Abstract
Objective:
The purpose of this study was to investigate participants’ experiences of and satisfaction with the content and outcome of 13 different sessions of a 4-day diabetes education programme and to compare participants’ experiences with the extent of educator talk in the sessions. A 10-second event coding was used to evaluate educators’ application of participatory methods in patient education.
Method:
Four diabetes education courses, each consisting of 13 sessions with 10–12 participants, were monitored, using the 10-second event coding to assess educator talk ratios. Three focus group interviews were performed after the course, and 19 exploratory interviews were performed with participants within 3 months of the end of the course. Participants were asked about their experiences of personal outcomes derived from participation in the programme in general and from participation in each session. Qualitative data were analysed using systematic text condensation focused on participants’ perceptions of the personal outcomes derived from each session. Participant reports were compared to measured educator talk ratios to assess relationships between experiences and educator talk ratios.
Results:
Positive participant-reported outcomes such as learning from each other and a feeling of safety and freedom were associated with low educator talk ratios in specific sessions. However, participants appreciated high talk ratios when educators presented knowledge attendees perceived as essential and meaningful to everyday life.
Conclusion:
The educator talk ratio is a useful metric to evaluate the quality of group-based diabetes education using participatory methods. However, it must be used in combination with an assessment of education content and format.
Introduction
Diabetes is one of the most common chronic disorders in West and poses serious challenges for patients and healthcare systems in terms of resources and health risks. The provision of effective ongoing education and support has long been recognised as necessary to equip people with diabetes with the knowledge, skills, attitudes and motivation required for self-management of disease and effective coping with a chronic condition. However, the traditional focus in diabetes education on biomedical issues using didactic methods such as slide presentations and instruction via lecture has not significantly improved diabetes outcomes (Cooper et al., 2003; Kulzer et al., 2007). In the beginning of the 1990s, empowerment was introduced as a promising method and philosophy in patient education. It is well documented that empowerment-based diabetes education is linked to improved health-promoting behaviours and self-management skills. These skills are crucial to enable patients to obtain better clinical and psychosocial outcomes (Anderson and Funnell, 2000; Costello, 2013; Danish Health and Medicines Authority, 2009, 2012; Davies et al., 2008; Funnell et al., 2005; Kulzer et al., 2007; Simovska, 2008).
Empowerment-based patient education implies the active participation of participants. Central to empowerment is a less hierarchical relationship between educators and participants. Diabetes educational standards recommend that educators use a collaborative approach to goal setting in which participant–educator relationships are characterised by shared responsibility for learning and an emphasis on participants’ values and concerns (Marrero et al., 2013). This requires educators to facilitate the teaching process in such a way as to actively involve participants. Facilitation is a participatory tool for sharing power or handing it over to participants (Hajhosseiny, 2012; Nossum et al., 2013). In this context, we define facilitation as the ability to encourage participants (patients) to be actively involved in sessions, to motivate and manage group discussion and to organise the programme based on participants’ problems, challenges and preferences as experienced in everyday life with diabetes (Anderson and Funnell, 2005; Danish Health and Medicines Authority, 2013). This allows participants to reflect on their personal situation and priorities, develop plans that motivate them and subsequently make informed choices about self-management of their diabetes (Adolfsson et al., 2004; Costello, 2013; Pierce et al., 2000).
Educator talk as a quality indicator for the education process
Previous studies showed that it can be challenging for educators to apply in practice the methods of empowerment and participation in patient education (Paterson, 2001). In evaluating the quality of diabetes education, it is challenging to objectively and efficiently assess to what extent empowerment and participation are actually implemented in patient education processes. Qualitative interviews, one way of evaluating empowerment and participation, comprise a subjective and time-consuming method of quality measurement, subject to a range of recall biases. There is a need for a simplified method (Skinner et al., 2008). Coding interactions at 10-second intervals is a simple quantitative method that measures the proportion of educator talk in group-based education. A similar method was reported by Wayne et al. in a study evaluating medical student education (Davis et al., 1994). Skinner et al. adapted this approach and studied the correlation between measured educator talk ratios and participant-reported outcomes in diabetes education. They found a significant correlation between low educator talk ratios and diabetes education effectiveness in terms of changes in participants’ beliefs about diabetes. Furthermore, low educator talk ratios predicted improved metabolic control in people attending the education programme (Skinner et al., 2008).
