DAFNE Educator Programme (DEP) Training Workshop Curriculum

Transcription

1 DAFNE Educator Programme (DEP) Training Workshop Curriculum DAFNE T01.002, Version 12 July 2011

2 CONTENTS DEP Training Workshop Day 1 (slide and handout)... 6 Delegate List... 7 Day 1: Welcome, Housekeeping and Introductions DEP Training Workshop (slide) DEP Steps (slide) Aims in Step 4 (slide) What should I collect in my DEP file? (slide and handout) Experiences of observing a DAFNE course Experiences of observing a DAFNE course (slide) Attitude 15 Questionnaire The DAFNE philosophy The DAFNE philosophy (handout double side and stapled) Aims of DAFNE (slide) DAFNE beliefs and values (slide) What are the aims of the DAFNE philosophy (slide) Educator behaviours (slide) The DAFNE approach to food DAFNE principles (slide) Practical use of the glycaemic index Glycaemic Index (slides) Glycaemic index game (laminate each page individually) Glycaemic index game (cut and laminate each picture) The glycaemic index (slide) The glycaemic index and DAFNE (slide) The DAFNE approach to food Lunchtime CP counting Estimating CHO food diary (handout as a booklet or double side and stapled) Estimating difficult carbohydrates Lunch - CP counting (slide) Workstation 1 Carbohydrate Portion Estimation (handout) Workstation 2 Carbohydrate Portion Estimation from Labels (handout) Workstation 3 Snacks and DAFNE (handout) Snacks and DAFNE exercise (handout double side) Snacks and DAFNE exercise answers (slide) Workstation 4 Familiarising yourself with DAFNE Resources (handout) DAFNE T01.002, Version 12 July

3 Starting and adjusting the DAFNE insulin regimen Commencing the DAFNE insulin regimen (handout) Long-acting insulin analogue and DAFNE (handout) Insulin dose adjustment examples - reduction (handout) Insulin dose adjustment examples escalation (handout) Insulin dose adjustment examples corrections (handout) Insulin Dose Reduction Example (handout) Unfolding case example 1 Mary (handout) Unfolding case example 1 Mary (trainer notes/discussion points) Unfolding case example 2 Carl (handout) Unfolding case example 2 Carl (trainer notes/discussion points) Unfolding case example 3 Mohammed (handouts) Unfolding case example 3 Mohammed (trainer notes/discussion points) Homework task day DAFNE T01.002, Version 12 July

4 Day 2: Day 2 (slide and handout) Feedback from homework day The DAFNE curriculum and lesson planning Basic principles of adult learning (slide) Checklist for preparing lesson plans (slide and handout) What is a curriculum? (slide) DAFNE curriculum example (slides) Writing lesson plans: Getting some practise Blank lesson plan (handout not stapled x 8 copies per delegate) Example lesson plan (slide) Sharing ideas/strategies for specific sessions DAFNE: Exercise Physiology Educator Notes (handout) Minor or Severe illness Minor Sick Day Rules Severe Sick Day Rules Workstation 2 - Alcohol scenarios 1 (handout) Workstation 2 - Alcohol scenarios 1 answers (slide) Workstation 2 - Alcohol and DAFNE 2 (handout) Workstation 2 - Alcohol and DAFNE 2 answers (slide) Workstation 2 - Alcohol scenarios 3 (handout) Workstation 3 - DAFNE and Exercise (handout double side) Workstation 3 - DAFNE and Exercise answers (slide) Workstation 3 - Physical activities scenarios (handout) Workstation 3 - Physical activities scenarios answers (slide) Annual Review Workstation 4 Annual Review (handout) Therapeutic patient education and adult education theories Therapeutic patient education (slide) Cycle of experiential learning (slide) Adult learning theory (slide) Social learning theory (slide) An overview of educational theories underpinning DAFNE (handout) Goal Setting and Action Planning DAFNE T01.002, Version 12 July

5 Day 3: Day 3 (slide and handout) Managing groups: Tips/scenarios Strategies for effective group processes use ground rules (slide) Strategies for effective group processes become a facilitator (slide) Helping groups work more effectively (handout double side) Interventions for regaining control (handout double side) Dealing with difficult participants (handout) Dealing with difficult participants (game use at own discretion) Coping with problem participants (handout) and game use at own discretion) Card game (cut and laminate) Preparation for peer review DoH structured education criteria (slide) Who are the reviewers (slide) Ground rules for the DEP reviewer (slide) Peer reviewed course our expectations (slide) DEP review documentation (slides) Effective recruitment strategies Patient recruitment criteria (slide) Sheffield recruitment strategy (slide) Pre-course appointment/data collection: practise Pre-course appointment exercise (handout) Blank Core Baseline Data Collection form (handout) Standard operating procedure (handout double side and stapled) Blank Full Baseline Data Collection form (handout double side and stapled) Standard operating procedure (handout double side and stapled) EQ-5D (handout double side and stapled) PAID (handout) HADS (handout) DSQoL SF Follow-up and support from DAFNE graduates Initial follow-up (slide) Recurring follow-up (slides) Catering arrangements and DAFNE resources Choose a venue (slide) Catering arrangements (slide) DAFNE resources (slide) Local resources (slide) DAFNE resources purchase requisition (slide) Delivering DAFNE locally personal plan Personal plan (handout double side) Summary/feedback/evaluation Feedback from Peer Reviewed DAFNE week form Evaluation (handout) DAFNE T01.002, Version 12 July

6 1-Day Follow-Up Workshop Programme (slide and handout) Delegate List Welcome, Housekeeping and Introductions Follow-up Workshop (slide) Feedback from Peer Reviewed DAFNE week form (handout from original) Learning from Each Other s Experiences Learning From Each Other s Experiences (slide) Unresolved Issues/Prioritising Issues for Day DAFNE Curriculum Revisited Timetabling Exercise (handout) Timetable (handout) The DAFNE database whose responsibilities? Promoting DAFNE Awareness in Your Service DAFNE Awareness Workshop Agenda (handout) DAFNE Awareness Workshop Case Study (handout) DAFNE Awareness Workshop Case Study Guidelines (slide) DEP Guidelines for DAFNE Educators (handout) DEP Reviewers Buddy List (handout) Quality Assurance for DAFNE DoH Structured Education Criteria (slide) Quality Assurance (Internal ongoing) (slide) Quality Assurance (External) (slide) Future Contribution to DAFNE Collaborative Remit of the DAFNE Collaborative (slide) Evaluation of DEP and Personal Plan Day Follow-Up Evaluation Form (handout) Personal Plan following Peer Reviewed Course (handout double side) DAFNE T01.002, Version 12 July

7 DAFNE Educator Programme (DEP) Training Workshop Day 1 08:45 ARRIVE and TEA / COFFEE 09:00 Welcome, housekeeping and introductions Aims and expectations of the workshop Experiences of observing a DAFNE course 10:00 TEA / COFFEE 10:15 The DAFNE Philosophy: 11:00 The DAFNE approach to food Practical use of the Glycaemic Index 12:30 LUNCH Estimating difficult CHOs; advice for snacks; working out CPs from food labels 14:45 TEA / COFFEE 15:00 Starting and adjusting the DAFNE insulin regimen: Case studies and curriculum dose adjustment examples 17:00 Homework tasks DAFNE T01.002, Version 12 July

8 DEP TRAINING WORKSHOP (venue) (date) Delegate list Name Profession Centre DAFNE T01.002, Version 12 July

9 WELCOME, HOUSEKEEPING AND INTRODUCTIONS LEARNING GOALS METHODS MATERIALS/MEDIA Participants should. Be informed of location of toilets, fire exits, etc. Feel welcomed and valued and able to contribute to the programme. Get to know each other. Describe location of toilets and fire escapes. Explain procedure if fire alarm sounds (also if any alarm tests expected on the day). Welcome of participants by trainers and introduction of trainers/guests. Illustrate outline of DEP and explain how the training workshop fits into programme. Thank participants for attending observation weeks and completing the tasks as directed. Explain we are all continuing to learn from DAFNE and current Educators are excited about receiving feedback and experience from trainees to further develop the programme. Ask participants to contribute/question/comment through the workshop to gain as much as they need to in preparing to teach DAFNE themselves. Stress that materials used in the DEP workshop have been specifically developed to train Educators and may not be suitable/appropriate to use in DAFNE (patient) courses. Ask participants to introduce themselves to the rest of the group, indicating their profession, place of work and how they became interested/involved in DAFNE. OHP and title acetate Acetate DEP outline Name badges/sticker DAFNE T01.002, Version 12 July

10 WELCOME, HOUSEKEEPING AND INTRODUCTIONS LEARNING GOALS METHODS MATERIALS/MEDIA Share individual expectations of Flip chart and pens the DEP training workshop. Identify sessions that they would like to spend time discussing during the 3 day DEP. Ask participants in pairs (or 3 s) to discuss their expectations of the training workshop and feedback to the rest of the group. Ask, were there any sessions that you feel you would like to spend time discussing during the DEP? Collect onto flipchart-stick on wall for later (Day 2) Explain that these will be kept on the wall to come back to later. Flip chart and pens Be aware of the aims and structure of the training workshop. Illustrate and discuss the aims of Step 4. Outline the programme: Day 1, Day 2 and Day 3 (copy of the full programme is included in the DEP files). Explain that there will be homework tasks to allow us to get the most out of the 3 days. Explain Day 1 consolidates experiences from observation week and develops core DAFNE skills: Day 2 enables sharing ideas and practising lesson planning: day 3 prepares for peer reviewed course and looks at strategies for setting up DAFNE in new centres. Explain the evidence/paperwork they should be accumulating in their DEP file. Explain the importance of continuing to deliver DAFNE as a 5-day out-patient course at present. Acetate Aims (page 28 DEP file) Acetates/handouts What should I collect in my DEP file? DAFNE T01.002, Version 12 July

11 WELCOME, HOUSEKEEPING AND INTRODUCTIONS LEARNING GOALS METHODS MATERIALS/MEDIA Feel able to discuss unresolved issues from their preparatory work and observation week. Be made aware that they will be asked to complete a detailed evaluation form at the end of the 3 days to help. Ask participants to list any issues noted on their forms and 3.6 in DEP file and stick onto prep-prepared flip chart. Ask participants to look in their folders and find the evaluation forms. Sections of this form can be filled in at the end of each day or the whole form can be completed at the end of the 3 days. Stress how crucial feedback is to developing and improving the DEP process. Flip chart Post-it notes DEP folders DEP evaluation form NOTE FOR TRAINERS PLEASE COLLECT OBSERVATION COURSE FEEDBACK FORMS FROM DELEGATES DAFNE T01.002, Version 12 July

12 DAFNE EDUCATOR PROGRAMME (DEP) TRAINING WORKSHOP DAFNE T01.002, Version 12 July

13 DEP steps 1. Orientation 2. Background reading 3. Observational course 4. Training workshop 5. Personal preparation time 6. Peer-reviewed course 7. Follow up workshop DAFNE T01.002, Version 12 July

14 Aims in Step 4 Review and consolidate knowledge of nutrition and develop competencies in applying this to DAFNE. Review and consolidate knowledge of insulin regimen and develop competencies in applying this to DAFNE. Anticipate the demands of being a DAFNE educator and have plans for meeting these. Reflect upon adult learning and patient empowerment skills. Prepare for peer-reviewed course. DAFNE T01.002, Version 12 July

15 What should I collect in my DEP File? Evidence of pre-course reading: Completed pages: Signed copy of The Learning Contract (1.7) Questions to consider to help assimilate the reading material (2.8) Remaining questions and issues (2.9) Evidence from observation week: Completed forms: Observation sheets for all relevant sessions (3.7) Issues arising from observation week (3.6) DAFNE Attitude 15 Questionnaire Case study based on guidelines in DEP File (3.4) Additional notes taken during week Evidence from training workshop: Notes and supporting materials from sessions and workshops Additional resources / materials collected Personal Plan for delivering DAFNE locally Evidence from peer-supported course: Personal lesson plans for all relevant sessions Copies of DEP Reviewer s completed documentation: Evidence Forms Learning Outcomes Forms Summary Forms Additional notes of self-evaluation Evidence from follow up workshop: Notes and supporting materials from workshop Additional resources collected Personal plan for development Continuous Professional Development: Evidence from peer-supported course (as above) Internal Quality Assurance review documentation DAFNE T01.002, Version 12 July

16 EXPERIENCES OF OBSERVING A DAFNE COURSE LEARNING GOALS METHODS MATERIALS/MEDIA Have the opportunity to share experiences of observing a DAFNE course. Become familiar with a range of attitudes to DAFNE. Pairs / small groups to discuss their observation week: What went well? What didn t go well? Was there anything that made you feel uncomfortable? Have your perceptions of attitudes to DAFNE changed? Large group feedback. Perceptions / changes of note listed on flipchart. Acetate of guidelines for discussion of observation week DAFNE Attitude 15 Questionnaires Flip chart and pens DAFNE T01.002, Version 12 July

17 Experiences of observing a DAFNE course What went well? What didn t go well? Was there anything that made you feel uncomfortable? Have your perceptions or attitudes to DAFNE changed? DAFNE T01.002, Version 12 July

18 DAFNE ATTITUDE 15 QUESTIONNAIRE Whilst much of the DEP is focused on knowledge and skills, to become competent (as a DAFNE Educator) it also helps to consider attitude. This was a key part of the early preparation of the original DAFNE Educators after the visit to Germany and their many visits to us. Unfortunately there is little time for long discussion about attitudes during the DEP. For this reason we have developed the DAFNE Attitude 15 Questionnaire which is designed to help you express your thoughts. There are no right and wrong answers as each can be qualified or pre-empted by an argument. The important part of the DEP is that you have at least given these issues some thought. AIM To explore beliefs about DAFNE Please answer each question by saying how much you agree or disagree, and then use the explanation line to qualify your response if it feels necessary. 1 Patients just need support and encouragement to improve their diabetes control. Disagree Partly disagree Partly agree Strongly agree Explanation: Most Health Care Professionals know more about controlling blood sugar levels than most people with Type 1 diabetes. Disagree Partly disagree Partly agree Strongly agree Explanation: People learn more when they feel safe, and free of criticism. Disagree Partly disagree Partly agree Strongly agree Explanation: People differ in how quickly they learn. Disagree Partly disagree Partly agree Strongly agree Explanation: DAFNE T01.002, Version 12 July

19 5 It is better to listen to patients than achieve all the objectives in the DAFNE programme. Disagree Partly disagree Partly agree Strongly agree Explanation: Learning in groups will always mean that people do better. Disagree Partly disagree Partly agree Strongly agree Explanation: After attending a DAFNE course, a patient should need significantly less help in subsequent clinics. Disagree Partly disagree Partly agree Strongly agree Explanation: Having explicit learning objectives stops you from being patient centred. Disagree Partly disagree Partly agree Strongly agree Explanation: If a person picks up knowledge quickly, then they will acquire a skill quickly. Disagree Partly disagree Partly agree Strongly agree Explanation: It will be possible to predict which patients do well, and which have difficulty with DAFNE. Disagree Partly disagree Partly agree Strongly agree Explanation: DAFNE T01.002, Version 12 July

20 11 You can teach attitudes (good, bad, like, dislike) through providing information. Disagree Partly disagree Partly agree Strongly agree Explanation: If you can t count carbohydrates, you cannot do DAFNE. Disagree Partly disagree Partly agree Strongly agree Explanation: After two months of DAFNE people should know all that is necessary to control blood sugar levels. Disagree Partly disagree Partly agree Strongly agree Explanation: It is more important to concentrate on objectives than enthusiasm during the DAFNE programme. Disagree Partly disagree Partly agree Strongly agree Explanation: DAFNE has been developed over several years it is as good as it gets. Disagree Partly disagree Partly agree Strongly agree Explanation: DAFNE T01.002, Version 12 July

21 THE DAFNE PHILOSOPHY LEARNING GOALS METHODS MATERIALS/MEDIA Participants should. Be clear about the aims of a philosophy. Introduce the session to the group (5 mins) When DAFNE was developed it was implicit to the researchers that DAFNE had a clear philosophy. The DAFNE philosophy underpins everything we do, as a whole collaborative and as individuals, it is important that we all understand what the philosophy is and why it is important. Hopefully the reason why we are all here is that we share this philosophy! Why have philosophies?( 10 mins) Ask the group: What do you think a philosophy is? Why do you think a philosophy is important? Work in pairs for 5 minutes and collate group answers. Using the group s responses discuss: A philosophy is a something that determines our core beliefs, attitudes and values and as such will influence our behaviour, thoughts and ideas. The importance of a philosophy is to underpin the content, process and care that shapes the delivery and ongoing development of DAFNE and in theory all education programmes. DAFNE philosophy is drawn from Therapeutic Patient Education (in line with the Berger and Assal models) and from Person Centered philosophy. Blue tack Post- it notes Flipchart paper and pens DAFNE T01.002, Version 12 July

22 THE DAFNE PHILOSOPHY: CAN YOU TELL WHAT IT IS YET? LEARNING GOALS METHODS MATERIALS/MEDIA Be familiar with the DAFNE philosophy. To have reflected and considered how this will affect their own behaviour as educators delivering DAFNE What are the aims of the DAFNE philosophy?(10 mins) Discuss the aims of the DAFNE philosophy using acetate with excerpt from philosophy. Ask the group: how might this be different from traditional methods of education in type 1 diabetes. Collate the answers, which might include the following: Autonomy and self management Confidence and competence Skills based training Carbohydrate counting to facilitate insulin dose adjustment Flexible lifestyle Experiential learning Decisions made by the person with diabetes Responsibility lies with the person with diabetes Ultimately improved outcomes Facilitate a discussion around these issues, particularly if there are any areas of concern expressed by DEP trainees. Educator behaviours (20mins) Discuss the Beliefs and Values from the DAFNE philosophy. Using an acetate. Ask people to spend a moment reading and considering the beliefs and values and ask if there are any areas of concern or anything they disagree with? Lead a short discussion. Copies of the philosophy Acetate: Aims of DAFNE Flipchart and pens Acetate: DAFNE Beliefs and Values DAFNE T01.002, Version 12 July

23 THE DAFNE PHILOSOPHY: LEARNING GOALS METHODS MATERIALS/MEDIA In groups of 3 ask them to list the behaviours that educators might exhibit if they were trying to implement the philosophy. Ask each person to write each comment on a post it note and transfer to flipchart. Pre-prepared flipcharts Post-it notes pens Answers might include: (option to use pre-prepared acetate) Use of open questions Use of reflection to seek clarification and demonstrate empathy Acknowledging each members contribution Trying to avoid saying no Allowing opportunities for reflection Time to practice new skills and gain feedback Providing space for DAFNE participants to work things out for themselves (problem solving) Using active learning methods Avoiding a high percentage of educator talk Providing options rather than absolute answers Involving all the participants Non- judgmental attitudes Honest, accurate and up to date content Demonstrating Empathy and warmth Encouraging individuals to set their own goals Providing support and encouragement Pace of learning is flexible and fits to the learner Acknowledging previous experience and expertise DAFNE T01.002, Version 12 July

24 THE DAFNE PHILOSOPHY: LEARNING GOALS METHODS MATERIALS/MEDIA Allowing participants to be responsible for their own learning Ensuring participants have as much control as possible over the process and decisions made Non threatening, relaxed and enjoyable Positive encouragement of group/individuals Responds to the group atmosphere The DEP trainer discussed that these behaviours are important and reflect style of delivery of a DAFNE course. Much of this forms part of what is assessed in DEP peer review. DAFNE T01.002, Version 12 July

25 The DAFNE Philosophy The philosophy is the foundation upon which the DAFNE programme is based. The philosophy makes explicit the core beliefs, values and attitudes of the members of the DAFNE Collaborative. The DAFNE philosophy is drawn from Therapeutic Patient Education from which the DAFNE programme was derived (1, 2,) and person-centred philosophy that promotes active behaviour change (3). The philosophy underpins the content and processes of diabetes care that guides and shapes the DAFNE programme, its delivery and ongoing development. Aims The principal aim of the DAFNE programme is to facilitate autonomy, competency and confidence in the self- management of diabetes by providing skills- based training in the areas of carbohydrate counting and insulin dose adjustment in a comprehensive range of situations. This includes the development of problem solving skills, that ultimately leads to improvement in biomedical and quality of life outcomes in people with type 1 diabetes and eventual improvements in long-term health outcomes The DAFNE programme aims to enable individuals with type 1 diabetes the ability to have a flexible lifestyle, as it teaches skills that encourages insulin doses to be adapted according to lifestyle choices, using algorithms which can ensure more predictable blood glucose levels and subsequently the experience of a greater sense of personal control. Through experiential learning the DAFNE programme encourages individuals to become activated self- managers, building on their own experience and expertise within the framework of skills and guidance that DAFNE principles provide. The DAFNE programme acknowledges that the person with diabetes drives the decisionmaking process, but aims to encourage the seeking of support when necessary and from whoever is most appropriate to the individual, that will help sustain behaviour change. The responsibility of DAFNE clinicians is to provide optimal therapeutic educational care so that choices are fully informed, whilst recognising that ultimate responsibility and choice rests with the person with diabetes. Beliefs and Values The philosophy of DAFNE is essentially person-centred and recognises that responsibility for self-management lies within the individual with diabetes. DAFNE philosophy recognises that clinicians have responsibility to but not for people with type 1 diabetes. The DAFNE philosophy holds the view that human nature is basically constructive and that people aim to maximise their quality of life via the choices given their interpersonal and external circumstances. DAFNE T01.002, Version 12 July

