did my educator training, the philosophy, modelled by the trainers, just oozed out,” she continues. “The effect was incredible. It was like coming home. I could see how it would impact on patients and it gave evidence and credence to the way I wanted to work.”

Two practitioners deliver the patient education so the new educator is never on their own. Following each of their first three courses, as part of a quality assurance framework, they use self-reflection to examine their own style and behaviour in the session as well as the content. After courses four and five, once the new educator has become more confident, they do a peer review with their colleague.
The educator can then ask for a first quality development external visit, to be done by an assessor trained in objective observation – using an observational sheet and observational tool and feedback.
The observation sheet looks at behaviour, using open questions, facilitating interaction and valuing contributions, explains training strategy group member Heather Daly, who is nurse consultant at University Hospitals of Leicester trust. The observation tool measures who is doing the talking.
“It’s not just about content,” she says. “Just giving information does not give people skills or change behaviour. Content needs to be covered, but how and to what level, what is needed to fill in the gaps, is determined by the patients.”

Educators are encouraged to practise using the sheet and tool with programme colleagues and bring them into their own reflective processes before the external assessment. As part of the visit, educator and assessor agree an action plan to help the educator continue to improve the quality of their work.
A further visit takes place in the next six months. Educators who demonstrate a consistent and developing approach to the programme philosophy and principles at this stage gain accreditation with the national programme and the opportunity to move on to take trainer and quality assessor training themselves.

Feedback, reflection and development is not just for individuals. Over the life of the national programme and earlier pilot studies, the patient course, educator training and training quality and development framework have all gone through cycles of consultation and revision.

Cumbria PCT acting dietetic manager Cheryl Taylor explains one such cycle: “The course contains some food choices sessions. Some of the educators without a dietetics background felt they weren’t handling them as well as they would like to. Similar feedback was coming from the quality assurance visits. As a result, the educator training for the food sessions and the relevant content in the educator’s manual was improved.”

Another development influenced by the feedback process has been to give aspiring educators an opportunity to see a live or recorded patient course before their training weekend. Previously trainers used to model the whole course but it became apparent that the educators wanted to start trying the new approach to education during their training.

Culturally appropriate course content for a number of black and minority ethnic communities – in Gujarati, Urdu and other languages – is being put together, and work on various elements of an approach that integrates the national programme with clinical management, annual reviews and medication planning is under way.

The programme philosophy seems to offer an alternative approach to helping patients manage other conditions.

“We know that lots of models for weight management don’t work,” says Glasgow South East community health diabetes lead dietician Maureen Cullen. “But how long have we been telling people what they should be doing with their diets, how to watch their calories as a way of losing weight?
“We talk about patient-centred care – but if somebody only has a limited understanding of their condition, how can they possibly make the right decisions for themselves?”

how desmond maintains high standards
“We knew from the literature that a lot of people running education programmes have no idea of the quality of their courses. Even when a programme works well they don’t know that will continue when it is rolled out, because the teaching will vary,” says Sue Cradock, consultant nurse in diabetes/chronic
disease at Portsmouth Hospitals trust and Portsmouth City primary care trust and DESMOND collaborative founder member.

Hence the need for a quality assurance process. This uses two main tools to assess an educator’s performance: the observational sheet, which details the behaviours the educator should demonstrate, and the observational tool, a measure of how much talking is being done by patient or educator.
“We couldn’t just go out and look and see if what people are doing is what we want them to do,” she explains.

“The tools give us feedback, describe actions and style in some way and allow us to see how well people are able to change their usual didactic approach into something that DESMOND espouses – because hard as it is for people with diabetes to change their behaviour, it is just as hard for healthcare professionals.”

A model for other conditions
DESMOND programme director Marian Carey believes sufferers of other conditions, and chronic disease patients in particular, can benefit from the programme’s approach. The view is shared by the 2007 HSJ Awards judges, who gave it the skills development prize.

“[Another DESMOND-style programme] would need to be led by a multidisciplinary steering group, with a psychologist on board, to help work through the [programme’s] adult learning theories and care philosophy,” she says. “These principles have a very strong basis in research and are applicable to any long-term condition.

“The curriculum for the patient education programme is the foundation for everything. Once you have a curriculum, you can build your training and quality assurance.”

She says as much as 80 per cent of the DESMOND training would be transferable, with 20 per cent being disease specific.

Careful thought should be given to where the project is based. “We decided on a host NHS trust to maintain links with research and academia, to bolster credibility and keep costs to a minimum.”