The purpose of this study was to investigate participant experiences of and satisfaction with the content and outcome of all 13 sessions of a 4-day diabetes education programme and to compare these experiences with the extent of educator talk in the sessions. We explored the association between educator talk ratios and participant-reported outcomes in diabetes education in a large Danish hospital.
Method
To assess to what extent empowerment and participation were implemented, we assessed educator talk ratios in a 4-day diabetes education programme based on the empowerment philosophy and methods in a large specialist diabetes clinic in a Danish university–affiliated hospital. After the programme had concluded, we investigated participants’ experience of and satisfaction with the content and outcome for the programme as a whole and for each session.
Intervention
The aim of the patient education programme was to provide relevant knowledge about diabetes treatment and care, to empower participant to take responsibility for self-management of their diabetes, to be capable of changing their diabetes-related and lifestyle behaviours (if appropriate) and to (re)gain control of their diabetes. The programme consisted of 13 sessions focused on different topics (Table 1). Four types of educators were involved; nurses and dieticians were the primary educators, and diabetologists and chiropodists/podiatrists taught in one session each. The programme was provided to groups stratified by diabetes type and treatment, with 10–12 persons with diabetes and a varying number of their relatives in each group. Four diabetes education courses were monitored to assess the educator talk ratio, and data were collected from April 2012 to December 2012 (Table 2).
Educator talk ratios in diabetes education.
The patient education programme.
The theoretical framework of the programme was confluent pedagogy, a concept with many similarities to the empowerment philosophy. Confluent pedagogy seeks to integrate the transmission of diabetes knowledge (theory), exchange of experiences among participants and practical learning/training. The empowerment philosophy was operationalised in educational exercises inviting the participants to reflect on their own experience, for example, using the research-based problem-solving method known as guided self-determination and a practical education session consisting of a visit to a supermarket (Zoffmann and Kirkevold, 2012).
Participants
We conducted three focus groups with patients and 19 exploratory interviews with participants within 3 months of the conclusion of the programme (Table 3). We interviewed four to five participants from each of the four courses, purposefully sampling to represent different ages, genders, type of diabetes and treatment. Family members were not included in the sample.
Characteristics of 19 interviewed participants and the three focus groups.
Data collection
Educator talk ratios were measured as described by Skinner et al. (2008). A researcher seated in the back of the room observed the session, recording every 10 seconds whether the educator or the participants were talking or whether something else was happening. Three recording categories were used: ‘educator talk’, ‘participant talk’ and ‘miscellaneous’. Event coding did not occur during the practical education session that consisted of a visit to a supermarket. Participants were dispersed throughout the store, and coding would have required additional equipment and personnel.
Interviews were focused on personal outcomes participants derived from the programme in general and from each session. Questions were related to the aim of the patient education programme; participants were asked about their experiences of attending each session and the programme as a whole.
All interviews were conducted by the same researcher. In focus groups, the interviewer also acted as moderator, encouraging group interaction. Interviews 3 months after programme conclusion were focused on determining whether participants had been capable of changing their diabetes behaviour and lifestyle (if appropriate), whether they had (re)gained control of their diabetes during the previous 3 months and which part of the sessions were most/least helpful in everyday life.
Analysis
The 10-second event coding was analysed by calculating the percentage of educator talk for each programme session. This proportion was compared to Skinner’s suggested standards for maximum educator talk ratios in patient education sessions: 40%–65%, depending on the focus of the session, from encouraging participants to share experiences and become actively involved to transmitting knowledge/theory to facilitating the teaching process (Skinner et al., 2008). A high educator talk ratio was interpreted as reflecting low patient participation, and a low educator talk ratio was interpreted as reflecting high patient participation. The miscellaneous category reflected coding that occurred, for example, when educators were writing on the board or participants were completing a written individual reflecting tool. The miscellaneous category, representing more varied content than the other categories, was not in itself an object of analysis in this paper. However, it was necessary to calculate educator talk ratios.
Qualitative data were analysed using systematic text condensation (Malterud, 2012). Analysis consisted of four steps: (1) reading all material to obtain an overall impression and bracketing previous preconceptions, (2) identifying units of meaning representing different aspects of participants’ perceptions of the course, (3) condensing and abstracting the meaning within each coded group and (4) summarising the contents of each coded group to generate descriptions and concepts reflecting the most important participant experiences.