26 In accordance with person-centred philosophy DAFNE clinicians communicate empathy and non-judgemental support for all those who participate in the programme regardless of the decisions they make. These core qualities underpin the conditions that provide open and honest dialogue regarding optimising self-management. DAFNE clinicians have responsibility to facilitate optimal exploration of values, beliefs and barriers each individual has in relation to his/her diabetes and to provide honest and accurate information about risks and eventualities. DAFNE philosophy recognises that the sharing of ideas between people with diabetes and health care professionals is a two way process that can facilitate improvements in both service delivery and outcomes for people with diabetes DAFNE clinicians will act as a resource, facilitating and supporting the process of life-long change in individuals with type 1 diabetes. Skills and Processes The DAFNE programme provides structured therapeutic education which provides a problem-solving environment that teaches knowledge and skills in the management of diabetes and builds confidence in making informed choices. The DAFNE programme is delivered using adult education principles that includes: o being learner- centred through acknowledgement of each individual s personal experience and expertise o offering a structured framework for the development of practical therapeutic skills in dose adjustment and carbohydrate counting, allowing opportunity for practise and experiential learning o use of open questions and reflections that encourages active participation, personal awareness and the application and practise of new skills o facilitation of active group participation, in particular, valuing peer group support and the role- modelling of problem solving skills within the group o encouraging a problem solving approach to personal barriers and consideration of treatment options o use of goal setting to create personally relevant action plans thereby promoting meaningful involvement of individuals with type 1 diabetes in their own self care The DAFNE programme has a responsibility to provide the highest standard of content and delivery by adhering to the 4 key criteria that fulfils the NICE requirements (4) (a structured curriculum, trained educators, quality assurance and audit) and by ensuring that all aspects of care discussed is evidence based and accurate. DAFNE T01.002, Version 12 July

27 References 1. Muhlhauser, I, Jorgens V, Berger M et al., Bicentric evaluation of a teaching and treatment programme for Type 1 (insulin-dependent) diabetic patients: improvement of metabolic control and other measures of diabetes care for up to 22 months. Diabetologia, : (6) : Muhlhauser I, Berger M. Evidence-based patient information in diabetes. Diabetic Medicine (12): Anderson RM, Funnell MM. The Art of Empowerment Stories and Strategies for Diabetes Educators. 2 nd Edition. (2005) American Diabetes Association. Virginia 4. Structured patient education working group: Report from the Patient Education Working Group. Department of Health DAFNE T01.002, Version 12 July

28 Aims of DAFNE The principal aim of the DAFNE programme is to facilitate autonomy, competency and confidence in the self- management of diabetes by providing skills- based training in the areas of carbohydrate counting and insulin dose adjustment in a comprehensive range of situations. This includes the development of problem solving skills that ultimately leads to improvement in biomedical and quality of life outcomes in people with type 1 diabetes and eventual improvements in long-term health outcomes. The DAFNE programme aims to enable individuals with type 1 diabetes the ability to have a flexible lifestyle, as it teaches skills that encourage insulin doses to be adapted according to lifestyle choices, using algorithms which can ensure more predictable blood glucose levels and subsequently the experience of a greater sense of personal control. Through experiential learning the DAFNE programme encourages individuals to become activated self- managers, building on their own experience and expertise within the framework of skills and guidance that DAFNE principles provide. The DAFNE programme acknowledges that the person with diabetes drives the decisionmaking process, but aims to encourage the seeking of support when necessary and from whoever is most appropriate to the individual, that will help sustain behaviour change. The responsibility of DAFNE clinicians is to provide optimal therapeutic educational care so that choices are fully informed, whilst recognising that ultimate responsibility and choice rests with the person with diabetes. DAFNE T01.002, Version 12 July

29 DAFNE Beliefs and Values The philosophy of DAFNE is essentially person-centred and recognises that responsibility for selfmanagement lies within the individual with diabetes. DAFNE philosophy recognises that clinicians have responsibility to but not for people with type 1 diabetes. The DAFNE philosophy holds the view that human nature is basically constructive and that people aim to maximise their quality of life via the choices given their interpersonal and external circumstances. In accordance with person-centred philosophy DAFNE clinicians communicate empathy and nonjudgemental support for all those who participate in the programme regardless of the decisions they make. These core qualities underpin the conditions that provide open and honest dialogue regarding optimising self-management. DAFNE clinicians have responsibility to facilitate optimal exploration of values, beliefs and barriers each individual has in relation to his/her diabetes and to provide honest and accurate information about risks and eventualities. DAFNE philosophy recognises that the sharing of ideas between people with diabetes and health care professionals is a two way process that can facilitate improvements in both service delivery and outcomes for people with diabetes. DAFNE clinicians will act as a resource, facilitating and supporting the process of life-long change in individuals with type 1 diabetes. DAFNE T01.002, Version 12 July

30 What are the aims of the DAFNE philosophy? Autonomy and self management Confidence and competence Skills based training Carbohydrate counting to facilitate insulin dose adjustment Flexible lifestyle Experiential learning Decisions made by the person with diabetes Responsibility lies with the person with diabetes Ultimately improved outcomes DAFNE T01.002, Version 12 July

31 Educator behaviours Use of open questions Use of reflection to seek clarification and demonstrate empathy Acknowledging each members contribution Trying to avoid saying no Allowing opportunities for reflection Time to practice new skills and gain feedback Providing space for DAFNE participants to work things out for themselves (problem solving) Using active learning methods Avoiding a high percentage of educator talk Providing options rather than absolute answers Involving all the participants Non- judgmental attitudes Honest, accurate and up to date content Demonstrating Empathy and warmth Encouraging individuals to set their own goals Providing support and encouragement Pace of learning is flexible and fits to the learner Acknowledging previous experience and expertise Allowing participants to be responsible for their own learning Ensuring participants have as much control as possible over the process and decisions made Non threatening, relaxed and enjoyable Positive encouragement of group/individuals Responds to the group atmosphere DAFNE T01.002, Version 12 July

32 THE DAFNE APPROACH TO FOOD LEARNING GOALS METHODS MATERIALS/MEDIA Understand and feel comfortable about the DAFNE approach to food. Reflect upon and practise skills in carbohydrate estimation. Ask - Participants to summarise DAFNE approach to food and compare this to previous advice on food in Type 1 Diabetes. Ask - Group to list pros/cons of DAFNE and food. Debate the above issues as a group and aim to deal with any outstanding concerns. Summarise the principles of DAFNE and food: Insulin is the treatment for Type 1 Diabetes. Insulin can be matched to lifestyle (not lifestyle to insulin). Estimating carbohydrate allows an appropriate insulin dose to be given. This allows dietary freedom. DAFNE is about blood glucose management so does not deal in any depth with healthy eating. Discuss - Carbohydrate estimation is a key skill in DAFNE that requires practise. Like DAFNE participants, DEP trainers will be undergoing the same process of learning how to count carbohydrate. Ask - Group to reflect on observed DAFNE course and some of the difficulties they have seen in learning to estimate carbohydrate. Ask-What methods did you see used to teach CHO counting skills? Collect answers. Flipchart and pens Acetate DAFNE principles Flipchart and pens DAFNE T01.002, Version 12 July

33 DAFNE Principles Insulin is the treatment for Type 1 diabetes. Insulin can be matched to lifestyle (not lifestyle to insulin). Estimating carbohydrate allows an appropriate insulin dose to be given. This allows dietary freedom. DAFNE is about blood glucose management so does not deal in any depth with healthy eating. DAFNE T01.002, Version 12 July

34 PRACTICAL USE OF THE GLYCAEMIC INDEX LEARNING GOALS METHODS MATERIALS/MEDIA Understand the concept of Glycaemic Index and its role in DAFNE Discuss DAFNE is based on counting CPs to calculate a suitable insulin dose. Do all types of carbohydrate have the same effect on blood glucose? Evidence from research on the Glycaemic Index shows different carbohydrates have a different effect on blood glucose which is mainly related to the physical structure of the food and/or its accompanying ingredients. Ask group in groups of 2-4 to sort carbohydrate foods into rapid, fast, medium and slow acting and those that have little on blood glucose. Discuss and feedback answers. Ask - What are the implications of the Glycaemic Index for DAFNE? Summarise The Glycaemic Index Demonstrates the most effective hypo treatments. Dispels the myth that sweet foods such as chocolate/cake cannot be eaten in Type 1 Diabetes. Can explain unexpected blood results. Acetates Glycaemic index game Flipchart and pens Refer to Glycaemic Index table in Course Handbook Acetates Practical use of the GI Glycaemic Index DAFNE T01.002, Version 12 July

35 PRACTICAL USE OF THE GLYCAEMIC INDEX LEARNING GOALS METHODS MATERIALS/MEDIA The main messages for DAFNE participants are: Rapid acting carbohydrate is a hypo treatment. Acetate Glycaemic Index and DAFNE Fast, medium and slow carbohydrates should be counted as CPs. Carbohydrates with little or no effect usually require no insulin (unless taken in large quantities). DAFNE T01.002, Version 12 July

36 Glycaemic Index This theory was first investigated by Dr Jenkins in Pasta Glucose Time DAFNE T01.002, Version 12 July

37 Methodology 50g of CHO (test food) is given to an individual Blood sugars are measured: 1st hr - every 15 minutes 2nd hr - every 30 minutes 3rd hr (diabetes only) every 30 minutes Results are compared with glucose or white bread DAFNE T01.002, Version 12 July

38 Simple vs complex CHO No longer true Not based on chemical analysis of the food but rather than effects of the food on the body when eaten Think LOW, MEDIUM and HIGH GI DAFNE T01.002, Version 12 July

39 High GI very rapid effect (hypo treatment) DAFNE T01.002, Version 12 July

40 Medium GI CHO that can be matched by insulin DAFNE T01.002, Version 12 July

41 Low GI little to no effect (unless eaten in large quantities) DAFNE T01.002, Version 12 July

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46 The Glycaemic Index Demonstrates the most effective hypo treatments Contradicts the myth that sweet foods, e.g. chocolate should be avoided May explain unexpected blood glucose results DAFNE T01.002, Version 12 July

47 The Glycaemic Index and DAFNE Rapid Acting CHO Hypo treatment Fast / Med / Slow Count CPs Acting CHO Match with insulin CHO with little No insulin effect DAFNE T01.002, Version 12 July

48 THE DAFNE APPROACH TO FOOD INTRODUCTION OF LUNCHTIME CP COUNTING LEARNING GOALS METHODS MATERIALS/MEDIA Explain - Actively counting CPs is the best way to learn this skill. Participants will count CPs in their own food and drink throughout the 3-day workshop and as homework and will document this. They will be supervised at lunchtimes. Carbohydrate portion estimation booklet This enables participants to: Assess their current skills in CP estimation and therefore identify training needs. Appreciate how it feels to have to count all CPs taken. Understand what it is like to be supervised at mealtimes. DAFNE T01.002, Version 12 July

49 CARBOHYDRATE PORTION ESTIMATION DAFNE T01.002, Version 12 July

50 Practising CP estimation Please note down your CP estimates for each meal, snack and drink (including alcohol) you have throughout the next 3 days. This will enable you to: Assess your current CP estimation skills. Identify future training needs. Understand how it feels to have to count CPs each time you eat/drink. Appreciate how DAFNE participants feel when being supervised at mealtimes. DAFNE T01.002, Version 12 July

51 Date Time Food / Drink CP value Comments: DAFNE T01.002, Version 12 July

52 Date Time Food / Drink CP value Comments DAFNE T01.002, Version 12 July

53 Date Time Food / Drink CP value Comments DAFNE T01.002, Version 12 July

54 Date Time Food / Drink CP value Comments DAFNE T01.002, Version 12 July

55 Date Time Food / Drink CP value Comments DAFNE T01.002, Version 12 July

56 DAFNE Educator Programme (DEP) 3-day Training Workshop DAFNE T01.002, Version 12 July

57 ESTIMATING DIFFICULT CHOs; SNACKS; FOOD LABELS LEARNING GOALS METHODS MATERIALS/MEDIA Demonstrate an ability to assess difficult to estimate carbohydrates. Consider strategies to help DAFNE participants with CP estimation. Demonstrate an ability to calculate CPs from labels and consider strategies to help course participants with these. Understand and practice DAFNE advice regarding snacks DISCUSS PEOPLE S EXPERIENCES OF COUNTING CPS AT LUNCHTIME. Ask What was difficult? How did it feel to be supervised? What information did you use for difficult CHO foods? How could you help DAFNE participants with these issues? Practical activities Set up workstations for each activity and divide group into teams of 3-4 people to visit each workstation. Station 1 Provide selection of plated CP foods that are difficult to estimate, eg pasta, chips, cereal, rice, jacket potatoes. Ask team to guess CPs and compare with answers then reflect on how to help DAFNE participants develop their CP counting skills with these foods. Station 2 Provide a selection of pre-packaged foods. Ask teams to estimate CP value of their personal serving size using the nutritional information on the label. Reflect on the difficulties and how these could be overcome. Station 3 Provide a selection of scenarios that involve having a snack and ask the group to use DAFNE approach to these scenarios (they may need to refer to the Course Handbook). Flipchart and pens Workstation instructions CP list Plated food Scales Workstation instructions Food packets Calculator Answer List Workstation instructions Snack scenarios and answers CP list Food models / photos Course Workbook DAFNE T01.002, Version 12 July

58 ESTIMATING DIFFICULT CHOs; SNACKS; FOOD LABELS LEARNING GOALS METHODS MATERIALS/MEDIA Feedback Reconvene to main group to debrief and Flipchart and pens summarise 1. What difficulties did they encounter with estimating difficult CPs. How could these be overcome? 2. What are the difficulties when calculating CPs from labels. How can you help DAFNE participants with these? 3. What are the main points of advice in the DAFNE approach to snacks? Become familiar with DAFNE resources and consider their use within a DAFNE course. Station 4 Set up a workstation with a selection of plate models, food models and a recipe book. Ask group to work through estimating the CHO in the plate models and food models and using their CHO portion guide, calculate the CP s in a recipe. What key issues around nutrition does this exercise help DAFNE graduates with, and consider how they could include this in their lesson planning, eg the effect of portion size on CPs, that savoury foods often contain more CHO than sweet foods, the difference between using a dry weight ingredient and a cooked weight ingredient to calculate CHO. Summarise Carbohydrate estimation skills are the cornerstone of DAFNE. DEP trainees will need to continue to practice CP counting beyond the 2-day workshop to continue to develop their skills. Plate models, food models, recipe book DAFNE T01.002, Version 12 July

59 Lunch CP counting Estimate your CPs What was difficult? How did it feel to be supervised? What information did you use for difficult CHO foods? How could you help DAFNE participants with these issues? DAFNE T01.002, Version 12 July

60 WORKSTATION 1 Carbohydrate Portion Estimation Visually estimate the CP value of the CHO on each plate. Discuss and compare your answers with your colleagues. What advice could you give to your DAFNE participants when estimating these foods? DAFNE T01.002, Version 12 July

61 WORKSTATION 2 Carbohydrate Portion Estimation from Labels For each of these foods, decide how much you would eat in a serving and calculate the CP value. Discuss and compare your answers with your colleagues. Discuss any difficulties you think DAFNE participants may have when reading labels. How could you help? DAFNE T01.002, Version 12 July

62 WORKSTATION 3 Snacks and DAFNE Here are some scenarios that involve eating a snack Use DAFNE snack guidelines to suggest a way of managing these scenarios. Discuss your ideas with your colleagues. How do DAFNE participants feel about the approach to snacks? What are the main issues? DAFNE T01.002, Version 12 July

63 Snacks and DAFNE Exercise Workstation 1. Your QA:CP ratios are: Breakfast 2:1 Midday 1:1 Evening 1:1 You are in a meeting at work. There is a coffee break at 11am and you fancy a custard cream biscuit. Lunch is scheduled for 12.30pm. How much insulin will you take and when? 2. Your QA:CP ratios are: Breakfast 1½:1 Midday 1:1 Evening 1:1 It is 12.15pm and you eat a Snickers bar on the way to meet a friend for lunch. Your BG before lunch at 1pm is 11mmol/l. You have ½ a thin 9 pizza, salad and a glass of apple juice. How much insulin will you take and when? 3. Your QA:CP ratios are: Breakfast 3:1 Midday 2:1 Evening 2:1 Background insulin 14u am, 14u pm You have a very busy day at work and end up working late, but managed to eat something at 6pm. On your way home at 11pm you decide to call at a burger bar. Your BG is 14.5mmol/l. You order a standard burger in a bun, regular fries and a milkshake. How much insulin will you take and when? DAFNE T01.002, Version 12 July

64 4. Your QA:CP ratios are: Breakfast 2:1 Midday 1½:1 Evening 1:1 Your lunch break is pm. Your friend has a later lunch break (1-1.30pm) and is going to bring you your favourite jam doughnut from the bakers in the High Street. You have a Pot Noodle and diet cola for your lunch. How much insulin will you take and when? 5. Your QA:CP ratios are: Breakfast 2:1 Midday 1½:1 Evening 1½:1 Background insulin 10u am, 10u pm You get up at 8am and your BG is 7.2mmol/l. You decide to skip breakfast, but feel peckish at 10.30am so you eat a Cornish pasty. How much insulin will you take and when? DAFNE T01.002, Version 12 July

65 Snacks and DAFNE Exercise Workstation 1. Your QA:CP ratios are: Breakfast 2:1 Midday 1:1 Evening 1:1 You are in a meeting at work. There is a coffee break at 11am and you fancy a custard cream biscuit. Lunch is scheduled for 12.30pm. How much insulin will you take and when? 1 CP no action required. Record in diary and correct at lunchtime if required. 2. Your QA:CP ratios are: Breakfast 1½:1 Midday 1:1 Evening 1:1 It is 12.15pm and you eat a Snickers bar on the way to meet a friend for lunch. Your BG before lunch at 1pm is 11mmol/l. You have ½ a thin 9 pizza, salad and a glass of apple juice. How much insulin will you take and when? CPs = Snicker 3½, apple juice 2, half 9 pizza 4½ = total 10 Inject for total of 10 CPs at 1.00 pm, but don t correct the 11 mmol/l 3. Your QA:CP ratios are: Breakfast 3:1 Midday 2:1 Evening 2:1 Background insulin 14u am, 14u pm You have a very busy day at work and end up working late, but managed to eat something at 6pm. On your way home at 11pm you decide to call at a burger bar. Your BG is 14.5mmol/l. You order a standard burger in a bun, regular fries and a milkshake. How much insulin will you take and when? CPs = Burger and bun 3, regular fries 3, regular shake 6½ = total 12½ In theory using a 2:1 ratio = 25 units and blood glucose level of 14.5 = +2-3 correction in theory = 27/28 units of insulin.? suggest use 1:1 ratio and be cautious about correction initially DAFNE T01.002, Version 12 July

66 4. Your QA:CP ratios are: Breakfast 2:1 Midday 1½:1 Evening 1:1 Your lunch break is pm. Your friend has a later lunch break (1-1.30pm) and is going to bring you your favourite jam doughnut from the bakers in the High Street. You have a Pot Noodle and diet cola for your lunch. How much insulin will you take and when? Pot noodle = 5½ CPs Doughnut = 3½ CPs Option 1 2 separate injections using a 1½ ratio Option 2 have injection after lunch/before snack Option 3 or before snack 5. Your QA:CP ratios are: Breakfast 2:1 Midday 1½:1 Evening 1½:1 Background insulin 10u am, 10u pm You get up at 8am and your BG is 7.2mmol/l. You decide to skip breakfast, but feel peckish at 10.30am so you eat a Cornish pasty. How much insulin will you take and when? Cornish pastie = 6½ CPs? retest blood glucose,? may need correction Inject with pastie using 2:1 or 1½ ratio DAFNE T01.002, Version 12 July

67 WORKSTATION 4 Familiarising yourself with DAFNE resources Estimate the CPs in the plate models and food models and using the CHO portion guide, calculate the CP s in a chosen recipe. What key issues around nutrition does this exercise help DAFNE graduates with? Consider how you would include this in your lesson planning. DAFNE T01.002, Version 12 July