Qualitative data analysis was focused on participants’ perception of personal outcomes derived from each of the 13 sessions. When participants were asked about their opinion of having participated in the programme as a whole, they referred first and most positively to sessions that had a low degree of educator talk. Our interpretation was that sessions with a low degree of educator talk were more significant to participants than were sessions with a high degree of educator talk. Interview findings were subsequently systematically integrated with the results of the 10-second event coding in the following way. Educator/patient talk ratios for sessions were categorised into two groups: (1) low degree of educator talk and (2) high degree of educator talk. Interview data were also dichotomised into two categories: (1) positive statements of personal outcomes and participant experiences of attending the programme and (2) negative statements of personal outcomes and participant experiences of attending the programme. Categories of educator talk ratios and patient-reported experiences were then compared for each session and for the programme as a whole.
Results
Table 3 presents session educator talk ratios. In 15% of sessions, educators talked less than 40% of the time. In 30% of sessions, educators talked less than 65% of the time. Qualitative analysis of participant-reported experiences revealed three themes: learning from each other, a need for time to ask individual and pertinent questions and the importance of generating knowledge about diabetes.
Learning from each other
We found substantial links between session educator talk ratios and participant-reported outcomes. A key finding was the importance of educator-facilitated participant discussion and exchange of experiences. As one participant had stated, It is very important that people with diabetes sometimes have the opportunity to meet, and it should preferably be guided by a nurse or a doctor or a more experienced person with diabetes … But it is important (that it take place in a) setting where there is space to move, and where you can exchange experiences, I think it’s very rewarding to come together, sit eight people around a table, and then have a discussion. It gives, I think, its weight in gold.
Exchange of experiences and being in a group were highly valued by all participants, and several participants pointed out this factor as the most useful element of the programme. Peer support and sharing of experiences among participants had been planned to occur in the sessions ‘collaboration and motivation’ and ‘experiences and recapitulation’. These two sessions had the lowest educator talk ratios and were the only ones during which educators had talked less than participants. One participant had expressed it this way: Especially the part where we share some of the experiences we’ve had, I think it was very positive, […] how the others experience everyday life and the small things and annoying things. I definitely think that to learn from each other’s experiences is really important.
Participants described exchanging experiences in the group as valuable for reflecting and learning from each other. They also expressed a preference for potential opportunities to select, present and discuss relevant and challenging issues in everyday life with diabetes. One woman had mentioned that the opportunity to exchange experiences with peers had been missing in the programme, which may have reflected the generally high educator talk ratio. She would have liked to hear how other participants experienced everyday challenges with diabetes: […] I would have liked to discuss a bit more, what do you do, do you have any good ideas […]. The group is not so big, so we could easily have done it once in a while.
Participants expressed dissatisfaction with sessions that had the highest educator talk ratios. The sessions that were focused on management of complications, prevention and treatment, and foot care had had the highest educator talk ratios, and the majority of participants had expressed dissatisfaction with these sessions. As one participant had stated, It’s not something she needs to spend a whole hour [management of complications, prevention and treatment] to stand and blather on about.
The majority of participants also mentioned that sessions with high educator talk ratios had contained exclusively factual and theoretical content and were ‘dry’. Participants had not felt they gained help or support for everyday life with diabetes during these sessions: We had a session […] about what diabetes does inside the body, then, I think it was miserable. It was presented in a very boring way; it was dry […]. And she did not say anything I did not already know.
Participants reported that, compared to diabetologists and chiropodists, nurses and dieticians had been better at facilitating dialogue and at turning the presentation of factual knowledge into material participants perceived as relevant. Greater satisfaction and better outcomes reported by participants for sessions conducted by nurses and dieticians may have been related to lower educator talk ratios. In addition, this finding could have also been related to the fact that participants perceive some educational themes as having more relevance to everyday life with diabetes.
A need for time to ask individual and pertinent questions
The course had consisted of a fixed curriculum with very little time allocated for participants to share experiences, which one participant had expressed this way: […] a realistic assessment of the programme: there is only the lunch break for sharing experiences.
Participants made it clear that they would have preferred more opportunities for participant talk in response to issues and questions they raised. Educators had used breaks to answer questions from participants ‘outside’ the defined curricular content, and some participants had described having been hesitant to leave the room during breaks because they were afraid of missing something important. The answers and discussions about these more personal questions were considered more important than the prescribed programme. A participant had expressed this perspective: It could be nice instead of asking in the breaks, that we had 5–10 minutes where you could discuss the stuff […] and have a chat about these things […] but I would like a little more in depth discussion of my stuff, some of the things I need to work with.
The lack of time for participants to talk about their individual needs and preferences for themes seemed to be associated with the general finding of high educator talk ratios.
The importance of generating knowledge about diabetes
We also found contrasting patterns when studying participants’ perceptions of sessions with the highest educator talk ratios. They had considered gaining knowledge about the disease and its treatment as an important learning outcome and described increased knowledge about diabetes as providing them with feelings of safety and security in everyday life. The sessions about diet had been perceived as particularly valuable. These sessions had had a high educator talk ratio, but knowledge about diet had apparently been a topic representing frequent challenges in everyday life: I learned more about food after the course. That’s what I was interested in knowing- what you can eat and things like that and that’s what I want to know.
When content was highly valued, high educator talk ratios were not associated with less positive participant perceptions of outcomes. However, participants had expressed a desire for interaction in other sessions to experience higher overall satisfaction: But it’s also all about basic knowledge, which in fact gives freedom and the opportunity to act independently. And not to be afraid of getting injured or doing something wrong. All the knowledge, I must say, I knew that already, but I listened to it all. So yes, I’ve got a lot out of it.
Discussion
In general, we found educator talk ratios that exceeded Skinner’s suggested maximum standards (Skinner et al., 2008). In only 15% of diabetes education sessions did educators talk less than 40% of the time, the standard for sessions facilitating participant experiences (Skinner et al., 2008). Similarly, in only 30% of the sessions had educators talked less than 65% of the time, the suggested maximum standard for sessions presenting diabetes knowledge. Less than half of the sessions met the recommended maximum talk ratios, raising the question of whether the education programme was actually using an empowerment-based philosophy as described in the curriculum. We also found generally inverse associations between educator talk ratios and participants’ perception of benefits derived from the diabetes education programme.
Our findings support educator talk ratios generated by the 10-second event coding as a quality indicator for the implementation of empowerment and participatory methods in patient education. However, educator talk ratios did not necessarily or exclusively reflect the communication skills of educators. Educator talk ratios may also have reflected the theme of the education session to some degree. However, educators had been responsible for the choice of theme and for engaging participants in its selection.
Educator talk ratios may be used in addition to other qualitative or quantitative indicators to evaluate the quality of patient education. The general finding of this study was that low educator talk ratios generated better participant-reported outcomes. However, attention must be paid to the theme of the patient education session because some themes, such as those conveying disease-specific knowledge, may have had high educator talk ratios but were still considered very useful and appreciated by participants.
Educator talk ratios may also provide an indicator of educator communication skills that are very important to obtaining better outcomes through patient education. A systematic review of physician–patient communication found that objectively measured verbal and nonverbal skills among physicians, such as empathy, friendliness, warmth and open body language, were positively associated with health outcomes (Pawlikowska et al., 2012). Field observation and interaction analysis of patient–educator interaction in participatory group-based patient education could support the measurement of educator talk ratios as a method for assessing the quality of patient education. The degree to which empowerment and participatory methods are used in practice could be an important element of the quality assessment of patient education.
A tension between the traditional approach and the empowerment approach
An important finding was that participants highly valued group dialogue, participant activation and variations in themes collaboratively defined by participants and educators. Including themes suggested by participants was perceived as essential for improving daily life with diabetes. Participants reported that this had enabled them to achieve a new understanding of learning as a profoundly social process. Meaning and knowing are not founded inside the individual but are negotiated and dynamically created and re-created through participation in socially organised activities (Simovska, 2008). Evidence in patient education suggests that social learning techniques and a high level of participant activation are connected to the promotion of appropriate health behaviours and lead to improved outcomes (Harrison et al., 2011; Simovska, 2008). Our findings support this suggestion.