68 STARTING AND ADJUSTING THE DAFNE INSULIN REGIMEN LEARNING GOALS METHODS MATERIALS/MEDIA Participants should.. Understand how and when to transfer DAFNE participants from their existing insulin regimen to a DAFNE regimen Understand how insulin is used in DAFNE Consider any differences between how insulin is used in DAFNE and traditional care. Reflect on the DAFNE insulin regimen and algorithms Ask participants to refer to their case study from observation week and discuss in pairs / small groups: What was the pre-dafne regimen? When did the participant change regimen? What were their starting doses on DAFNE regimen? Collect (selection of) answers note on flip chart. Discuss pro s/con s; any right or wrong way? Discuss the origins of DAFNE and the Berger model. NB evidence in terms of background insulin is for bd isophane, so use of analogues (Lantus/Levemir) is according to local preferences and long-term evidence will be collected on the DAFNE database. In small groups discuss the purpose of QA and BI in DAFNE. Reflect and discuss the differences between how QA and BI is used in the DAFNE regimen and traditional care. Discuss pros and cons of DAFNE insulin regimen compared to other/previous regimen. Discuss any challenges you think this may represent for you as a DAFNE educator, for patients and for the wider diabetes MDT. Ask group for feedback, collect responses on flipchart. Feedback key/common discussion points and list on flipchart. Case studies Flip chart and pens DEP handout Commencing the DAFNE insulin regimen Flipchart and pens Flipchart and pens DAFNE T01.002, Version 12 July

69 STARTING AND ADJUSTING THE DAFNE INSULIN REGIMEN LEARNING GOALS METHODS MATERIALS/MEDIA Each group to be provided with insulin action posters (1 each group, concentrating on basal/bolus illustrations only). Discuss how would they explain it to their course participants. DAFNE Insulin Action Posters Understand the format and process of individual insulin dose adjustment sessions during a DAFNE week Trainer note: It is important that trainee Educators are able to explain that bd isophane and meal-time soluble is the evidence base for the Düsseldorf regimen, but should also be able to discuss the relative pros and cons of both QA and long-acting analogues. Large group feedback on each poster. Discuss how these could be used within course week. (NB useful to relate to insulin production in non-diabetic). Centre teams / small groups to discuss how the individual (patient) insulin dose adjustment sessions were delivered on their course(s) and how the patients in their case studies progressed through the week Feedback and list key points, eg: Time of day / where on timetable Group discussion Acetate diary pages Each person feeding back their results in turn Use of Step-Wise approach by Educators Who lead the session(s) What changes were actually made to doses during the week etc Course timetables Observation sheets Case studies DAFNE T01.002, Version 12 July

70 STARTING AND ADJUSTING THE DAFNE INSULIN REGIMEN LEARNING GOALS METHODS MATERIALS/MEDIA Discuss what did / didn t work well. Provide advice from the point of view of an experienced Educator, including common problems Demonstrate ability to problemsolve real life examples Reflect on DAFNE insulin dose adjustment theory/principles. Provide groups with unfolding case examples (3) there are 8 pages to each example, looking at each stage of the week s course that their diary would be discussed. Facilitators of the DEP may wish to role play these examples for the participants. For each example (page), consider the following questions: What is the problem (if any)? What are the possible causes (NB CP estimation)? What questions would you ask (NB CP estimation)? Is there a clear pattern / have you got enough information to make/suggest any changes? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage? What was actually done? Was it by pt or Educator? What would you have done differently? Why? Large group feedback / discussion of key issues. Emphasis on the fact that there is often no absolute right or wrong and that following DAFNE guidelines should mean no disasters occur. Ask participants how they observed the insulin dose adjustment examples being used on their course. Unfolding case examples (3) Observation sheets/timetables DAFNE T01.002, Version 12 July

71 STARTING AND ADJUSTING THE DAFNE INSULIN REGIMEN LEARNING GOALS METHODS MATERIALS/MEDIA Understand the structured approach to insulin dose adjustment within the DAFNE programme Discuss the learning goals and step-wise approach relating to insulin dose adjustment from curriculum and their importance in the DAFNE programme as a whole Explain the format of the Dose Adjustment examples, ie: Heading relates to curriculum section (a) is the problem (b) is the suggested solution Show example page of curriculum, emphasising discussion points provided for each example. Demonstrate the systematic (step-wise) approach to using an example, by using problem (a), followed by solution (b). DEP handout Using the DAFNE Dose Adjustment examples Dose adjustment example acetates (Insulin Dose Reduction 12.3 Example 1(a) and 1(b)) Example curriculum page 85 (12.3 Insulin Dose Reduction Example 1) Explain that these are provided in Essential Curriculum Resources file and must be reproduced on acetate in preparation for course. DAFNE T01.002, Version 12 July

72 DAFNE Educator Programme (DEP) Commencing the DAFNE Insulin Regimen The Berger Model is based on twice daily isophane (NPH): at bedtime and in the morning, plus soluble insulin matched to carbohydrate portions (CPs). Many DAFNE course participants will be using bd isophane, with either soluble or rapid-acting analogue to cover CPs, however a significant number of people (or DAFNE Centres) use analogue long acting insulin, therefore the following guidelines should help you to advise your course participants about their insulin prior to commencing the course. Bear in mind that many people seem to be over-insulinised and do require quite dramatic reductions in their overall insulin doses when doing DAFNE! Changing from a bd pre-mixed insulin regimen: Option 1 (standard): Berger regimen : 12u isophane at bedtime and 12u isophane in the morning. Soluble or rapid-acting analogue 1u per 1 CP (1:1 ratio) Continue usual pre-mixed insulin up to and including Sunday evening and commence DAFNE regimen on Monday morning. (Educator to estimate breakfast CPs and advise QA dose for Monday morning). Option 2 ( resistant or sensitive ): If insulin resistant (e.g. >1u/kg total daily dose) and high HbA 1c : Commence Berger regimen, but using 14u-16u isophane twice daily Consider 1½:1 or possibly 2:1 QA:CP ratios If insulin sensitive (e.g. <30u total daily dose): Commence Berger regimen, but using 6u-8u isophane twice daily Consider ½:1 QA:CP ratios Changing from a conventional basal/bolus regimen: Option 1 (isophane or Levemir): Berger regimen : 12u at bedtime and 12u in the morning, as above. Starting from Sunday bed-time, with a suggested QA dose for Monday morning (approx 1u QA ; 1 CP) Adapt starting doses according to insulin sensitivity. Option 2 (Lantus): Consider leaving dose of Lantus unchanged, or approx 24u/24hrs (adapt according to sensitivity). Main benefits from Lantus (ie reduced fasting BG) may be achieved from taking it at bedtime, rather than in the morning. If planning to convert from Lantus to isophane or Levemir, consider the washout period for Lantus and plan to change 2-3 days prior to the course. Considerations Views and reasons for doing DAFNE Views about BG monitoring and extra insulin injections How do they feel about taking insulin at bedtime? Are there any issues around nocturnal hypos? What is their hypo awareness like? What is their current HbA 1c? DAFNE T01.002, Version 12 July

73 Long-acting insulin analogues and DAFNE These are suggested guidelines for people who come to a DAFNE course using long acting insulin analogues as their background insulin. Once per day long acting insulin analogues: Commonly Glargine has been used more often as a once per day basal insulin than Detemir. The dose of once per day long acting insulin analogues should be in keeping with the current DAFNE guidelines, and most patients are recommended to reduce their dose to between 24 and 28 units at bedtime. The time of administration may have been determined by the pattern of previous hypoglycaemia or for concordance reasons. These reasons need to be explored and addressed on an individual basis. The time of administration will impact upon the ratios of rapid-acting insulin. Bedtime administration may result in better basal insulin cover through the morning, but poorer basal cover during the following afternoon and evening-this may mean that a higher evening meal ratio Is required. Ratios for rapid-acting insulin: The time action profile for once daily long acting insulin analogues differs from twice daily NPH insulin, and may impact upon the ratios of rapid-acting insulin. It is recommended to start with the usual DAFNE ratios, incorporating the impact of the dawn phenomenon, with a higher ratio at breakfast time than at meals later in the day. People using once daily long acting insulin analogues at bedtime may require a lower breakfast ratio (less than 2:1) and a higher ratio with their evening meal (greater than 1:1), reflecting the wearing off of Glargine over the final few hours of the 24 hour period. Dose of long acting insulin analogues: Patients using long acting insulin analogues are often over-insulinised, and require a review and reduction of their dose. People on less than 24 units per 24 hrs of long acting insulin analogues may have had problems with hypoglycaemia on higher doses, and should continue on their usual dose at the start of the DAFNE course week. Changes to long acting insulin analogue dose through the DAFNE week are made using the DAFNE blood glucose targets, taking into account any episodes of hypoglycaemia. Duration of action of long acting insulin analogues is dose dependent, a reduction in dose may highlight shortcomings in the duration see below. Frequency of long acting insulin analogues People using once daily insulin glargine may find that their basal insulin is wearing out over the final few hours of a 24 hour period. DAFNE T01.002, Version 12 July

74 In this case Insulin Glargine can be switched from once daily to twice daily, one dose before bed and the second first thing in the morning. This results in a conventional DAFNE-type basal bolus insulin regimen, using both rapid-acting and long-acting insulin analogues. The use of twice daily Insulin Glargine may permit more flexibility in basal dosing to accommodate exercise, although Insulin Detemir maybe a better option in this circumstance. NB. Audit data from the DAFNE database have demonstrated that the best glycaemic improvements will result from taking background insulin twice daily, whatever the preparation (NPH or analogue). Switching to a different basal insulin: On occasions the indication for use of Insulin Glargine may not be readily apparent, and there maybe a more appropriate basal insulin, although this will invariably lead to a switch to twice daily basal insulin dosing.. The best example is the patient who exercises on a frequent basis, and thus has variable insulin requirements. If there are problems with glycaemia relating to exercise, then twice daily NPH insulin or Insulin Detemir should be considered. There remains uncertainty as to the safety of Insulin Glargine in pregnancy, and our practice is for the pregnancy session to incorporate the pros and cons of using Glargine in the context of pregnancy (this also tends to feature in the Questions and Answers session). Again a switch to twice daily NPH insulin or Insulin Detemir should be considered. DAFNE T01.002, Version 12 July

75 DAFNE Educator Programme (DEP) Using the DAFNE Dose Adjustment Examples Encourage participants to use a systematic analysis for each example (and for their own BG results!) DAFNE T01.002, Version 12 July

76 DAFNE Educator Programme (DEP) Using the DAFNE Dose Adjustment Examples What Are The Learning Outcomes? (see: T02.002, Patient Course Curriculum) Principles : Understand that insulin dose adjustment requires a systematic approach (E) State the stages of the step-wise approach to insulin dose adjustment (E) Reduction : State the causes and risk factors for hypoglycaemia (E) Know when the insulin dose should be reduced (E) Understand that they should first rule out the causes of hypoglycaemia (E) Understand that for hypos that occur during the day, they should wait 24 hours to see if the same pattern occurs before adjusting insulin dose (E) Understand that they should identify the insulin responsible for the hypoglycaemia (E) Understand that the QA:CP ratio is adjusted by about ½ a ratio, or BI by about 10%, i.e. 1-2 units (E) Understand that they should only change one dose at a time (E) Demonstrate use of the step-wise approach in relation to the dose adjustment reduction examples provided (E) Remember that the dose has to be reduced if BG values are repeatedly too low (E) Understand why you may need less insulin (E) State what long-term situations may cause insulin sensitivity to be improved (E) NB: Please note that any reference to the old DUK campaign of 4 s the floor has been removed from the DAFNE curriculum. Please do not refer to this within the context of DAFNE as it is confusing and does not reflect the DAFNE targets. It is recommended that a discussion around when to treat (a hypo-bg less than 3.5mmol/l) and when one might need to eat (if BG is below the pre meal target of 4.5mmol/l but above hypo) is more appropriate. DAFNE T01.002, Version 12 July

77 Insulin Dose Adjustment Examples Educator Reference Notes / Discussion Points Reduction Examples: Section Example Specific Learning Outcomes? Discussion Points Solution Isophane/Levemir Reduction 1 Lantus Reduction 1 Isophane/Levemir Reduction 2 Lantus Reduction 2 Isophane/Levemir Reduction 3 Lantus Reduction 3 Isophane/Levemir Reduction 4 Lantus Reduction 4 Understand that in the case of night-time hypos, the relevant BI dose has to be reduced the next evening (E) Remember to recheck night-time BG following change to BI (E) Understand that in the case of night-time hypo and high morning BG, the morning BG should not be corrected with extra QA (D) Hypo 2 2½ hrs after breakfast BI starting to kick in More likely to be due to QA Hypo 1½ - 2 hrs after breakfast BI is working More likely to be due to QA Hypo 2hrs after evening meal Very little BI around then QA has to be the cause Hypo 1 1½ hrs after evening meal BI not yet having much effect More likely to be due to QA Hypo during the night All possible causes considered and ruled out No QA since evening meal Only BI working in the night Don t wait for a pattern Hypo during the night; High morning BG Same discussion as above (e.g. 3) If BG raised following a hypo, there is a risk of repeated hypos if it is corrected with QA, so do not correct BG at next mealtime following a hypo (night-time or daytime) Morning QA:CP ratio reduced from 2:1 to 1½:1 Evening QA:CP ratio reduced from 1½:1 to 1:1 Reduce BI the next evening Recheck BG at 3am (should be >4.5mmol/l) Do not correct high morning BG Reduce BI the next evening Recheck BG at 3am (should be >4.5mmol/l) DAFNE T01.002, Version 12 July

78 Reduction Examples: Section Example Specific Learning Outcomes? Discussion Points Solution Isophane/Levemir Reduction 5 Lantus Reduction 5 Isophane/Levemir Reduction 6 Lantus Reduction 6(i) Lantus Reduction 6(ii) Understand how having a CHO-free meal can aid decision-making in dose adjustments (E) Understand how having a CHO-free meal can aid decision-making in dose adjustments (E) Hypo 2 2½ hrs after lunch 6hrs into action of morning BI Cause could be either QA or BI, but more likely at peak of QA Hypo 1½ - 2 hrs after lunch BI is working Cause could be either QA or BI, but more likely at peak of QA Hypo 4 5 hrs after lunch (beyond action of QA) 9 10 hrs into action of BI Lunch ratio 1:1 unlikely to need less than 1:1 Try having CP-free lunch and test BG If BG still drops, BI is causing the problem Hypo 4 5 hrs after lunch (beyond action of QA) BI working (taken am) All BG at lower end of range Lunch ratio 1:1 unlikely to need less than 1:1 More likely due to BI than QA Hypo 4 5 hrs after lunch (beyond action of QA) All BG at lower end of range, with marked drop overnight Lunch ratio 1:1 unlikely to need less than 1:1 Try having CP-free lunch and test BG If BG still drops, BI is causing the problem Lunchtime QA:CP ratio reduced from 2:1 to 1½:1 Morning BI reduced BI reduced BI reduced Check BG at 3am following BI change DAFNE T01.002, Version 12 July

79 Escalation : State the causes of high blood glucose levels (E) Know when the insulin dose should be increased (E) Understand that they should first rule out the reasons for high BG levels (E) Know that they should wait 24 hours to see if the same pattern occurs before adjusting an insulin dose (E) Understand that they should identify the insulin responsible for the high BG (E) Understand that the QA dose is increased by about ½ a ratio, or the BI dose is increased by about 10%, i.e. 1-2 units (E) Understand they should only change one dose at a time (E) Demonstrate use of the step-wise approach in relation to the dose adjustment examples provided (E) DAFNE T01.002, Version 12 July

80 Escalation Examples: Section Example Specific Learning Outcomes? Discussion Points Solution Isophane/Levemir Escalation 1 Lantus Escalation 1 Isophane/Levemir Escalation 2 Lantus Escalation 2 Isophane/Levemir Escalation 3 High BG before lunch QA finished working BI kicking in More likely that BG rose after breakfast, so QA:CP ratio not high enough High BG before lunch QA finished working BI working All other BG in target range and stable overnight More likely that BG rose after breakfast, so QA:CP ratio not high enough High BG at bedtime Very little BI around after 16hrs Must need higher QA:CP ratio with evening meal High BG at bedtime and morning BI still working 16hrs into action Bedtime corrective dose having predictable effect, so BI looks OK Evening QA:CP ratio must be too low High BG before evening meal 6hrs after lunch Morning BI still working QA finished working but BG could have gone up after lunch Increasing morning BI may cause lunch BG to be too low Try increased QA:CP ratio Morning QA:CP ratio increased from 1½:1 to 2:1 Evening QA:CP ratio increased from 1:1 to 1½:1 Lunch QA:CP ratio increased from 1:1 to 1½: 1 DAFNE T01.002, Version 12 July

81 Escalation Examples: Section Example Specific Learning Outcomes? Discussion Points Solution Lantus Escalation 3 Isophane/Levemir Escalation 4 Lantus Escalation 4 Isophane/Levemir Escalation 5 Understand how having a CHO-free meal can aid decision-making in dose adjustments (E) Understand how having a CHO-free meal can aid decision-making in dose adjustments (E) High BG before evening meal 6hrs after lunch BI still working 10hrs into action All other BG in target and stable overnight QA finished working but BG could have gone up after lunch Increasing BI may cause lunch BG to be too low Try a CP-free lunch and test BG; stable BG indicates BI is OK High BG before evening meal Similar to previous e.g. (3) could be either QA or BI Perhaps an increased QA:CP ratio had caused afternoon hypos More leeway with lunch BG Try CP-free lunch and test BG; rising BG indicates BI too low High BG before evening meal Similar to previous e.g. (3) could be either QA or BI BI 20hrs into action Lunch QA:CP ratio already 3:1; Perhaps an increased QA:CP ratio had caused afternoon hypos BG drifting down overnight, so little leeway for increasing it High BG in the morning Evening BI taken at tea-time instead of bed-time (maybe mixing QA and BI doses together for 1 less injection, or trying to space BI doses 12hrs apart) Tail end of BI in the morning not strong enough to counteract Dawn Phenomenon Generally better to have evening BI as late as possible, i.e. at bed-time Lunch QA:CP ratio increased from 1:1 to 1½: 1 Morning BI increased Split BI to get better 24-hr coverage Consider bd Isophane or Levemir Evening BI moved to bed-time Check 3am BG following change to BI (should be >4.5mmol/l) DAFNE T01.002, Version 12 July

82 Escalation Examples: Section Example Specific Learning Outcomes? Discussion Points Solution Lantus Escalation 5 Isophane/Levemir Escalation 6 Lantus Escalation 6 Understand that in the case of high BG in the morning, the BG should be checked in the night (E) Remember not to increase bed-time BI dose without checking 3am BG first (E) High BG in the morning BI taken in the morning (maybe due to previous hypos at night) BI at tail end of action, not strong enough to counteract Dawn Phenomenon BG in target range the rest of the day and at bedtime BG in target at bed-time but high in the morning Probably not enough BI to counteract Dawn Phenomenon Essential to rule out night-time hypos before increasing BI BG should always be >4.5mmol/l at 3am (although natural to dip) BG in target at bed-time but high in the morning Corrective QA has reasonable effect BG all at upper end of target range QA:CP ratios all 2:1 More likely to need increased BI but need to rule out night-time hypos BG should always be >4.5mmol/l at 3am (although natural to dip) Check 3am BG to rule out night-time hypos (should be >4.5mmol/l)Move BI to bed-time Recheck 3am BG May need less than 3:1 ratio in the morning with better BI coverage BG tested at 3am is safely above hypo range Evening BI increased Recheck 3am BG BG tested at 3am is safely above hypo range BI increased Recheck 3am BG DAFNE T01.002, Version 12 July

83 Corrections : Know the DAFNE guideline for BG correction (E) Understand that by self-monitoring their BG it is possible predict the effect of 1 unit of QA insulin (E) Know that when blood glucose levels are above 11mmol/l, the 2-3mmol/l guideline does not apply (E) Be aware of other possible causes of a raised BG level (E) Know when it is appropriate to increase the insulin dose (E) DAFNE T01.002, Version 12 July

84 Corrections Examples: Section Example Specific Learning Outcomes? Discussion Points Solution 14.2 Corrections Corrections Corrections 3 Understand that pre-meal BG below target range (i.e mmol/l) can be corrected by reducing the mealtime QA insulin dose or increasing the amount of carbohydrate. (E) As example 2. Blood glucose levels generally in target range. Day 2: lunchtime BG raised?had a snack mid-morning without QA insulin.?underestimated breakfast CPs. Corrective QA dose solved the problem. No recurrence of problem on day 3 so no need for change to BI or QA:CP ratio at breakfast. Blood glucose levels generally in target range. Day 2: lunchtime BG below 4.5mmol/l. Usually on QA:CP ratio of 1:1 at lunch, so dose reduced by 1u (i.e. 6u for 7 CPs). No recurrence of problem on day 3, so no other action required. Option to eat an additional CP (same effect as reducing QA dose by 1u). Correct high BG at lunchtime on day 2 with extra QA. Remember 1u QA can reduce BG by 2-3 mmol/l. Correct low BG at lunchtime on day 2 by taking less QA. 1 less unit will allow BG to raise by 2-3 mmol/l. Correct low BG at lunchtime on day 2 by taking additional CP. Remember 1 CP can raise BG by 2-3 mmol/l DAFNE T01.002, Version 12 July

85 Insulin Dose Reduction 12.3 Number = eg in curriculum section Example 1(a) (a) example gives the problem Refers to curriculum section (b) example gives the solution Date Date Date Time 07:30 10:00 12:00 18:00 22:00 CP Blood glucose Quick-acting Background Time 07:30 09:30 12:00 18:00 22:00 CP Blood glucose Quick-acting Background Time CP Blood glucose Quick-acting Background Comments Comments Comments DEP Workshop What is the main problem in this example? Hypo during the morning Are there any specific Learning Outcomes attached to this example? (list) No What are the possible discussion points? (see p85 of Curriculum) 2-2 ½ hrs after breakfast BI will be starting to kick in, but BG more likely to have dropped due to action of QA (whether it is soluble or analogue) What is the suggested solution? (p86 of Curriculum) Reduce morning QA:CP ratio from 2:1 to 1½:1 DAFNE T01.002, Version 12 July

86 Unfolding Case Example 1 Mary Mary is a 40 year old occupational therapist, diagnosed 4 years ago. Weight 75.7kg Height 166cm BMI 27.5 HbA1c 7.1% Has lipohypertrophy, but no DKA/no severe hypos Has performed 42 capillary BG tests in 2 weeks prior to DAFNE course, but doesn t record in a diary Has altered hypo awareness (<3mmol/l) Has been waiting almost 2 years to do the DAFNE course. On PAID questionnaire, the majority of items are Not a Problem, with a couple of Minor Problems. DAFNE T01.002, Version 12 July

87 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP 3 4 Taking Insulatard 15u bd Mon BG Starting ratios 1:1 QA 4 4 BI 15 Time Comments CP Tue BG QA Wed Thu Fri BI Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Monday afternoon)? DAFNE T01.002, Version 12 July

88 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP Inactive all day! Mon BG QA BI Time Comments CP 5 Tue BG 4.3 QA 5 Wed Thu Fri BI 15 Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Tuesday morning)? DAFNE T01.002, Version 12 July

89 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP Mon BG QA BI Time Comments CP Check night-time BGL Tue BG QA BI Time Comments CP 2 Wed BG QA 2+3 BI 15 Time Comments CP Thu BG QA BI Time Comments CP Fri BG QA BI Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Wednesday morning)? What would you have done differently? Why? DAFNE T01.002, Version 12 July

90 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP Mon BG QA BI Time Comments CP Tue BG QA BI Time Comments CP 2 3½ 2½ Wed BG QA BI Time Comments Mary decided to try 1½ :1 at CP 1½ 3½ tea Thu BG and at breakfast She also wants to try 2:1 at QA 5 lunch Fri BI 15 Time CP BG QA BI Comments Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Thursday morning)? What would you have done differently? Why? DAFNE T01.002, Version 12 July

91 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP Mon BG QA BI Time Comments CP Tue BG QA BI Time Comments CP 2 3½ 2½ Wed BG QA BI Time Comments CP 1½ 3½ 5 1½ 2+3 Thu BG QA BI Time Comments CP 2+4 Mary thinks she may need to reduce her BI further (?am as Fri BG well as QA 6 pm) BI 15 Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Friday morning)? What would you have done differently? Why? DAFNE T01.002, Version 12 July

92 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP 3 4 Taking Insulatard 15u bd Mon BG Starting ratios 1:1 QA 4 4 BI 15 Time Comments CP Tue BG QA Wed Thu Fri BI Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments Obviously started off low this morning need to watch this is it a pattern or just 1 st day phenomenon? (Actually had 2u QA at bedtime last night as BG 8.9mmol/l!). Can t draw any conclusions at present. What is she having for tea tonight? How will she work it out? What has she got to help (ie CP list)? Does she/you envisage any difficulties? Explain about 1u QA per CP and to continue on 15u Insulatard bd for now. Emphasise BG targets (especially bed-time) and correct treatment of hypos/corrective QA. DAFNE T01.002, Version 12 July

93 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP Inactive all day! Mon BG QA BI Time Comments CP 5 Tue BG 4.3 QA 5 Wed Thu Fri BI 15 Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments Give encouragement has recorded BGs at appropriate times -> helpful information. What were her 3 CPs at evening meal? How did she work them out? How accurate was she? How did she decide on her QA dose? Was this 2u for CPs + 3 corrective? no, should have written 3+2. Mary feels her BGs were too high yesterday because she was sitting all day, hence needing corrective QA. She is happy that her BG is OK this morning. Discuss BG targets again 4.3mmol/l is too low at breakfast did she over-correct at bedtime (again), or is night BI too high? watch both of these DAFNE T01.002, Version 12 July

94 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP Inactive all day! Mon BG QA BI Time Comments CP 5 2 Tue BG QA 5 2 Wed Thu Fri BI 15 Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments BG was within target at lunch. Nothing to be too concerned about at this stage. What is she eating /doing this evening? How will she estimate CPs? Does she need any guidance? Is she confident to use her CP list? Was there anything from today s hypo session that she needs to take on board? (Vigilance with reduced hypo warnings.) Continue on 1:1 ratios and 15u bd, but be cautious with corrective QA. Perform a 3am test to check night BI. DAFNE T01.002, Version 12 July

95 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP Mon BG QA BI Time Comments CP Check night-time BGL Tue BG QA BI Time Comments CP 2 Wed BG QA 2+3 Thu Fri BI 15 Time CP BG QA BI Time CP BG QA BI Comments Comments Managed to do night-time test well done! BG has risen slightly between lunch and tea 2 days is it a clear enough pattern? How is Mary s CP estimation at lunch-time? Will try 1½:1 today. What were her 3 CPs at evening meal? How did she work them out? Seems to be accurate. Corrective QA not having much effect through evening (same as Monday). High this morning not same pattern. How is she feeling in herself? ( Not 100% ) Has she remembered to check for ketones? (Several BGs >13mmol/l) No will test at coffee time. DAFNE T01.002, Version 12 July

96 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP Mon BG QA BI Time Comments CP Tue BG QA BI Time Comments CP 2 3 ½ Try 1½:1 at lunch Wed BG Got a toothache! QA Thu Fri BI 15 Time CP BG QA BI Time CP BG QA BI Comments Comments Ketones negative, but has now got a toothache. Discuss using minor illness rules, i.e. use corrective QA and continue to check for ketones if BG >13mmol/l. May make it difficult to ascertain patterns for now. How confident is she to estimate her CPs tonight? Is she planning anything different? Continue on 15u bd and 1:1, 1½:1, 1:1. DAFNE T01.002, Version 12 July

97 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP Mon BG QA BI Time Comments CP Tue BG QA BI Time Comments CP 2 3½ 2½ Wed BG QA BI Time Comments Mary decided to try 1½ :1 at CP 1½ 3½ tea Thu BG and at breakfast She also wants to try 2:1 at QA 5 lunch Fri BI 15 Time CP BG QA BI Comments Following dose adjustment principles session yesterday, decided to increase all ratios to 1½:1. Was this appropriate? Was there enough evidence to do that? Illness is confusing the picture at present, so will need to keep an eye on it. Corrective at bed-time not excessive, but woke up hypo at 4.30am. Has she remembered the rule about night hypos? Yes will reduce night BI tonight. Wants to try 2:1 at lunch. Has only had 1 day on 1½:1, but eager to get BGs down. Remind her of DAFNE IDA rules, but it is her decision ultimately just need to be safe in the longterm. DAFNE T01.002, Version 12 July

98 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP Mon BG QA BI Time Comments CP Tue BG QA BI Time Comments CP 2 3½ 2½ Wed BG QA BI Time Comments Reduce night BI to 13u (due to CP 1½ 3½ 5 1½ hypo Thu BG last night) Fri QA 5 10 BI 15 Time CP BG QA BI Breakfast 1½:1 ratio seemed to work OK continue. Comments What were her CPs at lunch? How accurate was she? She feels she jumped in with the ratio increase too early and will go back to 1½:1 tomorrow. Confident to estimate CPs tonight and staying on 1½:1 for tea. Reducing BI to 13u tonight. DAFNE T01.002, Version 12 July

99 Name: Mary HbA1c: 7.1% Insulins: QA: Humalog BI: Insulatard Time Comments CP Mon BG QA BI Time Comments CP Tue BG QA BI Time Comments CP 2 3½ 2½ Wed BG QA BI Time Comments CP 1½ 3½ 5 1½ 2+3 Thu BG QA BI Time Comments CP 2+4 Mary thinks she may need to reduce her BI further (?am as Fri BG well as pm) QA 6 BI 15 BG stayed low through yesterday evening -? due to too much QA at lunch, or is morning BI too high now illness has settled down Mary considering both. Treating hypos appropriately good! Discuss safety issues re correcting raised BG following hypos (bed-time last night) discourage this practice. Rechecked night BG OK at 3am, but woke up hypo at 7am! Could be that relatively high dose of Insulatard having prolonged action/peak. Has lipohypertrophy re-emphasise injection sites! Mary wants to reduce her BI anyway in anticipation of going back to work. DAFNE T01.002, Version 12 July

100 Unfolding Case Example 2 Carl Carl is a 62 year old who works 5am-2pm as a cleaner in a supermarket. He was diagnosed 50 years ago. He has treated angina, hypertension and hypercholesterolaemia. He has retinopathy, treated with laser 19 years ago. He has slight lipohypertrophy, but no DKA and has had 1 severe hypo (with paramedic assistance) in last 5 years. Hypo awareness is generally good (>3mmol/l). Weight 62.8kg Height 160cm BMI 24.5 HbA1c 8.1% (has been stable for at least past 2 yrs) He has performed 56 capillary BG tests in past 2 weeks prior to DAFNE course does not record in a diary. On PAID questionnaire, Feeling discouraged with your diabetes treatment plan and worrying about low blood sugar reactions are Somewhat serious problem. Uncomfortable social situations related to your diabetes care, Worrying about the future and the possibility of serious complications, Feelings of guilt or anxiety when getting off track with diabetes management, Coping with complications of diabetes and Feeling burned out by the constant effort needed to manage diabetes are Moderate Problem DAFNE T01.002, Version 12 July

101 Name: Carl HbA1c: 8.1% Insulins: QA: Novorapid BI: Glargine Time Comments CP 3½ 8 Taking Glargine 12-14u nocte Mon BG Starting ratios 1:1 QA 6 8 BI Time Comments CP Tue BG QA Wed Thu Fri BI Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Monday afternoon)? DAFNE T01.002, Version 12 July

102 Name: Carl HbA1c: 8.1% Insulins: QA: Novorapid BI: Glargine Time Comments CP 3½ 8 5 1½ Mon BG QA BI 13 Time 7.30 Comments CP 5 Tue BG 11.2 QA 5 Wed Thu Fri BI Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Tuesday morning)? DAFNE T01.002, Version 12 July

103 Name: Carl HbA1c: 8.1% Insulins: QA: Novorapid BI: Glargine Time Comments CP 3½ 8 5 1½ Mon BG QA BI 13 Time Comments CP ½ Tue BG QA BI 12 Time Comments 1½ CP Wed BG QA 10 Thu Fri BI Time CP BG QA BI Time CP BG QA BI Comments Comments Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Wednesday morning)? DAFNE T01.002, Version 12 July

104 Name: Carl HbA1c: 8.1% Insulins: QA: Novorapid BI: Glargine Time Comments CP 3½ 8 5 1½ Mon BG QA BI 13 Time Comments CP ½ Tue BG QA BI 12 Time Comments 1½ CP ½ 2 2 Wed BG QA BI 12 Time Comments CP 4½ Carl tried 2:1 at teatime Thu BG Wants to try 1½:1 at lunch QA 5+1 Fri BI Time CP BG QA BI Comments Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Thursday morning)? What would you have done differently? Why? DAFNE T01.002, Version 12 July

105 Name: Carl HbA1c: 8.1% Insulins: QA: Novorapid BI: Glargine Time Comments CP 3½ 8 5 1½ Mon BG QA BI 13 Time Comments CP ½ Tue BG QA BI 12 Time Comments 1½ CP ½ 2 2 Wed BG QA BI 12 Time Comments CP 4½ 5½ 4 2 Thu BG QA BI 12 Time 8.00 Comments CP 3 Thinking he may need to increase Fri BG 8.7 Glargine QA 5 BI Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Friday morning)? What would you have done differently? Why? DAFNE T01.002, Version 12 July

106 Name: Carl HbA1c: 8.1% Insulins: QA: Novorapid BI: Glargine Time Comments CP 3½ 8 Taking Glargine 12-14u nocte Mon BG Starting ratios 1:1 QA 6 8 BI Time Comments CP Tue BG QA Wed Thu Fri BI Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments Usually takes 5u QA at each meal (added 1u to breakfast dose today due to high BGL); felt nervous about taking 8u at lunchtime. What is he planning to eat/do this evening. What CHO is he likely to have? Has he carbcounted in the past? What info has he got to help him? (CP list / labels, etc). Usually decides on dose of Glargine depending on bed-time BGL had 13u last night, so to stick to this for a couple of days for consistency. Stay on 1u per CP (1:1 ratio) for any CPs at tea-time/bed-time. DAFNE T01.002, Version 12 July

107 Name: Carl HbA1c: 8.1% Insulins: QA: Novorapid BI: Glargine Time Comments CP 3½ 8 5 1½ Mon BG QA BI 13 Time 7.30 Comments CP 5 Tue BG 11.2 QA 5 Wed Thu Fri BI Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments BGL stable through afternoon/evening. What were 5 CPs at tea-time? How did he calculate them? How accurate was he? BGL stable, so looks as though he was about right. Not confident to take QA for CPs at bedtime reassure that he will feel more confident when he sees how the DAFNE regimen works for him. If QA taken, fasting BGL probably would have been 2-3mmol/l lower. Glargine dose possibly OK as BG would have been stable overnight if no CPs at bed-time. Encourage to try corrective QA for BGs above target at mealtimes (breakfast). DAFNE T01.002, Version 12 July

108 Name: Carl HbA1c: 8.1% Insulins: QA: Novorapid BI: Glargine Time Comments CP 3½ 8 5 1½ Mon BG QA BI 13 Time Comments CP ½ Tue BG QA BI 12 Time Comments 1½ CP Wed BG QA 10 Thu Fri BI Time CP BG QA BI Time CP BG QA BI Comments Comments Feeling frustrated BGL are all over the place. Different patterns to Monday most likely CP estimation, but need to double-check injection sites, etc. Did he change anything following insulin session yesterday morning? No What were 5 CPs at tea-time? How did he estimate them? How confident is he that he got it correct? What about CPs at bed-time? Did take QA insulin well done! However, reduced Glargine as he was taking QA discuss keeping BI stable, regardless of CPs/QA. How did he calculate the 6½ CPs? Seems like an over-estimation (cocoa)! -> Hypo at 2am most likely due to this. Did well not to over-treat hypo. BGL not bad this morning.?different breakfast what was it? DAFNE T01.002, Version 12 July

109 Name: Carl HbA1c: 8.1% Insulins: QA: Novorapid BI: Glargine Time Comments CP 3½ 8 5 1½ Mon BG QA BI 13 Time Comments CP ½ Tue BG QA BI 12 Time Comments 1½ CP ½ 2 2 Wed BG QA BI 12 Time Comments CP 4½ Carl tried 2:1 at teatime Thu BG Wants to try 1½:1 at lunch QA 5+1 Fri BI Time CP BG QA BI Comments BGL at tea-time very high different again to other days, but?due to 2 hypos in 1 day? Decided to try 2:1 ratio at tea-time not disastrous due to high BGL, but not clear that this is indicated. What were the 2 CPs? Did he eat less because he wasn t hungry, or because BG was high? If necessary, remind that with DAFNE it s OK to eat to your appetite and inject the appropriate amount of QA no need to fast to get BG down! Also remind of safe corrective strategy and that 1u reducing BG by 2-3mmol/l is less predictable >11mmol/l; limit to 4u until sure of sensitivity. Remembered target BG for bed-time and didn t inject QA for CPs as they were to correct below-target BG. Also remembered to re-check night-time BG. DAFNE T01.002, Version 12 July

110 Name: Carl HbA1c: 8.1% Insulins: QA: Novorapid BI: Glargine Time Comments CP 3½ 8 5 1½ Mon BG QA BI 13 Time Comments CP ½ Tue BG QA BI 12 Time Comments 1½ CP ½ 2 2 Wed BG QA BI 12 Time Comments CP 4½ 5½ 4 2 Thu BG QA BI 12 Time 8.00 Comments CP 3 Thinking he may need to increase Fri BG 8.7 Glargine QA 5 BI Check CP estimation again at tea-time. BGL more stable again Carl feels everything will be generally lower when he s back at work next week, but thinking of increasing Glargine if it isn t. Went for 1½:1 ratios across the board despite yesterday s discussions, but knows he needs to keep a check on this and may need to re-adjust next week. DAFNE T01.002, Version 12 July

111 Unfolding Case Example 3 Mohammed Mohammed is a 43-yr-old consultant surgeon. Diagnosed 3yrs ago. Treated initially as type 2 put on sulphonylurea and metformin, but progressed quickly to insulin (probably LADA). Weight 79.5kg, Height 182cm = BMI 24 HbA1c 10.9% No lipohypertrophy / no DKA / no severe hypos. Has performed 1 capillary BG test in past 2 weeks prior to DAFNE course not recorded in diary. Has general medical knowledge about diabetes, but little understanding about carbohydrates and insulin. Worried about hypos, especially at work and frequently over-treats, or over-eats to avoid them. On PAID questionnaire, most items are Not a Problem or Minor Problem, with Worrying about low blood sugar reactions and Feelings of guilt or anxiety when getting off track with diabetes management being Moderate Problems DAFNE T01.002, Version 12 July

112 Name: Mohammed HbA1c: 10.9% Insulins: QA: Novorapid BI: Detemir Time Comments CP 3½ 0 Taking Detemir 10-12u bd Mon BG and Metformin 500mg bd QA 10 0 Starting ratios 1:1 BI 10 Feeling unwell pm home early Tue Wed Thu Fri Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments Comments Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Monday afternoon)? DAFNE T01.002, Version 12 July

113 Name: Mohammed HbA1c: 10.9% Insulins: QA: Novorapid BI: Detemir Time Comments CP 3½ Mon BG QA BI Time 8.00 Comments CP 3½ Has always taken 9u at breakfast Tue BG 10.0 (always has the same thing) Wed Thu Fri QA 9 BI 12 Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Tuesday morning)? DAFNE T01.002, Version 12 July

114 Name: Mohammed HbA1c: 10.9% Insulins: QA: Novorapid BI: Detemir Time Comments CP 3½ Mon BG QA BI Time Comments CP 3½ 5 7 2½ Tue BG QA BI Time 8.00 Comments CP 3½ Has decided to try 3:1 at tea as it Wed BG 9.3 seemed a more reasonable dose Thu Fri QA 11+1 BI 12 Time CP BG QA BI Time CP BG QA BI Comments Comments Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Wednesday morning)? What would you have done differently? Why? DAFNE T01.002, Version 12 July

115 Name: Mohammed HbA1c: 10.9% Insulins: QA: Novorapid BI: Detemir Time Comments CP 3½ Mon BG QA BI Time Comments CP 3½ 5 7 2½ Tue BG QA BI Time Comments CP 3½ 3 4 Wed BG QA BI Time 8.00 Comments CP 3½ Thu BG 8.7 QA 12 BI 12 Time Comments CP Fri BG QA BI Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Thursday morning)? What would you have done differently? Why? DAFNE T01.002, Version 12 July

116 Name: Mohammed HbA1c: 10.9% Insulins: QA: Novorapid BI: Detemir Time Comments CP 3½ Mon BG QA BI Time Comments CP 3½ 5 7 2½ Tue BG QA BI Time Comments CP 3½ 3 4 Wed BG QA BI Time Comments CP 3½ He is thinking about 3:1 for all Thu BG meals QA BI Time 8.00 Comments CP 3½ Fri BG 8.4 QA 11 BI 12 Remember to refer to the Dose Adjustment Step-wise approach. What is the problem? What are the possible causes? What questions would you ask? Is there a clear pattern? Which insulin(s) need to be adjusted? What advice would you give / what decisions would you be expecting from the patient at this stage (Friday morning)? What would you have done differently? Why? DAFNE T01.002, Version 12 July

117 Name: Mohammed HbA1c: 10.9% Insulins: QA: Novorapid BI: Detemir Time Comments CP 3½ 0 Taking Detemir 10-12u bd Mon BG and Metformin 500mg bd QA 10 0 Starting ratios 1:1 BI 10 Feeling unwell pm home early Tue Wed Thu Fri Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments Comments Will miss whole afternoon session (monitoring and dose adjustment planning). Is he fed up with it, or is he planning to return tomorrow? How confident is he to estimate any CPs tonight and tomorrow morning? Refer to CP list and common foods to him. Advise 1u QA per CP. Record BGs, CPs, QA and BI in diary. DAFNE T01.002, Version 12 July