Our study also clearly indicated that participant activation in education processes was associated with educator talk ratios. High educator talk ratios may indicate that educators find it challenging to apply social learning techniques in practice. This interpretation is supported by evidence; most educators intellectually and theoretically agreed with the empowerment philosophy, but successful application of empowerment as a method in practice was rare (Paterson, 2001). Educators are most often socialised into a biomedical paradigm derived from the treatment of acute illness, in which they act as experts providing advice and recommendations that they assume participants need to self-manage their illness. Educators feel responsible for patients’ self-management and generally expect and want patients to follow recommendations given by healthcare professionals (Adolfsson et al., 2004). This creates tension between the traditional didactic approach of selecting and conveying information and the empowerment approach of establishing a more equitable distribution of power between participants and healthcare professionals (Adolfsson et al., 2004; Anderson and Funnell, 2005). This tension has been reflected by participants experiencing educator–patient interaction as paternalistic, even when educators were professing to be adopting the empowerment approach (Anderson and Funnell, 2010; Hernandez, 1996; Paterson, 2001).
Meaningfulness as an important motivating factor
The need for themes that are meaningful in relation to everyday life was obvious in this study and confirms previous findings (Csikszentmihalyi and Csikszentmihalyi, 1988). Participants had appreciated high educator ratios when the educator talk had been combined with the exchange of experiences with peers. This may be interpreted as the expression of ‘meaningfulness’, which is a psychological learning concept. Meaningfulness is an important motivating factor for involvement in education processes. Participants need to experience learning activities as meaningful to fully engage in them (Engelung et al., 2011). Patient education processes optimally combine professional knowledge suitable for problem solving in everyday life and the facilitation of group discussions (Barr et al., 2003). Thus, educators in patient education should be both skilled facilitators and able to juggle different roles as medical experts, facilitators and social mediators – switching readily between talking and letting participants do the talking (Engelung et al., 2011; Nielsen and Danielsen, 2012). Specifically designed tools to enhance dialogue and involvement may be necessary to support the actual translation of empowerment principles into patient education practice.
Strengths and limitations of the study
Strengths of the study include comprehensive data collection in four full courses with participants of varying age, both genders and type 1 and type 2 diabetes. Several researchers performed the 10-second event coding with identical results, thus confirming that the method was reliable and easy to use. Our findings confirm those of the few previous studies and are aligned with pedagogical research and theory about social learning. Limitations include the fact that all observations were performed in a single diabetes education setting. However, the programme we observed is the largest and most comprehensive diabetes education programme in Denmark, involving many educators.
Although educator talk ratios seemed very useful as a quality indicator, the method has practical and technical limitations. Event coding was difficult to use outside the classroom setting, for example, during practical training on a supermarket visit. However, practical training involved a high level of participant activation and participation, potentially reducing the need to measure educator talk ratios. A recent report considered experience through practice to be a highly underrated mechanism in patient education (Grøn et al., 2012).
Conclusion
Educator talk ratios can potentially be used as an indicator of quality in the application and evaluation of empowerment philosophy and participatory methods in patient education practice. In our study, high educator talk ratios generally reflected sessions that participants found less relevant or lacking a meaningful learning outcome. However, educator talk ratios must be assessed in context and cannot take the sole form of an average over all sessions in a patient education programme. High educator talk ratios can be valuable when conveying disease-specific knowledge that participants perceive as relevant to everyday life. Educator talk ratios should vary with the theme presented and the method for selecting themes, for example, with or without participant involvement. Educator talk ratios are suggested as an important and informative metric to assess the quality of participatory patient education when used in combination with other indicators. Additionally, educator talk ratios could potentially be used to supervise educators and to form a framework for observing patient education. Educators could use talk ratios over time to gauge changes in their ability to facilitate participatory and empowerment-based patient education, and ratios could be compared across professions and individuals and benchmarked against suggested standards. In this study, there were strong indications that the curriculum and the process should be revised to incorporate more participant involvement within the presentation of content.
Footnotes
Acknowledgements
We thank Nete Schwennesen who was the principal investigator for a larger study in which this study was nested and who managed the data collection. We thank all participants and health professionals at the Department of Endocrinology, Odense University Hospital, for their participation and support throughout the study. We confirm all patient/personal identifiers have been removed or disguised so that the patient/person(s) described are not identifiable and cannot be identified through the details of the story.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.