118 Name: Mohammed HbA1c: 10.9% Insulins: QA: Novorapid BI: Detemir Time Comments CP 3½ Mon BG QA BI Time 8.00 Comments CP 3½ Has always taken 9u at breakfast Tue BG 10.0 (always has the same thing) Wed Thu Fri QA 9 BI 12 Time CP BG QA BI Time CP BG QA BI Time CP BG QA BI Comments Comments Comments Encouragement has done BG testing (doesn t usually) and recorded everything! What exactly were his 1 CP at 6.30pm and his 6 CPs at 7pm? How did he work them out? How accurate was he? What was his reasoning behind the 8u corrective at 10.50pm? Perhaps wasn t disastrous as he was unwell and maybe had underestimated tea-time CPs. Discuss safe corrective practice as in front of diary. Discuss 1:1 starting ratios and ask about trying it at breakfast-time (Mohammed not keen as he s certain it won t be enough and would rather try 3:1) NB 3 x 3½ = 10.5u. DAFNE T01.002, Version 12 July

119 Name: Mohammed HbA1c: 10.9% Insulins: QA: Novorapid BI: Detemir Time Comments CP 3½ Mon BG QA BI Time Comments CP 3½ 5 7 2½ Tue BG QA BI Time 8.00 Comments CP 3½ He decided to try 3:1 at tea as it Wed BG 9.3 seemed a more reasonable dose Thu Fri QA 11+1 BI 12 Time CP BG QA BI Time CP BG QA BI Comments Comments Has continued to test and record good! Lunch-time corrective wasn t excessive. Not a pattern yet, but?morning BI or lunch ratio. What were his 7 CPs at evening meal? How did he work them out? Decided himself to have 3:1 for evening meal. Worked well, but point out that insulin adjustment principles will be discussed this morning and it is usually advised to increase by only ½ ratio. Did well to remember to have CPs as BG below target at bed-time, maybe didn t need as much as 2½ - that s why BG above target this morning. DAFNE T01.002, Version 12 July

120 Name: Mohammed HbA1c: 10.9% Insulins: QA: Novorapid BI: Detemir Time Comments CP 3½ Mon BG QA BI Time Comments CP 3½ 5 7 2½ Tue BG QA BI Time Comments CP 3½ 3 4 Wed BG QA BI Time 8.00 Comments CP 3½ Thu BG 8.7 QA 12 Fri BI 12 Time CP BG QA BI Comments All BGs <10mmol/l yesterday! That s great will have an impact on HbA1c if maintained! Check CP estimation for evening meal seems accurate enough. Corrective QAs still not having much effect. Likely that morning BI needs increasing, but Mohammed would rather concentrate on QA:CP ratios as he feels his BGs may be lower when he goes back to work next week (fair/good decision). BG stable overnight, so good indicator that night BI is OK. Could have safely corrected by 1u at bedtime.?12u QA this morning corrective. DAFNE T01.002, Version 12 July

121 Name: Mohammed HbA1c: 10.9% Insulins: QA: Novorapid BI: Detemir Time Comments CP 3½ Mon BG QA BI Time Comments CP 3½ 5 7 2½ Tue BG QA BI Time Comments CP 3½ 3 4 Wed BG QA BI Time Comments CP 3½ He is thinking about 3:1 for all Thu BG meals QA BI Time 8.00 Comments CP 3½ Fri BG 8.4 QA 11 BI 12 Good demonstration of further change in BG through afternoon (even though still above target). Had 2 CPs at 10.15pm as he felt his BG was dropping now feels he didn t need them. BG would have been in target at bed-time. Mohammed is confident that his BGs will be lower next week when he is busy again, so not concerned about them being just above target at present. If not, he will consider looking at BI (morning). Will continue on 3:1, 1½:1, 3:1 ratios. DAFNE T01.002, Version 12 July

122 HOMEWORK TASK DAY 1 LEARNING GOALS METHODS MATERIALS/MEDIA Practise theory of DAFNE insulin dose adjustment Each centre pair to work through the dose adjustment examples in the DAFNE workbook to be completed as homework. If the Centre is likely to use primarily Lantus, they should review the Lantus examples, but answer the same questions for each, ie: What is the main problem in this example? Are there any specific Learning Outcomes attached to this example? (list from Curriculum) What are the possible discussion points? (see Curriculum) What is the suggested solution? (in Curriculum) Dose adjustment example handouts / worksheets. DAFNE course curriculum. DAFNE T01.002, Version 12 July

123 DAFNE Educator Programme (DEP) Training Workshop Day 2 09:00 Feedback from homework 10:15 TEA / COFFEE 10:30 The DAFNE curriculum and lesson planning 11:15 Writing lesson plans: getting some practise LUNCH Sharing ideas / strategies for specific sessions, eg Sick Day Rules Exercise Alcohol Annual Review TEA / COFFEE Therapeutic Patient Education Adult Education / Learning Theories 15:45 Goal Setting and Action Planning 17:00 Close DAFNE T01.002, Version 12 July

124 FEEDBACK FROM HOMEWORK DAY 2 LEARNING GOALS METHODS MATERIALS/MEDIA Demonstrate an understanding of DAFNE insulin dose adjustment theory Practise using the DAFNE dose adjustment examples in the workbook Have an opportunity to discuss any concerns or misunderstandings regarding the regimen and/or adjustments Each group to feed back on 1 example (chosen by DEP trainer from 12.6, Reduction Example 4; 12.8, Reduction Example 6; 13.5, Escalation Example 3; 13.7, Escalation Example 5; 13.8, Escalation Example 6) explaining discussion points and rationale for answer(s) Discuss the DAFNE workbook and how it can be used during the DAFNE course Discussion of key points, e.g.: Only using pre-meal readings Night time hypos Not correcting high BG following hypo Ways of evaluating BI (overnight profile; missing meal, etc) Examples same whether pt on soluble QA or analogue QA Questions and answers / suggestions Suggest Centres/individuals consider how they will use the examples in their own course(s) and to plan time to work through all the examples before delivering their first course. Dose adjustment example handouts / worksheets. DAFNE course curriculum. DAFNE workbook Dose Adjustment Example Acetates (questions(a) and solutions(b) for Levemir / Isophane and Lantus) DAFNE T01.002, Version 12 July

125 THE DAFNE CURRICULUM and LESSON PLANNING LEARNING GOALS METHODS MATERIALS/MEDIA Understand what a curriculum is Understand the format of the DAFNE curriculum Reflect on Adult Education Theories Be able to design and plan teaching sessions using the principles of adult education Ask group what they understand about the term curriculum Collect responses and correct/elaborate, using acetate Illustrate an example session from curriculum, emphasising: Essential and Desirable learning goals Suggested methods / explanations / evidence Resources Discuss how it relates to Adult Education / Learning Theories. Emphasise that the order of topics within a session may be flexible, i.e. it is up to Educator to decide how to meet the learning goals. (Provide a personal example if possible) Ask What is your experience of lesson planning? When planning a session, what should you take into consideration? A lesson plan is a personal plan of how you will deliver a session. It should contain all the elements on the handout checklist for preparing lesson plans. What kind of teaching methods would you wish to use? Give an example of a teaching method, eg brainstorm and gather a list of other teaching methods from group, eg discussion, lecture, group activities, case study, simulation. Acetate What is a curriculum? Acetate(s) of eg curriculum session Flipchart and pens Acetates Handout Checklist for preparing lesson plans DAFNE T01.002, Version 12 July

126 THE DAFNE CURRICULUM and LESSON PLANNING LEARNING GOALS METHODS MATERIALS/MEDIA Discuss - Different teaching methods seen on observed DAFNE courses and how they fulfilled the principles of Adult Education. Show group an example of the DAFNE Curriculum and discuss its structure. Compare this with a lesson plan of the same session. Explain - The curriculum gives guidelines on the learning outcomes and content and the lesson plan focuses more on how this can be achieved, eg teaching methods and how long it will take. DAFNE T01.002, Version 12 July

127 Basic Principles of Adult Education Participants experience should be incorporated into the programme. Different teaching methods are needed to allow participants to gain appropriate knowledge and skills. Participants are responsible for their own learning. Teaching should start with what participants know and are interested in. Participants will learn from each other. People need opportunities to develop understanding, experiment, practise and reflect on what has happened. People should have as much control as possible in the education process. DAFNE will constantly go through a process of development, participants will inform this. Effective learning climate is non-threatening, relaxed and enjoyable. DAFNE T01.002, Version 12 July

128 Checklist for Preparing Lesson Plans Your lesson plan should contain: DAFNE learning outcomes Content with appropriate teaching methods Resources needed for each section Appropriate timings for each part of session The content should include: An introduction to the aims/content of session Using participant s current knowledge and experience Opportunities for them to learn from each other A range of teaching methods Methods which allow participants to practise their skills and reflect Opportunities for participants to have their say A summary of main principles at the end The style of delivery should: Be relaxed and non-judgemental Encourage participation from the group and individuals Respond effectively to the group s atmosphere Encourage a problem solving approach Include clear explanations and language that is appropriate to the group Encourage reflection DAFNE T01.002, Version 12 July

129 What is a Curriculum? Curriculum is a process that includes: Setting goals for learning, based on needs assessment Selecting subject matter and methods appropriate to the participants Developing materials and activities for learning Evaluating the results Understanding Curriculum Development in the Workplace. A Resource for Educators. Belfiore, M.E. (1996) DAFNE T01.002, Version 12 July

130 1.0 Introduction and Organisation Resources: Session - Introduction and Organisation 1. Patient pack including: Course Handbook Diary(ies) CP list Name badge Pencil with rubber Timetable 2. Lesson plan 3. Timetables for Educators and guests 4. Register of patients 5. Flipchart/whiteboard 6. Pens 7. DAFNE title flipchart 8. Flipchart: Expectations of the DAFNE course 9. Post-it notes 10. Hypo treatment box Learning goals: The patient should 1.1 Welcome and Housekeeping Resources Get to know the training team. (E) Be aware of the guest observers (if any). (E) Know essential housekeeping arrangements, ie fire escape, toilet etc. (E) Be aware of the background to DAFNE courses locally and internationally. (E) Know that they can reduce the risks of acute and long term diabetic complications. (E) Welcome the patients to the DAFNE course and introduce Educators and guest observers (if any). Explain any housekeeping for the week including room changes (if any), catering/refreshments arrangements including availability of hypo treatment, location of toilets, fire exits, etc. Explain: DAFNE is based on the principles of a course run successfully in Germany since 1980 s. Courses started in the UK in Thousands of people with Type 1 Diabetes in the UK and Republic of Ireland have now been trained in the DAFNE skills. Evidence shows that DAFNE has been shown to reduce short and long term complications and improve QoL. DAFNE title flipchart DAFNE T01.002, Version 12 July

131 Understand that the DAFNE course teaches the skills of insulin dose adjustment to support selfmanagement of their diabetes. (E) DAFNE course teaches you the skills needed to adjust you own insulin day to day. Learning these skills enables you to take over this major part of your treatment in order to successfully manage your diabetes. This will also enable you to become more independent of health care professionals. Define: Dose Adjustment For Normal Eating Understand that active participation is essential for the acquisition of new skills. (E) Encourage participants to play an active role during the sessions and feel free to ask questions at any time if anything is unclear. Learning goals: The patient should 1.2 Introductions and Expectations Resources Understand the value of discussing previous experiences of living with diabetes. (E) To become familiar with all other patients. (E) Identify their personal expectations of DAFNE. (E) Identify and agree to work within their group ground rules. (E) Ask the participants to introduce themselves (name badges if applicable), to discuss when their diabetes had been diagnosed, what their previous treatment had been, who had invited them to attend this training, why they came to this training and what problems they have with their diabetes. Invite the participants to list their expectations of the training week. Collect and discuss the various expectations on the flipchart. Invite the participants to identify the ground rules for the training week. Collect the ground rules on the flipchart. Name badges Flipchart Expectations of the DAFNE course Pens and post-it notes Flipchart and pens Learning goals: The patient should 1.3 Timetable Resources Understand the structure and contents of the week (course timetable). (E) Understand that it may be beneficial to invite a guest to some of the sessions. (E) Illustrate and discuss: The topics to be covered during the training course using the timetable. Emphasise: Participation of relatives/partners/friends is particularly desirable for the session on hypoglycaemia as they may be of assistance in the recognition and management of hypoglycaemic episodes. Timetable DAFNE T01.002, Version 12 July

132 Know that the contents of the course are summarised in the handbook. (E) Explain: The contents of course may be looked up in the Course Handbook and you may make your own additional notes in your handbook if you wish to. Course Handbook Learning goals: The patient should 1.4 Blood Testing and Hypoglycaemia Resources Understand the importance of blood glucose measurements prior to meals, snacks and treating hypos. (E) Be aware that hypos may occur during the week and that there is specific advice for their treatment which they should familiarise themselves with. (E) Emphasise: The importance of testing their blood glucose level before eating (lunch), before having snacks, and if feeling hypo. Explain: Hypos are not uncommon during the week (1-2 mild hypos per week can be expected). Please check your blood glucose level if you feel low. The advice for treating a hypo is slightly different on DAFNE to what you may have been previously taught, please familiarise yourself with this and do not hesitate to ask if you are unsure. Identify the recommended hypo treatments and where the box will be kept during the week. Hypo treatments box Learning goals: The patient should 1.5 Quiz and Summary Resources Understand the purpose of the quiz. (E) Be aware that the week is an introduction to the skills. They will be responsible for implementing on a daily basis, and review and update their own practice. (E) Explain: You will be asked to work through the quiz during the training week. The quiz helps the Educators find out whether the sessions have truly met your requirements and what information needs to be refreshed. Explain: You should not expect perfect blood glucose control by the end of the training week. The DAFNE skills need to be implemented on a daily basis. Keeping a record of your blood sugars, food and insulin in the DAFNE diary will help you identify patterns and make appropriate dose adjustments in the future for life long good glycaemic control. Quiz Pencil with rubber DAFNE T01.002, Version 12 July

133 WRITING LESSON PLANS : GETTING SOME PRACTISE LEARNING GOALS METHODS MATERIALS/MEDIA Understand how a lesson plan is different to a curriculum. Ask group for their thoughts on the differences between a curriculum and a lesson plan. Participants will be able to write a lesson plan using the DAFNE curriculum. Discuss: Personal plan of how you will meet learning outcomes Identify where session will be located within the course Prior consideration of timing for individual topics within a session Plan of methods / strategies and how core or personally developed resources will be used Effective way of getting to know the content of curriculum (look at it in detail). Explain that DAFNE Educators should develop their own lesson plans and may use different teaching methods from those observed (if they wish), as long as they cover the content of the whole curriculum, use a varied range of teaching methods and meet the learning outcomes. Divide into smaller groups 3-4 people (if any have previously produced lesson plans, try to place them with participants who have not). Ask each group to write a lesson plan using part of the DAFNE curriculum. Groups present their lesson plans and ideas. Feedback and discussion. Lesson plan pro forma Acetates of blank lesson plan (Copied section of) Curriculum OHP pens DAFNE T01.002, Version 12 July

134 DAFNE LESSON PLAN Session Title: Curriculum pages: (T02.002) Day: Time: Key aims of the session: DAFNE T01.002, Version 12 July

135 Session: Learning Outcomes Method Resources Time DAFNE T01.002, Version 12 July

136 DAFNE LESSON PLAN Session Title: Individual Dose Adjustment Practise Curriculum pages: (T02.002) Day: Tuesday - Friday Time: 9-10am and pm Key aims of the session: To enable individual participants to reflect on what they have learned in relation to CP estimation and insulin dose adjustment so that they can demonstrate application of the principles to their own blood glucose management. DAFNE T01.002, Version 12 July

137 Session: Learning Outcomes Method Resources Time Understand the benefits of sharing their BG results with the other group members (E) Understand that before adjusting insulin doses, they should check the accuracy of their CP estimation (E) Be able to reflect on insulin dose adjustment theory using the systematic step-wise approach (E) Be aware that hypoglycaemia should be treated with 1½-2 CPS of rapid-acting CHO (E) Be aware that a BG reading below target range at a mealtime can be corrected by injecting less QA insulin than required for CHO eaten (E) 1 st session / day: Explanation of the purpose and format of the session. Emphasise importance of everyone listening to each other. --- Each person in turn to display and discuss their diary, explaining: Which QA and BI they are using Their doses and ratios Their BG target ranges What CHO they have had and how they calculated the CPs Any challenges / difficulties Highlight and emphasise step-wise approach to dose adjustment to encourage safe practice and prevent tailchasing --- Address specific issues as required, eg: Hypoglycaemia / BG below target range Can they identify cause(s)? Recognition / symptoms Appropriate treatment? Insulin adjustment / correction CHO (e.g. at bedtime) Diary on acetate OHP Pens Posters BG target ranges, Insulin actions Course Handbook p24 Poster Treating a hypo 2 mins 5 10 mins each DAFNE T01.002, Version 12 July

138 Session: Learning Outcomes Method Resources Time Be aware that a BG reading below target range at bedtime can be corrected by eating additional CPs (E) Be aware that a BG reading above target range can be corrected with extra QA insulin (but used cautiously until sensitivity known) (E) Know that, apart from during illness, high BG should not be corrected in between meals (E) Be aware that if BG is more than 13mmol/l on more than 1 occasion, or a one-off reading of more than 17mmol/l, with no clear cause, they should test for ketones Hyperglycaemia Can they identify any cause(s)? Appropriate use of correction dose When is adjustment to BI or QA:CP ratio appropriate? Recurrent high readings Screening for ketones Poster Guidelines for corrections DAFNE T01.002, Version 12 July

139 SHARING IDEAS / STRATEGIES FOR SPECIFIC SESSIONS - WORKSTATIONS LEARNING GOALS METHODS MATERIALS/MEDIA Note: This session can be quite flexible in its delivery and needs to be based on the issues that were highlighted by the DAFNE trainees on Day 1. It may be necessary to alter the content and provide additional resources dependent on the trainee s requirements. Understand the aims of the session Introduce session - this is an opportunity to share ideas on some of the sessions that might be more challenging to deliver. Refer to flipchart collected yesterday for sessions the group wanted to spend more time on. Discuss with group that there are 4 workstations: Sick day rules Alcohol Physical activity Annual review/planning difficult sessions Given the time available they will be able to do 3 out of 4 of these. Workstation 1 Sick Day Rules Ask group what difficulties they anticipate in delivering this session. Ask group to outline the main areas to be covered in this session. Demonstrate the order and flow that you, as an educator, would use to deliver this session. Using handouts, discuss minor and severe sick day rules. Use examples and encourage reference to DAFNE handbook. Pens flipcharts post-it s DAFNE T01.002, Version 12 July

140 SHARING IDEAS / STRATEGIES FOR SPECIFIC SESSIONS - WORKSTATIONS LEARNING GOALS METHODS MATERIALS/MEDIA Workstation 2 Alcohol NB This session needs careful facilitation. The key points covered should be; Long acting insulin analogues, how educators feel about advising participants to take QA with alcoholic drinks containing CPs. This workstation needs to be semi-supervised. Ask the trainees to work their way through the worksheets: Alcohol and DAFNE principles (No 1) Alcohol and DAFNE (No 2) Alcohol Scenarios (No 3) Workstation 3 Physical Activity DAFNE and Exercise Physical activity scenarios Workstation 4 Annual Review/Planning Difficult Sessions The group are asked to identify sessions other than the above which they would like some support in planning to make as interactive as possible. The DEP trainer facilitates a session looking at lesson planning and methods used and may wish to use the annual review session as an example using the Leicester model. DAFNE T01.002, Version 12 July

141 DAFNE: Exercise Physiology Educator Notes The DAFNE Curriculum sets out to teach patients with Type 1 Diabetes how to remove diabetes as a limiting factor to being more active, and to normalise function. By increasing the patient s understanding of exercise physiology a greater confidence in his/her own training and performance can be instilled. It is important that the individual with Type 1 diabetes knows that the greatest advantage of exercise is its cardioprotective effect, rather than improved glycaemic control 1,2 ; the latter of which is more pronounced in Type 2 Diabetes and overweight individuals with Type 1 Diabetes by improving insulin sensitivity. However, by demonstrating the levels of commitment required by rigorous BG monitoring before and after exercise, and adjusting insulin or CP intake accordingly as per DAFNE guidance, the risk of hypos, or decline in BGs can be minimised 1,3. Exercise Physiology During exercise working muscles demand more oxygen; this is met by increased cardiac and respiratory output. Adequate amounts of oxygen need to be delivered to prevent premature fatigue. In addition to this there needs to be rapid mobilisation and redistribution of metabolic fuels to ensure there is adequate energy available for the working muscles. The provision of fuel in the blood is dependent on the effects of the sympathetic nervous system (SNS) and hormones on the liver and adipose tissue 1,2,4. Blood glucose levels can rise or fall depending on the type, duration and intensity of activity an individual takes part in, these factors also influence whether the activity is anaerobic or aerobic in nature, or a mixture of the two. Oxygen consumption There is a linear relationship between aerobic metabolism and maximal exercise intensity in most forms of exercise, whereby when walking, cycling or running faster, our oxygen consumption (VO 2 ) increases in parallel. This consumption of oxygen will continue to increase until it reaches a maximum rate (VO 2max ) this is shown by the plateau on the graph below. Exercise can only be continued for a short while at this level as there is no further increase in oxygen uptake. An individual s VO 2max is determined by several factors including weight, height, age, sex, habitual activity levels and inherited factors 1. It is generally considered the best indicator of cardiorespiratory endurance and aerobic fitness. Definition: Exercise intensity Intensity Mild Moderate Intense %VO 2 max DAFNE T01.002, Version 12 July

142 ( G r a p h taken from Metabolic responses in the non-diabetic state 2 Endocrine: Insulin Adrenaline (Proportional to exercise intensity and glycaemia) Glucagon Growth Hormone Endorphins Cortisol SNS: Adipose tissue lipolysis Plasma FFA Insulin and Glucagon release Consequences of hormonal response to exercise Amino acids Liver + Rise in adrenaline & Glucagon Blood Glucose - Muscle Glycerol and FFA increased Adipose tissue + - Fall in Insulin Rise in adrenaline and SNS stimulation (Diagram taken from Professor Ian McDonald s Lecture notes 2 ) DAFNE T01.002, Version 12 July

143 Aerobic exercise Glycogen stores are the major fuel source in aerobic exercise and are mobilised almost immediately when such exercise commences 5, lasting approximately minutes 1. During moderate exercise, insulin levels fall concurrently with a rise in glucagon. The fall in insulin not only reduces glucose uptake by inactive muscles, (making sure any that is available is spared for the active muscle and the brain) but also removes any inhibition of adipose tissue lipolysis. Whereas, the concurrent rise in glucagon and adrenaline stimulates hepatic glucose production and along with the activation of the SNS, stimulates adipose tissue lipolysis 9. All of these processes maintain glucose levels within a narrow range and hypoglycaemia rarely occurs in the non-diabetic individual 1,5,7,8. Gluconeogenesis (production of non-sugar carbon substrates) and intestinal absorption also contribute to blood glucose production; followed by the metabolism of muscle triglycerides and circulating FFA derived from adipose tissue 1. (Diagram taken from Dr. Ian Gallen s Lecture note 3 ) Skeletal muscles require a continuous supply of ATP in order to sustain activity during endurance events, in the presence of oxygen this ATP is provided aerobically. Endurance activities: Rowing, cycling, long-distance running, a day s hiking. Fuels utilised 1 : Mix of CHO and fat in varying ratios depending on the intensity of the activity; for example, in exercise of 50% of VO2max energy is equally derived from carbohydrate and fat metabolism6. Fats (the preferred fuel source) are mobilised from stores by adrenaline in mild to moderate activity, and are either used directly by the muscle or converted into ketone bodies by the liver. As exercise intensity increases so does the rate at which CHO is utilised6, to the extent at which during very high intensity activities CHO is the sole fuel source used9. Therefore, both blood glucose and muscle glycogen are depleted most during these types of activities. In the presence of oxygen, glucose and fats are burnt up completely. During recovery it is predominantly fat (intramuscular triglyceride stores) that is utilised. Protein is only used to a minor extent, never providing more than 10% of the total energy. DAFNE T01.002, Version 12 July

144 Anaerobic exercise If there is an insufficient supply of oxygen for the muscles (anaerobic exercise), fats cannot be used for energy and there is a need for anaerobic glycogenolysis to contribute to ATP production. Lactic acid is produced from the incomplete burning of glucose; this builds up in the muscles and limits the amount of exercise that can be done. The first 2 minutes of exercise may be purely anaerobic so there may be no change 10 or a rise in blood glucose levels 6. This is the energy system that fuels very intense exercises of a very short duration such as weight lifting, as described later 9. Type 1 diabetes and Exercise The hormonal adaptations that occur in an individual without diabetes are essentially lost in the insulin deficient person with Type 1 diabetes 7. Hypoglycaemia An excess of insulin can result in a hypoglycaemic episode during, immediately after, or for a number of hours after the activity itself 2,5,8 ; this is due to the increased uptake of blood glucose by the working muscles and the resulting inhibition of the counter-regulatory hormones. This latter effect prevents the release of glucose from muscle and liver glycogen stores whilst reducing the availability of free fatty acids due to the diminishing mobilisation of fat stores. Added to this, is the potential for enhanced insulin absorption due to increased body temperature and a rise in skin blood flow 2,8. Some individuals with Type 1 diabetes (especially those with good glycaemic control) have noted reduced hypoglycaemia awareness and lowered glucagon and adrenaline responses 2. This can come from repeated hypoglycaemic episodes and therefore leads to a heightened risk of hypos overall; in addition the sweating and tachycardia due to the physical effort can mask hypo warning signs if similar in nature 1. Consequences of hormonal response to exercise Adipose tissue Liver Glycerol and FFA increased Amino acids Rise in adrenaline & Glucagon Blood Glucose Fall in Insulin Rise in adrenaline and SNS stimulation - Muscle But if Insulin fails to decrease then more blood glucose will be taken up by tissues and less FFA and glycerol release potential for hypoglycaemia (Diagram taken from Professor Ian McDonald s Lecture notes 2 ) DAFNE T01.002, Version 12 July

145 Muscle glycogen repletion takes priority following exercise; if insulin levels are inadequate before or after the activity less is stored before, or restored after the exercise. For the minutes following exercise the resynthesis of muscle glycogen can occur without insulin 1,10, after this it is required, making the level of muscle glycogen repletion after exercise insulin dependent. Therefore, if higher intensity exercise is undertaken following this, larger amounts of blood glucose need to be utilised as the muscle glycogen stored is limited, which results in both fatigue and a faster drop in blood glucose levels. Hepatic glycogen stores are more slowly replenished. The time it takes for repletion of glycogen stores explains why the hypoglycaemic episode may occur a number of hours following the exercise. Hyperglycaemia Raised blood sugars following activity may also occur in the individual with Type 1 diabetes, either because: 1) The individual is insulin deficient. OR 2) Following extremely intense exercise. 1a) Pre-exercise high blood glucose levels with ketones If there is a severe lack of circulating insulin an excessive hormonal response occurs resulting in hyperglycaemia and the production of ketones; this is due to an increase in hepatic glucose production and reduced glucose disposal by the working muscle. The release of counter regulatory hormones as a response to exercise itself will further elevate blood glucose levels and cause metabolic disturbance. Therefore, hyperglycaemia during activity can lead to lesser use of muscle glycogen and a greater use of blood glucose 1,6. Hyperglycaemia (>13mols/l) with ketonuria is a contraindication to exercise, as suggested in the DAFNE curriculum this needs to be corrected with QA insulin, blood glucose levels decline and urinary ketones disappear before exercise can be resumed. 1b) High blood glucose levels without ketones This occurs if there is a relative or mild deficiency in insulin, perhaps due to an excess of CPs at the last meal, exercising soon after eating (which can occur during the DAFNE week if going for a walk in the exercise session soon after having lunch), or a consequence of stress. There is no need to abstain from the activity but to monitor blood glucose levels before and after exercise as usual and keep well hydrated. It is more than likely that BG levels will fall 6 if they do not fall extra QA insulin may be required 1. 2) Very short intense exercise with normal blood glucose levels The first seconds of exercise is powered by creatine phosphate and ATP and is anaerobic (without oxygen) in nature 10. Glucose is not involved in the energy production and therefore it is not likely that blood glucose levels will fall following very intense/short duration activities such as weight lifting, pole vaulting, and sprint racing. In fact blood glucose will rise due to the release of counter-regulatory hormones such as adrenaline 1,8,9. causing hepatic glucose output to exceed the rate of glucose uptake 6. The state of insulin resistance created may last a few hours following the activity itself. In which case, the individual with diabetes would need to take additional insulin to bring their blood glucose levels down after the activity. Exercise can remain solely anaerobic for up to the first 2 minutes 10. DAFNE T01.002, Version 12 July

146 Summary There are a number of physiological changes (cardiac, respiratory, neural and hormonal) that occur during exercise that can affect glycaemia and therefore performance of the individual with Type 1 diabetes. The action of manipulating insulin doses before, during and after the event, and adapting CP intake according to blood glucose levels are a learned skill that come with perseverance and dedication. Suggestions of which are outlines in the DAFNE curriculum for physical activity and exercise. DAFNE T01.002, Version 12 July

147 DAFNE Educators Reading List: Diabetes and Exercise 1. Nagi D (ed). Exercise and Sport In Diabetes. Wiley, MacDonald IA. Lecture notes: What is different about diabetic physiology? Royal Society of Medicine, June Gallen I. Lecture notes: Diabetes and Sport. Royal Society of Medicine, June Wilmore JH and Costill DL. (2005) Physiology of Sport and Exercise: 3rd Edition. Champaign, IL: Human Kinetics Maughan R (ed) Nutrition in Sport: Volume VII. 2002: Blackwell Science 7. American Diabetes Association: Diabetes mellitus and exercise; position statement. Diabetes Care 2004; 27(1): Riddell M. Lecture notes: Blood glucose control during and after exercise in Type 1 diabetes: Is it at all possible. IDF Congress, December Marliss E and Vranic M. Intense exercise has unique effects on both insulin release and its roles in glucoregulation. Diabetes 2002; 51 (1): Colberg S. The Diabetic Athlete. Human Kinetics, 2001 Websites DAFNE T01.002, Version 12 July

148 Minor or Severe? MINOR: Ketones negative/trace (<1.5mmol/l on Optium) BG Slightly/moderately raised SEVERE: Ketones more than a trace (>1.5mmol/l on Optium) BG raised DAFNE T01.002, Version 12 July

149 Minor Sick Day Rules BG < 8 mmol/l Usual dose(s) of BI Usual ratios of QA:CP* BG monitoring 4-6 hrs * NB may mean only BI required if not eating BG > 8 mmol/l Corrective doses of QA* Usual dose(s) of BI (may consider increasing by 20% if long duration illness) BG monitoring 4-6 hrs Ketone monitoring if BG > 13 * NB may mean having corrective QA even if not eating DAFNE T01.002, Version 12 July

150 Severe Sick Day Rules BG > 13 mmol/l Ketones mod-large (>3mmol/l on Optium) Calculate previous day s total insulin dose: tdd (BI and QA) Continue usual dose(s) of BI QA dose = 20% of tdd BG and ketone monitoring 2 hourly Repeat additional QA doses (20% of tdd) as required Drink >100ml fluid per hour CHO will help to stop ketones BG mmol/l Ketones small-mod (1.5-3mmol/l on Optium) Calculate previous day s total insulin dose: tdd (BI and QA) Continue usual dose(s) of BI QA dose = 10% of tdd BG and ketone monitoring 2 hourly Repeat additional QA doses (10% of tdd) as required Drink >100ml fluid per hour CHO will help to stop ketones DAFNE T01.002, Version 12 July

151 Workstation 2 Alcohol Scenarios (No 1) What are the core messages about alcohol and DAFNE? When considering what action to take in relation to alcohol, what foods need to be considered? How would you categorise these drinks: Lager Whiskey Gin and tonic Bacardi breezer Cider Port Sherry White wine with soda Baileys Stout Champagne What are the core dose adjustment rules for carbohydrate and non carbohydrate containing drinks? DAFNE T01.002, Version 12 July

152 Workstation 2 Alcohol Scenarios (No 1) Answers What are the core messages about alcohol and DAFNE? Alcohol can contribute to delayed hypoglycaemia and the key issue is that of safety and avoidance of severe hypos. Different types of alcohol have different effects on BG dependent on their CP and alcohol content and dose adjustment principles will vary according to this. DAFNE algorithms for alcohol are not rigorously scientifically tested and so need to be used with caution. When considering what action to take in relation to alcohol, what foods need to be considered? The type of alcohol (carbohydrate/alcoholic strength) The quantity The timing in relation to food Any additional snacks or meals Any physical activity Previous experiences How would you categorise these drinks: Lager Whiskey Gin and tonic Bacardi breezer Cider Port Sherry White wine with soda Baileys Stout Champagne (Those with and without carbohydrate: refer to handbook) What are the core dose adjustment rules for carbohydrate and non carbohydrate containing drinks? DAFNE T01.002, Version 12 July

153 Alcohol with no carbohydrate requires dose reduction of background insulin or/and extra CPs. Alcohol containing carbohydrate needs the above plus the addition of a dose of QA insulin (but not at the usual ratio. DAFNE T01.002, Version 12 July

154 Workstation 2 Alcohol and DAFNE (No 2) For which of the following alcoholic drinks may you need to consider injecting QA insulin? ½ bottle of wine 5 bottles (330ml) of 5% bitter 4 small (120ml) glasses of red wine 1 pint of cider 3 gin and slimline tonics 4 Tia Maria and Diet Coke 1 liqueur coffee 5 pints of bitter How much QA might you suggest having? What factors would you consider when making this decision? Would you make any changes to BI? DAFNE T01.002, Version 12 July

155 Workstation 2 Alcohol and DAFNE (No 2) Answers / Discussion Points ½ bottle of wine No, but 3-5 units of alcohol so may consider having CPs before bed, depending on BGL 5 bottles (330ml) of 5% bitter = 3 pints of strong bitter Yes, 2u QA (4½ CPs) and as 6½ units of alcohol consider dropping BI at bedtime (Isophane/Levemir) or having CPs (Lantus) 4 small (120ml) glasses of red wine No, but 6 units of alcohol so may consider having CPs before bed depending on BGL 1 pint of cider No action required 3 gin and slimline tonics No action required as long as BGL within range if doubles = 6 units alcohol have some CPs before bed or less BI 4 Tia Maria and Diet Coke Yes, 1u QA (2 CPs). 1 liqueur coffee Depends on amount of sugar added to coffee, but usually no action required 5 pints of bitter Yes, 2-3u QA (5 CPs) and as 10 units of alcohol drop BI at bedtime (isophane/levemir) or have CPs (Lantus) DAFNE T01.002, Version 12 July

156 Workstation 2 Alcohol Scenarios (No 3) 1. Rosie is having a night out with friends. She has her evening meal at 6pm and meets her friends in the pub at 7:30pm. In the pub she plans to drink 4 pints of standard lager. How should Rosie prepare for this night out? 2. Dave is going to a wedding. The service is at noon and the meal is arranged for 4pm. Prior to the meal, and whilst the photographs are being taken, champagne is served. Dave unexpectedly drinks 3 glasses of champagne before the meal. What should Dave do to ensure he does not hypo due to the unexpected champagne? 3. Katie goes out clubbing with her boyfriend. She drinks 5 alcopops and dances until 3am. What does she have to think about in order to avoid going hypo? DAFNE T01.002, Version 12 July

157 Workstation 3 DAFNE and Exercise 1. Helen goes shopping in town every Thursday morning and she usually has a hypo mid-morning. Recently she has put on 2kg and she is keen to lose weight. How could she deal with this problem? a) Always stop for coffee and a cake mid-morning b) Reduce her BI by 10% on shopping days c) Reduce her QA at breakfast by 10-20% on shopping days d) Take some toffees to suck while she s shopping 2. George has been asked to come to school on Monday evening to help set up the hall for concerts that will start the next day. He will go after his evening meal and will be lifting and moving chairs and tables around for at least an hour. How could he prepare for this? 3. Pete has recently taken up playing squash. His friend phones him unexpectedly at 7.30pm to ask him to play a game. He has already had his evening meal and his QA at 6pm. How could he handle this situation? 4. Liz is reasonably fit and has decided to start training for a 10k run. The easiest time for her to fit in the running is first thing in the mornings before breakfast. Her fasting BGL is usually around 10-13mmol/l and it rises to 15-17mmol/l after the run; she doesn t feel like she is running as well as usual. Her BGL is in range at bedtime and when she has tested during the night it is 5-6mmol/l. How could she handle this problem? DAFNE T01.002, Version 12 July

158 5. Becky goes out to a club for the night with friends. They share a couple of bottles of wine she has about 4 glasses. They dance for 2 hours. While she is out she has some crisps (about 2 CPs), but no QA insulin. As she goes to bed at 2am she tests her BGL and it is 10.8mmol/l. What insulin should she take at bedtime? DAFNE T01.002, Version 12 July

159 Workstation 3 DAFNE and Exercise Answers / Discussion Points 1. Reduce QA insulin at breakfast Better to reduce insulin than eat more to help weight loss 2. Consider: Reduce QA by 10-20% at evening meal Reduce bedtime BI (10%) if a particularly strenuous session If supper eaten, reduce QA by 20% Remember hypo treatment 3. Can t reduce QA as it is unplanned, so: Pre-exercise BGL is likely to be raised post-prandially Take 2-3 CPs before the game (think about type of CHO) Consider additional CPs after the game if it is strenuous Consider dropping bedtime BI by 10%, or have additional CPs (Lantus) Remember hypo treatment 4. Likely that night-time BI not covering Dawn Phenomenon (may be less of an issue on Levemir or Lantus). Try: Take additional 1u QA prior to exercise (possibly with 1 CP) Reduce QA at next mealtime by 20%. Remember hypo treatment?consider reducing morning BI if it is a long run 5. Combination of exercise and alcohol! Do not correct high BG at bedtime with QA insulin Reduce bedtime BI by 20% or have additional CPs (Lantus) If on bd BI, do not give next dose until after 9am, or reduce dose if this isn t possible DAFNE T01.002, Version 12 July

160 Workstation 3 Physical Activity Scenarios 1. You plan to decorate all day (painting, wall papering). How would you plan to avoid hypos? 2. You decide to go swimming at 3:30pm for half an hour. Your blood glucose is 6.9 mmol/l. What should you do? 3. You are going to the gym for 1½ hours after work. You have not eaten since 12 noon and it is now 7:30pm. Your blood glucose is 13.5 mmol/l. What would you do before and after exercising to manage your blood sugars? 4. You have your evening meal at 6pm and plan to go cycling for an hour later on. What should you do? 5. Sunday afternoon you decide to mow the lawn. What would you do? 6. You are taking the dog out for a walk before breakfast for 20 minutes. Your blood glucose is 9.4 mmol/l. What do you do? 7. You help a friend move some furniture after tea. It takes 3 hours and turns out to be very strenuous. What would you do? 8. You plan to play badminton for 1½ hours after lunch. At lunchtime your blood glucose is 10.3 mmol/l. You have 6 CP's. Using your current ratio at lunch, how much insulin would you take? DAFNE T01.002, Version 12 July

161 Workstation 3 Physical Activity Scenarios Answers/discussion points You plan to decorate all day (painting, wall papering). How would you plan to avoid hypos? background + quick acting insulin at breakfast 30-50%, + quick acting at lunch by 30-50% +? at tea depending. You decide to go swimming at 3.30 pm for half an hour. Your blood glucose is 6.9 mmol/l. What would you do? Take 2-3 CPs depending how serious the activity -? combination short + long. You are going to the gym for 1½ hours after work. You have not eaten since 12 noon and it is now 7.30 pm. Your blood glucose is 13.5 mmol/l. What would you do before and after exercising to manage your bg? Check for ketones if present, inject extra QA -? 2 units. If not You have your evening meal at 6 pm and plan to go cycling for an hour later on. What would you do? teatime actrapid by 30%. Sunday afternoon you decide to mow the lawn. What would you do? Check BS.? eat CPs according to the level, or just carry hypo remedy. You are taking the dog out for a walk before breakfast for 20 minutes. Your blood glucose is 9.4. What do you do? Carry a hypo remedy. You help a friend move some furniture after tea. It takes 3 hours and turns out to be very strenuous. What would you do? QA insulin at tea by 50% eat extra CPs. background at night by 20%. You plan playing badminton for 1½ hours after lunch. At lunchtime your blood glucose is 10.3 mmol/l. You have 6 CPs. Using your current ratio at lunch how much insulin would you take? Based on a 1:1 ratio. 6 units for CPs = corrective by 30-50%. DAFNE T01.002, Version 12 July

162 ANNUAL REVIEW LEARNING GOALS METHODS MATERIALS/MEDIA Reflect on activities and methods used during the Annual Review session. Become familiar with some suggested activities/scenarios that can be used for the Annual Review sessions. Share ideas of how to develop resources to support the delivery of the session. Practise, talk through and discuss new ideas for the delivery of this session. What methods did you see used to deliver this session? List and share. Debate the pros and cons (what was helpful, what could have worked better?) Model or discuss local (to DEP trainer) methods used to deliver this session. What other ideas might be suggested to deliver this session, that are in keeping with DAFNE philosophy and TPE. The group should use any remaining time to debate, discuss or work through or practise their ideas for delivering this session. Annual Review curriculum Worksheet Local curriculum, lesson plans and resources for Annual Review sessions DAFNE T01.002, Version 12 July

163 WORKSTATION 4 Annual Review What methods did you see used to deliver this session? List and share. Debate the pros and cons (what was helpful, what could have worked better?) What other ideas might be suggested to deliver this session, which are in keeping with DAFNE philosophy and TPE? Use any remaining time to debate, discuss or work through or practise your ideas for delivering this session. DAFNE T01.002, Version 12 July

164 THERAPEUTIC PATIENT EDUCATION and ADULT EDUCATION / LEARNING THEORIES LEARNING GOALS METHODS MATERIALS/MEDIA Know the aim of the session is to discuss the educational theories that underpin DAFNE Introduction Explain - The aim of this session is to provide an opportunity to discuss the educational theories underpinning DAFNE. Ask group if they know the origins of the Düsseldorf Model. Discuss responses and explain Assal s Therapeutic Patient Education (TPE) Model: Acetate: Therapeutic Patient Education Know the 4 learning models that underpin DAFNE/TPE 1. Experiential learning model 2. Adult Learning Theory 3. Social Learning Theory Developed in Switzerland by a physician (Jean-Philippe Assal), who has diabetes himself. Several recognised theories are likely to have contributed to development of TPE: Experiential Learning Model (Kolb 1984) David Kolb (1984) sees learning as a core process of human development. Development results from learning that is gained through experience, and this is the basis of the experiential learning model. Essentially experiential learning uses concrete experiences to inform decisions and actions, through a process of reflection and reformulation and retesting, people can learn and develop. This can be a very powerful tool in learning and is likely to be much more credible than any information given by a healthcare professional. Acetate Cycle of Experiential Learning DAFNE T01.002, Version 12 July

165 THERAPEUTIC PATIENT EDUCATION and ADULT EDUCATION / LEARNING THEORIES LEARNING GOALS METHODS MATERIALS/MEDIA There are four stages in this process: 1. Concrete experience. The person must immerse themselves fully and openly in new experiences. 2. Reflective observation. The person must observe and reflect on concrete experiences from a variety of perspectives. 3. Abstract conceptualisation. The person integrates their observations with and reformulates theories. 4. Active experimentation. The person must apply and retest these theories in decision-making and problemsolving. (cited in Quinn 3 rd ed 1995) This cycle repeats and repeats to allow for experimentation and learning. Examples of this on DAFNE ask the group if they can recount any incidents of this during their DAFNE course Examples might include treating of hypos, trying sweet foods for the first time, eating a CHO free meal, testing out the algorithms for alcohol. Summary The DAFNE model allows for experiential learning by giving people a clear framework around CHO counting and insulin dose adjustment within which to experiment. Adult Learning Theory (Knowles 1990) Education systems for adults should be different to educational systems for children. Acetate Table of Adult Learning Theory DAFNE T01.002, Version 12 July

166 THERAPEUTIC PATIENT EDUCATION and ADULT EDUCATION / LEARNING THEORIES LEARNING GOALS METHODS MATERIALS/MEDIA Traditional education ( chalk and talk ) does not equip the learner with skills which are transferable in life long learning. Post it notes Flipchart Adult learning should promote self enquiry and autonomy. Ask the group to consider a positive learning experience they have had and compare it to an unhelpful learning experience. Ask them to list the qualities of the positive learning experience and of the unhelpful learning experience on post it notes. Collate post it notes onto flipchart paper and discuss. Now refer to the acetate Table of Adult Learning Theory and reflect on key points that adult learning should be learner centred and its core qualities will include: Personal relevance Active and task/problem based Involved in the learning Based on personal experiences Self directed/self motivated Social Learning Theory (Bandura 1977) Social learning theory is to support people in becoming active self managers and includes helping people in terms of their self esteem and confidence. Acetate Social Learning diagram Flipchart Pens Post-its DAFNE T01.002, Version 12 July

167 THERAPEUTIC PATIENT EDUCATION and ADULT EDUCATION / LEARNING THEORIES LEARNING GOALS METHODS MATERIALS/MEDIA There are 4 core aspects to social learning theory: Mastery This draws on peoples previous positive experiences and tries to transfer these skills to new situations This will include building on small successes Performing practical tasks that builds on personal skills Modelling/vicarious learning This includes observing an appropriate role model, trying or testing something out Learning from the suggestions of peers Emotional management Coping with emotions/anxieties Supporting individuals who show distress Action planning Setting concrete plans Developing specific strategies for situations or eventualities In pairs, ask can you think of an example during your observation week where social learning theory was evident? Examples might include: Mastery asking people about their previous experiences as part of the lesson, congratulating people who make small change to their insulin, congratulating people who manage without a bedtime snack for the first time in 10 years. DAFNE T01.002, Version 12 July

168 THERAPEUTIC PATIENT EDUCATION and ADULT EDUCATION / LEARNING THEORIES LEARNING GOALS METHODS MATERIALS/MEDIA Modelling/vicarious learning seeing someone else try a small carton of fruit juice to treat a hypo, someone during the dose adjustment session suggesting someone should have a corrective dose before bed. Emotional management supporting individuals who are upset, acknowledging and reflecting on people s anxieties around dose adjustment. Action planning recording the instructions for dose adjustment, in future goal setting. Summary The next session is around lesson planning, it would be worth you considering how you are going to provide opportunities for all of the above during the planning of your sessions. Handout summarising the key learning theories DAFNE T01.002, Version 12 July

169 Therapeutic Patient Education Enables patients to gain and maintain abilities for optimal management of their diabetes Provides information, practical learning and psychosocial support Should help patients and their families to better co-operate with health care providers Should be a continuous and systematic process integrated into the healthcare system Jean-Philippe Assal et al, DAFNE T01.002, Version 12 July

170 Cycle of Experiential Learning Concrete experience Testing implications of concepts in new Observations and reflections situations Formation of abstract concepts and generalisations DAFNE T01.002, Version 12 July

171 Adult Learning Theory Assumptions Pedagogy Andragogy Learner s need to know Children must learn what they are Adults need to know why they taught in order to pass their tests must learn something Learner s self-concept Role of learner s experience Dependency: decisions about learning are controlled by their teacher It is the teacher s experience that is seen as important. The learner s experience is seen as of little use as a learning resource Self-direction: adults take responsibility for their own learning Adults have greater, and more varied experience which serves as a rich resource for learning Learner s readiness to learn Person s orientation to learning Student s motivation Learner s readiness is dependent upon what the teacher wants them to learn Learning equates with the subjectmatter content of the curriculum The child s motivation is from external sources such as teacher approval, grades and parental pressures Adult s readiness relates to the things he or she needs to know and do in real life Adults have a life-centred orientation to learning involving problem-solving and task-centred approaches Adult s motivation is largely internal such as self-esteem, quality of life and job satisfaction DAFNE T01.002, Version 12 July

172 Social Learning Theory Observation Environment DAFNE T01.002, Version 12 July

173 Therapeutic Patient Education An overview of educational theories underpinning DAFNE 1. Therapeutic Patient Education (Jean-Philippe Assal Enables people to gain and maintain abilities for optimal management of their diabetes Provides information, practical learning and psychological support. Should help people to co-operate with health care providers Should be a continuous and systematic process integrated into the healthcare system 2. Experiential Learning model (Kolb 1984) Essentially experiential learning uses concrete experiences to inform decisions and actions, through a process of reflection and reformulation and retesting, people can learn and develop. This can be a very powerful tool in learning and is likely to be much more credible than any information given by a healthcare professional. Development results from learning that is gained through experience. Four stages: Concrete experience-the person must engage fully and openly in new experiences Reflective observation-the person must observe and reflect on their experiences from different perspectives Abstract conceptualisation-the person thinks about how their observations could be applied to their own lives and develops a theory or plan Active experimentation-the person applies their theory or plan to test it out This is a repetitive cycle of experimentation and learning. 3. Adult learning theory (Knowles 1990) See table. Education systems should be different for adults and children. Adult learning should be learner centred: Personally relevant-what the person needs to know and do in their lives Active, task and problem based The person is involved in the learning-they can influence what is covered and take responsibility for their own learning Based on personal experience Self directed and self motivated 4. Social learning theory (Bandura 1977) Supports people to self manage, looks at self esteem and confidence Four key aspects Mastery-draws on previous positive experience. Builds on small successes, develop personal skills through performing small practical tasks. Modelling/vicarious learning-observing others, trying and testing things out, learning from the actions and suggestions of peers. Emotional management-coping with emotions and anxieties, being supported. Action planning-making concrete plans, developing strategies DAFNE T01.002, Version 12 July

174 INTRODUCTION TO GOAL SETTING AND ACTION PLANNING LEARNING GOALS METHODS MATERIALS/MEDIA Understand why and how goal setting is part of the DAFNE curriculum and workbook To consider what it is we are trying to achieve by using goal setting and action planning Introduction Goal setting is part of DAFNE curriculum and has been introduced to ensure we continue to meet NICE criteria. What is it we are trying to help people achieve using goal setting and action planning? Getting people to think about their future and their long term goal for their diabetes. Getting people to think about this as being about a process of small steps (mini goals and action plans). Reflecting that DAFNE is the beginning of this journey. Ultimately setting behaviour based action plans that increase the likelihood of them implementing their intentions and that are focused on their long-term goals. Be able to identify DAFNE related long term goals Be able to identify specific DAFNE behaviours Ask participants Where in course did you observe goal setting taking place? Pairs/small group work What were the goals? (that participants wanted to achieve). What were the specific behaviours identified to enable participants to achieve their goals? Room continuum exercise Ask four volunteers from the group to stand against a wall at one end of the room facing another wall. Flipchart and pens DAFNE T01.002, Version 12 July

175 GOAL SETTING AND ACTION PLANNING LEARNING GOALS METHODS MATERIALS/MEDIA To develop and overview of short term action planning, short and long term goals and how they fit together Ask each person to think of a personal goal that they might set for themselves in the future (6 months 1 year). Using the room continuum exercise to model the overall process of goal setting. Breaking it down into What is their long term goal for the future and how important is it for them and how will they know when they ve got there? Facilitator lists on flipchart Note: It is important that you record the individuals own words not your interpretation of what they have said. Ask them to take one step forward what is that first step? This is their first mini goal. Ask them to list what it is they need to do in order to achieve their mini goal? This is their first action plan. Facilitator lists on flipchart. The facilitator then reflects back the action plan and asks questions like: When you do this how long will it take? What s going to stop you from doing it? How confident are they? Note to educator ensure that they identify? Specific behaviour When will they do it How will they know when they have achieved their goal How will they keep it going Is it realistic for them DAFNE T01.002, Version 12 July

176 GOAL SETTING AND ACTION PLANNING LEARNING GOALS METHODS MATERIALS/MEDIA Repeat the mini goal setting and steps using one or two of the four individuals until their long term goal is reached and they get to the opposite wall. Understand the process of goal setting for a DAFNE participant In groups of 4, using DAFNE case study, state: long term goals one priority goal what behaviour they focused on what barriers existed strategies to overcome barriers Share 1-2 examples. Discuss any issues that arise. If time: Ask the group to spend 5 minutes in pairs considering the key components or skills for educators in this process (what are you doing as an educator). Emphasise you are asking questions to get them to explore their goals and action plans but you are not telling them what to do. Reflect on the key component of action planning and so the competencies of educators Discuss the key components/competencies eliciting goal setting(long-term) facilitating identification of the short term goals (series of steps) exploring the options in terns of behaviours checking out action plans in terms of being behaviour based/smart exploring barriers checking out confidence and importance DAFNE T01.002, Version 12 July

177 GOAL SETTING AND ACTION PLANNING LEARNING GOALS METHODS MATERIALS/MEDIA using reflections, open/probing questions and encouraging problem solving summary and discussion To observe a demonstration of Action Planning session To practice and discuss how they will deliver the curriculum and use the DAFNE workbook. The two trainers then demonstrate how to fill in the final action plan using the example from the trainers day, with one trainer taking the role of the educator recording on the wipe clean resource and the other trainer taking the role of the patient; using the following example. In pairs practice completing the goal setting and action planning section of the workbook using their case study from a DAFNE course they have observed. Take turns at being the educator/dafne participant. Summary Final thoughts on goal setting/action planning. If this is a very new skill for individuals, consider accessing local course(s) on, for eg behaviour change. Goal setting wipe board My Plan booklet (reference) Resource for trainer of worked completed action plan DAFNE T01.002, Version 12 July

178 DAFNE Educator Programme (DEP) Training Workshop Day 3 09:00 Managing Groups Tips/scenarios for discussion Preparation for peer reviewed course: Your expectations Our expectations Role of the DEP Reviewer (who s yours?) Review documentation 11:15 TEA / COFFEE Recruitment strategies 12:00 Pre-course appointment / data collection: Getting some practise LUNCH Follow up and support for DAFNE graduates Catering arrangements and DAFNE resources 14:45 Delivering DAFNE locally Personal Plan 15:15 Summary / feedback / evaluation 15:45 Depart DAFNE T01.002, Version 12 July

179 MANAGING GROUPS : TIPS / SCENARIOS LEARNING GOALS METHODS MATERIALS/MEDIA Understand the aims of the session Reflect on group management strategies observed during observation week Evaluate different group management strategies Apply strategies to examples of problem participants Develop group consensus on the key elements of successful group management Explain - every DAFNE week is different because the participants are different, group management skills are important to ensure everyone gets the most out of the week. This session will look practically at useful strategies for managing groups/ In pairs discuss what group management strategies you saw being used during your observation week. Collect answers onto flipchart, share ideas (including ideas of those delivering the DEP) and evaluate pro s and con s of different strategies. Give handouts 1-3 for further reading after DEP. In Pairs/threes match the management strategy with the problem participant - see happy families game. Feedback from each small group on how and why they matched each character with a strategy. Ask-what are the key things and vital stages that contribute to successful group development and management? Collect answers and develop brief guideline to successful group management. eg: Establish effective learning environment ie friendly, informal Set ground rules Be a facilitator not a teacher Use group management skills Draw on group/peer pressure to help manage problem participants Flipchart and pens Handouts- Helping groups work more effectively and Dealing with difficult participants Happy families game followed by handout 4 answers. Powerpoint or acetate managing groups. Flipchart and pens DAFNE T01.002, Version 12 July

180 MANAGING GROUPS : TIPS / SCENARIOS LEARNING GOALS METHODS MATERIALS/MEDIA Apply group management strategies to scenarios Activity: In pairs draw scenarios from a hat and discuss how they would use group management skills discussed previously to control the DAFNE situation. Feedback to whole group for discussion and evaluation. Pre-prepared group management scenarios. DAFNE T01.002, Version 12 July

181 Strategies for Effective Group Processes User Ground Rules Ground rules are guidelines for interaction norms. Encourage positive functional behaviours. Solicit guidelines from the group itself don t impose. POST the guidelines and refer to as needed. Include additional norms on an ongoing basis as needed DAFNE T01.002, Version 12 July

182 Strategies for Effective Group Processes Become a Facilitator Manage interaction and participation that helps groups become more effective. Choose appropriate instructional methods and techniques. Help the group: a. Define goals and objectives b. Create an open climate c. Facilitate problem solving d. Evaluate results DAFNE T01.002, Version 12 July

183 Helping Groups Work More Effectively Handout 1 Groups are effective when they pay attention to both what they are doing (the task at hand) and how they are doing it (processes used to maintain an effective group). Many groups focus mainly on the task and ignore the process. As a result, effectiveness at achieving the group's goals is lowered. If one uses a car as an analogy, the task might be defined as providing transportation for someone in order to get from point A to point B. Any driver could do this (well, most drivers anyway) as long as the car functions properly. If, however, the auto's inner workings are not maintained -- oil and gas added, brakes checked, water pressure examined -- the car may have some trouble reaching its destination, not reach it at all, or it may in fact arrive, but only with serious damage to its internal mechanisms. The exact same phenomenon is true for groups. If maintenance functions are minimal, the results could be graphic. The group may not perform well, flounder and find itself irreparably split. Or, the results may be more subtle - a lack of group cooperation, some resources may remain untapped, a weak product is generated, a feeling may emerge that time has been wasted. One other harmful impact sometimes results when ineffective group maintenance produces conflict which is assumed to be related to the actual task. For example, an individual may disagree with someone else in the group because he/she has been unable to enter the discussion. The disagreement may have nothing to do with the task itself. This can often take the group off in irrelevant directions. There are specific functions that a group can perform which will increase the group's effectiveness. They are grouped into two categories of MAINTENANCE FUNCTIONS and TASK FUNCTIONS. The assumption is not that any given group will have all of these functions happening at the same time, but that a productive group will have a healthy and conscious mix of functions at appropriate times. Group Task Functions Initiating: Getting the group started on the task. Offering new suggestions, topics for discussion, plans, etc. Clarifying: Probing for meaning; defining terms, clearing up confusion, working to get the task clear. Asking a question or repeating a point, in different words to make it clear to all. Explaining: Giving practical examples to make a point clear. Reaching Task Agreement: Discussing and deciding the best way to proceed with the task given the time constraints; agreeing on time/task management process. Focusing: Staying on target; avoiding topic jumping or going off on tangents. Seeking Useful Information: Asking for facts, opinions or beliefs; asking for feelings or values. Drawing out resources of the group and identifying information that needs to be found elsewhere. DAFNE T01.002, Version 12 July

184 Giving Useful Information: Offering facts or opinions; stating beliefs or ideas; making feelings known appropriately; making suggestions, sharing relevant experiences. Summarising: Stating briefly the main points made so far. Checking Consensus: Seeing if everyone, especially the silent members agree on a point. Moving Towards Action: Reviewing; bringing related ideas together; restating - suggestions and positions; checking if group is ready to decide, suggesting a process for decision making. Group Maintenance Functions Gate Keeping: Inviting others to talk; suggesting time limits or other procedures to permit wide participation; keeping talk flowing; avoiding domination by one person. Mediating: Harmonizing; conciliating differences in points of view, suggesting compromises; disagreeing comfortably. Listening: Going along with the group; being a good listener; demonstrating that other's statements are heard; avoiding inappropriate interruptions. Diagnosing Difficulties: Addressing lack of information needed in order to make a decision or the fear of consequences of a decision that is blocking the group from reaching one. Harmonising: Helping those in conflict to understand one another s views. Evaluating: Creating an opportunity for people to express feelings and reactions towards the working of the group. Encouraging: Being friendly, warm, responsive through words or facial expressions; being supportive even when disagreeing, building on suggestions made by others, showing acceptance and appreciation of others and their ideas. Relieving Tension: Using humor; throwing oil on troubled waters; asking for a "coolingoff" period, making a well timed joke, bringing problem out into the open. DAFNE T01.002, Version 12 July

185 10 Interventions for Regaining Control of the Group Handout 2 Using active-training techniques tends to minimize the problems that often plague trainers who rely too heavily on lecture and full-group discussion. Nonetheless, difficulties such as monopolizing, distracting, and withdrawal still may occur. Below are interventions you can use; some work well with individual participants while others work with the entire group. 1. Signal nonverbaily. Make eye contact with or move closer to participant when they hold private conversations, start to fall asleep, or hide from participation. Press your fingers together to signal for a wordy participant to finish what he or she is saying. Make a "T" (for time out) sign with your fingers to stop unwanted behavior. 2. Listen actively. When participants monopolize discussion, go off on a tangent, or argue with you, interject with a summary of their views and then ask others to speak. Or acknowledge the value of their viewpoints and invite them to discuss their views with you during a break. 3. Encourage new volunteers. When a few participants repeatedly speak in class while others hold back, pose a question or problem and then ask how many people have a response to it. You should see new hands go up. Call on one of them. The same technique might work when trying to obtain volunteers for role playing. 4. Invoke participation rules. From time to time, tell participants that you would like to use rules such as the following: a. No one may laugh during a role play. b. Only participants who have not yet spoken can participate. c. Each new comment must build on a previous idea. d. Speak for yourself, not for others. 5. Use good-natured humor. One way to deflect difficult behavior is to use humor. Be careful, however, not to be sarcastic or patronizing. Gently protest the inappropriate behavior ("Enough, enough for one day!") or humorously put yourself down instead of the participant ( I guess I'm being stubborn, but..."). 6. Connect on a personal level. Even if the problem participants are hostile or withdrawn, make a point of getting to know them during breaks or lunch. It is unlikely that people will continue to give you a hard time or remain distant if you have taken an interest in them. 7. Change the method of participation. Sometimes, you can control the damage done by difficult participant by inserting new formats, such as using pairs or smail groups rather than full-class activities. 8. Ignore mildly negative behaviors. Try to pay little or no attention to behaviors that are small nuisances. These behaviors may disappear if you simply continue the session. DAFNE T01.002, Version 12 July

186 9. Discuss very negative behaviors in private. You must call a stop to behaviors that you find detrimental to the training session. Arrange a break and firmly request, in private, a change in behavior of those participants who are disruptive. Or create small-group activities and call aside the problem participants. If the entire group is involved, stop the session and explain clearly what you need from participants to conduct the training effectively. 10. Do not take personally the difficulties you encounter. Remember that many problem behaviors have nothing to do with you. Instead, they are due to personal fears and needs or displaced anger. Try to determine if this is the case and ask whether participants can put aside the conditions affecting their positive involvement in the training session. Reproduced from 101 Ways To Make Training Active by M. Silberman. Copyright 1995 by Pfeiffer and Company, San Diego, CA DAFNE T01.002, Version 12 July

187 Dealing with Difficult Participants Handout 3 by Robert W. Pike, CSP We all have them from time to time, but no one spends much time in a train-the-trainer session talking about how to handle them. Over the years I've done research with my participants asking them to identify the most common types of difficult participants. I ended up with fifteen that came up more than all the others. Among them are the know-it-all, the latecomer, the shy, the sceptic, the dominator, etc. For each we identified from 6 to 15 strategies that could be used to help deal with that person. We also identified some strategies that could prevent difficult participants from surfacing at all. Here are some of the key thoughts from our book, Dealing with Difficult Participants, by Bob Pike and Dave Arch. 1. There are two goals in dealing with a difficult participant: a. to get them on board b. to minimize their impact on others 2. Whenever possible use small groups of 5-7 for your preferred seating arrangement. Five is large enough for the group to have power enough to moderate most difficult behaviour. Seven is small enough to insure that people (even the shy) will have an opportunity to participate. 3. Divide your content into 20 minute blocks (for maximum retention) and seek to involve participants some way every 8 minutes. Involvement might be discussing something with a partner, doing something as a group, creating a flip chart that is posted on the wall, reflecting on the content and coming up with action ideas, etc. 4. For activities that involve the small groups always have a group leader. 5. Have a variety of ways to choose group leaders and rotate the leadership. Some methods for choosing group leaders include: the seven people in the group point a finger in the air; on the count of three they point at the person they want to lead; the person with the most fingers pointed at them leads, the person with the most (or least ) experience in the subject, the person with the most (or least) years with the organization, the person with the most (or least) letters in the first name as printed on their name tag or tent, etc. 6. Start with a value-added activity five minutes before the scheduled starting time. This activity should be done in small groups with people encouraging others that arrive to quickly join the group so that they can help. You can choose to let this run a couple of minutes into the formal class time. This will help people begin to understand that despite corporate norms or personal habits your sessions start and end on time and you expect to respect their time. DAFNE T01.002, Version 12 July

188 Hesitant Hanna: Shy reluctant, silent most of the time, easy to overlook, melts into the background Arguing Arthur - the voice of experience: Constantly looking for opportunities to disagree or to show others up, can be annoying and disruptive DAFNE T01.002, Version 12 July

189 Monopolizing Mike: Big talker gobbles up all the discussion time if allowed Not-listening Norma: Tends to interrupt, cut off and leap into the fray before others have had their say, can be because she is too eager and wants to advance her ideas DAFNE T01.002, Version 12 July

190 Rigid Roberta: Not obnoxious-but staunchly takes a stand on an issue and rarely moves Angry Arnie: Behaviour ranges from total silence to constant complaining he s mad at the world and nothing is right DAFNE T01.002, Version 12 July

191 Charlie the clown. Doesn t take anything seriously, life s a joke Complaining Chester: Blames, faults gripes shares endless pet peeves DAFNE T01.002, Version 12 July

192 Show off Sandra: Parades knowledge-big words name dropping Idea Stealing Ida: A master at putting down other peoples ideas, offers an endless barrage of suggestions to anything new or different-it ll never work: we ve tried it before. This is dangerous because it may inhibit others creativity. DAFNE T01.002, Version 12 July

193 Tangent Tony: Constantly talks about topics that are not relevant to the session. Repeatedly discusses individual issues which are not relevant to the session or other group members. Unwilling Ursula: Neither a volunteer nor a willing attendee-nurse sent her! DAFNE T01.002, Version 12 July

194 Negative Nellie: Down about everything, nothing will work for her, she can t do it. DAFNE T01.002, Version 12 July

195 Management: Must figure out ways to draw her out, smaller groups, pair work, ask easy questions that relate to their experiences, socialise with them at breaks, offer encouragement. Management: Let him know you appreciate his input but on a more selective basis. We haven t heard from.yet, can we discuss that further at the break, rely on peer pressure, do not put them down! Use a rationing technique. Management: Let the group deal with them-anyone want to respond to that? Say ok I understand your position, can we agree to disagree. Remember no trainer ever wins an argument with a participant! (they will side together in the end!) Management: Insist on sharing the discussion time, ask them to restate what someone else has said to help them listen. Ask for a comparative analysis-how does your idea compare with John s? Help them to see to incorporate others views. Refer to ground rules. Offer them a toffee! Management: Rescue the idea-ask what the rest of the group think about the idea. Ask them to come up with and idea of their own in lieu of the one they just trashed. Ask the group to come up with possibilities. Refer to ground rules. Management: Force them to problem solve-ask for solutions. Encourage exploration of the other side of the argument. Say You have identified everything that s bad, perhaps that makes you the ideal person to tell us one good thing about it? Management: Get them to admit there is another side of the story and acknowledge their points loudly (even on a flipchart). Management: Try to eliminate threats, ensure the environment is friendly, and consider a role play to let them vent in a positive manner, individual conference, refer to ground rules, consider clinical psychology referral. DAFNE T01.002, Version 12 July

196 Management: Ask them for a positive comment, just listen, ignore at times. Management: Deal with if hindering the group s progress. Compliment them for worthwhile serious contributions, do not reinforce humour attempts, ask to rephrase- I m sorry I didn t get your point Management: Stifle them, give them a recording job, wait for peer pressure. Management: Ignore, defer until a later more appropriate time, canvas the group for agreement to move on of defer until later. Ask to discuss their issues later/individually. Explain why it is necessary to stick with the timetable. Refer to ground rule if relevant. Management: Acknowledge you are here under duress! But you still have a choice as to how much you get out of this now that you are here. Work through/highlight what might be most appropriate for them. Make sure the sessions are not dull or boring. Find out what interests them and relate to their experiences. DAFNE T01.002, Version 12 July

197 Coping with Problem Participants Some Examples Activity/Handout 4 The Hesitant One - Hesitant Hanna Behaviours: Shy, reluctant, silent most of the time, easy to overlook, melts into the background. Management: Must figure out ways to draw her out. Smaller groups, pair work, ask easy questions that relate to back home experiences, socialize with them at breaks, offer encouragement. The Monopoliser Monopolizing Mike Behaviours: Big talker, gobbles all the air time if allowed. Management: Let him know you appreciate his input but on a more selective basis. We haven t heard from yet, can we discuss that further at break, rely on peer pressure, do not put him down!, use a rationing technique. Voice of experience Arguing Arthur Behaviours: Constantly looking for opportunities to disagree or to show others up, when beyond healthy disagreement can be annoying and disruptive. Management: Let the group deal with him anyone want to respond with that. Say ok I understand your position, can we agree to disagree. Remember no trainer ever wins an argument with a participant! (they will side together in the end). Non-listening Norma Behaviours: Tends to interrupt, cut off, and leap into the fray before others have had their say, can be because she is too eager and wants to advance her ideas. Management: Insist on sharing airtime. Ask Norma to restate what someone else has said to help her listen. Ask for a comparative analysis - how does your idea stack up with Anna s. Help her to see to incorporate others views. Idea Zapping Ida Behaviours: A master at putting down other peoples ideas, offers an endless barrage of suggestions to anything new or different it ll never work; we have tried that before, too late, too early dangerous because it may inhibit others creativity. Management: Rescue the idea from Ida s trash bin ask How do the rest of you see this? Ask Ida to come up with an idea of her own in lieu of the one she just zapped. Ask the group to come up with possibilities. Complaining Chester Behaviours: Blames, faults gripes shares endless pet peeves Management: Force him to problem solve ask for solutions. Encourage a search on the other side of things you told us how bad everything is you are a fair person tell us one good things about XXX. Rigid Roberta Behaviours: Not obnoxious but staunchly takes a stand on a issue and rarely moves Management: Get her to admit there is another side of the story and acknowledge her points loudly (even on a flipchart). DAFNE T01.002, Version 12 July

198 Hostile Harry Management: Best to keep you cool, rephrase in milder terms, get the group to respond to him. Angry Arnie Behaviours: Behaviour ranges from total silence to constant complaining, he is mad at the world, nothing is right. Management: Try to eliminate threats, ensure the environment is friendly, and consider a role play to let him vent in a positive manner, individual conference, recommend to his company removal and/or professional help. Negative Nellie Management: Ask her for something positive, just listen, ignore at times Charlie the Clown Management: Deal with if hindering the group progress. Compliment him for worthwhile serious contributions, do not reinforce humour attempts, ask for rephrasement I am sorry I did not get your point Show Off Sandra Behaviours: Parades knowledge big words, name dropping. Management: Stifle her, give her a recording job, wait for peer pressure. Tangent Tanya Management: Ignore, defer until a later more appropriate time, canvas the group for agreement, individual counselling explaining why it is necessary to stick with the program. The Unwilling Participant Behaviours: Those who are neither volunteers nor willing attendees. Boss sent them Management: Acknowledge, you are here against your will but you still have a choice you can stonewall the program or get the most out of it while you are here; work through what might be most appropriate for participant, make certain training is not dull or boring, provide just in time training, stress what is in it for me; introduce job relevant situations. DAFNE T01.002, Version 12 July

199 On the second day of the course one of the group says they won t be coming back as they don t feel this treatment regimen is suitable for them. Suggest possible ways to handle this. One of the participants has an HbA1c of 11.8%, they are very concerned about weight gain and express this concern during one of the discussions. Suggest ways of dealing with this. One of the participants breaks down during the complications session and leaves the room in tears. How would you deal with this without disrupting the rest of the group? One of the participants is very dominant and constantly interrupts you during sessions. How could you deal with this? A participant is clearly overconfident with CP estimation and consistently underestimates CP values of meals. What could you do to begin to resolve this? A participant discusses their alcohol intake; it is far in excess of healthy normal limits and they often binge-drink at weekends. How could you deal with this? DAFNE T01.002, Version 12 July

200 A participant asks if they could arrive late and leave early for the duration of the course due to family commitments. How would you deal with this? One of the participants has changed from a bd mixture to DAFNE regimen and they are disappointed that their BG levels are higher than they have experienced before. How would you help them? One of the participants feels that the other group members are making fun of them and they mention this to you at coffee break. How would you deal with this? DAFNE T01.002, Version 12 July

201 PREPARATION FOR PEER-REVIEW 60 min LEARNING GOALS METHODS MATERIALS/MEDIA Participants should.. Explain after this 3-day workshop the next stage of your DAFNE training is to teach a DAFNE course which will be peer reviewed. Understand the purpose of peerreview Question in pairs, make a list of your concerns and questions about peer review. Write each individual comment on a separate post it note and pin these to a blank flipchart at the front. The educator then themes these questions and gradually through the session deals with all of the issues. Why is peer review important? Educator discusses importance of peer review to DAFNE. Discuss responses as appropriate. Purpose of peer review: Be able to demonstrate an understanding and application of the DAFNE core principles and adult education methods Be able to demonstrate competence to run DAFNE courses independently in their own service Have agreed areas for ongoing professional development and improvement of the programme to ensure continued quality assurance of DAFNE Go on to successfully complete step 6 of the DEP and have their name entered on a register of DAFNE educators. Explain the importance of Quality Assurance and how the model is based on that in Germany (Fulda). Who are the reviewers? Refer to list provided by Central DAFNE Acetate: DoH Structured Education Criteria Acetate Who are the Reviewers? DAFNE T01.002, Version 12 July

202 PREPARATION FOR PEER-REVIEW 60 min LEARNING GOALS METHODS MATERIALS/MEDIA Be aware of the Quality Control processes built into the DAFNE Trial Be familiar with the peerreviewing process and documentation Explain that original educators in the Trial underwent inspection by OFSTED trained personnel; peer-reviewed each other (centres); were observed by psychologist; and were visited and observed by the educator from Düsseldorf. What will happen? Ground rules for the DEP Reviewer What is being reviewed? Discuss our expectations and run through the documentation. Illustrate and discuss the session specific and generic forms Explain that the reviewer will be as constructive as possible in observations and comments to enable appropriate development of skills and this should be seen as positive. On many occasions a peer reviewer has come away with lots of ideas of how to deliver DAFNE from new educators. What happens if someone doesn t complete a successful DAFNE peer review? This actually quite rare and the whole process is to facilitate professional development. People will be made aware of this before the end of their course and they will be given some options around repeating a peer reviewed week. Acetate Section 5 of DEP file Ground rules for the DEP Reviewer Acetate Peer reviewed course. OUR expectations Acetates DEP Review session specific form DEP Review generic forms DAFNE T01.002, Version 12 July

203 PREPARATION FOR PEER-REVIEW 60 min LEARNING GOALS METHODS MATERIALS/MEDIA Understand that trainers and reviewers also had to start somewhere, and can help them empathetically to develop their confidence and skills Stress again that this process should be seen as a positive experience, more like a mentorship and that the learning experience will be 2 way, ie the reviewer will also learn a lot from them. This will enable DAFNE to continue to develop. Discuss any concerns or issues as appropriate. Before you come back for the follow-up day for the DEP (day 4) you will be asked to complete a feedback form on your peer review experience. This is one of the ways that the standards for peer reviewers is maintained. DEP Peer-review schedule DAFNE T01.002, Version 12 July

204 DoH STRUCTURED EDUCATION CRITERIA Philosophy A structured curriculum Trained educators Be quality assured Be audited DAFNE T01.002, Version 12 July

205 Who are the Reviewers? Experienced DAFNE educators (minimum 4 courses). Attended 1 day s peer review training on documentation and giving feedback. People who are committed to DAFNE and the aim to increase the number of DAFNE centres. DAFNE T01.002, Version 12 July

206 Ground Rules for the DEP Reviewer The Peer Supported Course They should seek agreement with the DEP Trainee at the beginning of the course regarding their preferred method and timing of the feedback from sessions (at least daily). They should arrive on time for each session. They should sit at the back of the room/out of the way and be as unobtrusive as possible. They should not interrupt or attempt to participate in any of the sessions unless invited to do so by the DEP Trainee. If the DEP Reviewer observes a serious error they will get the attention of the DEP Trainee and arrange to speak (in confidence) in a way that does not undermine the DEP Trainee (after the session). Give feedback according to the principles. DAFNE T01.002, Version 12 July

207 Peer-reviewed course OUR Expectations Delivery of a 5-day DAFNE course Achieving learning outcomes from DAFNE curriculum Appropriate use of DAFNE resources Use of adult learning principles Appropriate advice on core skills (ie CP estimation and insulin dose adjustment) Effective group management skills Appropriate recruitment/preparation of participants DAFNE T01.002, Version 12 July

208 DAFNE EDUCATOR PROGRAMME PEER SUPPORT: LEARNING OUTCOMES Centre: DEP Trainee: DEP Reviewer: Date: Session No: 9.0 Session Title: Insulin Pump Curriculum Page No: Learning Outcome Achieved Not Fully Achieved Yes Partial No Evidence Educator aware? Strategy identified to achieve this Understand that pump therapy also requires blood glucose measurements 3-4 times a day. (D) Understand the drawbacks of pump therapy. (D) Understand the advantages of insulin pump therapy. (D) Be aware of current guidelines, eg NICE. (D) Please make any comments on the reverse DAFNE T01.002, Version 12 July

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218 EFFECTIVE RECRUITMENT STRATEGIES LEARNING GOALS METHODS MATERIALS/MEDIA Participants should.. Be familiar with the existing criteria for appropriate recruitment to the DAFNE programme Be aware of different recruitment methods and identify an appropriate strategy for their service Understand the importance of appropriate patient information to enable informed choice and commitment to the programme Explain and discuss the criteria Ask participants how they plan to recruit patients to courses in their service OR (in established centre) ask if they are aware of or involved in the recruitment process. Discuss the pro s and con s of various approaches. Discuss one example of (local) recruitment strategy. Discuss what information is required/essential in order to fully inform patients. Acetate/Centre Manual (section 6.1) Flip chart and pens Acetate: DAFNE Recruitment Strategy (Sheffield) DAFNE information leaflets DAFNE Posters DAFNE T01.002, Version 12 July

219 Identifying people who may be suitable and/or could benefit from DAFNE The DAFNE programme is for adults (>17yrs) with Type 1 diabetes for at least 6 months, or posthoneymoon. Potential participants need to understand that DAFNE involves MDI therapy (4+ injections/day) and relies on frequent capillary BG monitoring (4+ tests/day), therefore those who currently use a twice daily insulin regimen or are infrequent testers must be motivated and prepared to make these changes when they attend the course. They also need to be able to attend the full 5 days of the course, plus follow-up (supporting information for employers is available) Whilst there are no absolute exclusion criteria, we recommend that decisions about recruitment of patients with specific issues should be considered by the whole team; the Lead DAFNE Doctor has an important supporting role to play in this process: HbA 1c >110mmol/mol (~12%) may indicate a patient who is omitting insulin. Discuss how committed they are to a MDI regimen; how motivated are they to improve their glycaemic control? End-stage complications: Retinopathy how well can they independently manage essential skills such as CP estimation, BG monitoring, injections etc. (some resources may be available / reproduced locally in large print) Nephropathy whilst insulin action may be affected in ESRF, motivated patients should not be excluded. Those on haemodialysis should try to arrange evening / weekend sessions during the DAFNE week so as not to miss any of the course. Educators may prefer to have experience of delivering DAFNE and the support of diabetes / renal medical colleagues before taking on these participants Gastroparesis participants unable to eat normally due to nausea and vomiting, or requiring artificial nutrition for severe gastroparesis may not benefit from the DAFNE course Pregnancy pregnant Type 1 ladies can attend a course but will need adapted advice re frequency of monitoring and BG targets. Educators may prefer to have experience of delivering DAFNE and the support of diabetes / obstetric medical colleagues before taking on these participants Eating disorders patients may be unwilling to discuss dietary / CP intake with Educators or within the group, making dose adjustment very challenging. Educators may prefer to have experience of delivering DAFNE and the support of eating disorder / mental health colleagues before taking on these participants Communication (ability to hear/speak/understand/read English) use of translators / signers may result in incorrect information being relayed and increase time required to deliver sessions CSII pumps it is recommended that those on pump therapy receive the specific DAFNE CSII curriculum (additional Educator training and resources are available through Central DAFNE) Type 2 diabetes; Cystic Fibrosis; Pancreatic diabetes; MODY; Secondary diabetes although not Type 1, DAFNE principles may be applied. Educators may prefer to have experience of delivering DAFNE before taking on these participants as advice and information in the curriculum and Workbook will need to be adapted and clarified. We recommend a limit of 1 non-type 1 participant on any course. Participants must be flagged accordingly on the DAFNE databases. DAFNE T01.002, Version 12 July

220 DAFNE Recruitment Strategy (Sheffield) Patient identified according to DAFNE criteria Existing Type 1 Diabetes: ROUTINE Newly diagnosed T1 or unplanned pregnancy: FAST TRACK Referral to DAFNE waiting list Mailing: Letter DAFNE leaflet reply slip Reply: Not Interested. Remove from waiting list. Reply: Interested. Need to establish commitment! Letter to referrer copied to patient Appointment with Educator 1:1 Recruitment meeting Allocate course date. Mail: Confirmation letter Employer letter Plan pre-course appointment DAFNE T01.002, Version 12 July

221 PRE-COURSE APPOINITMENT / DATA COLLECTION : GETTING SOME PRACTISE LEARNING GOALS METHODS MATERIALS/MEDIA Participants should.. Understand that there are two levels of data collection and their centre will collect either core or full data sets. Be familiar with the DAFNE Data Collection Form and Standard Operating Procedure appropriate to their centre. Know the importance of ongoing Quality Assurance Practise completing a data collection form Be familiar with quality of life questionnaires appropriate to their centre. Explain that in order to support smaller centres who may not have admin support, centres will collect a core data set. The full data set collected by participating centres will be used for DAFNE research for the benefit of the whole DAFNE collaborative. Briefly demonstrate the DAFNE Pre-Course Data Collection form (current issue). Explain this and the SOP are provided in the Centre Manual. Discuss the importance of ongoing Quality Assurance in relation to current DoH recommendations, etc. Provide (centre) pairs with DEP pre-course appointment exercise handout and blank data collection form and ask them to complete as much of the form as they can, with the information provided. Discuss what can/cannot be recorded on the form and discuss what further information would be required at pre-course appointment. Discuss queries arising from exercise. If appropriate, provide handouts of HADS, PAID, EQ-5D, DSQoL and SF12 Data Collection Form Centre Manual DEP Pre-course Appointment Exercise handout. Blank pre-course data collection form. HADS, PAID, EQ-5D, DSQoL, SF12 DAFNE T01.002, Version 12 July

222 PRE-COURSE APPOINITMENT / DATA COLLECTION : GETTING SOME PRACTISE LEARNING GOALS METHODS MATERIALS/MEDIA Identify who will carry out data collection within their service and the time required. Understand what information should be given to the patient at their pre-course appointment so that they arrive on the course prepared and informed Reflect on strategies for commencing DAFNE insulin regimen and discuss when this will take place within their centre. Pairs to identify and allocate time scales for arranging appointments prior to their peer-reviewed course. Ask group what information they think they would need to give their patients. Discuss and list on flipchart, eg: Venue Times Catering arrangements Parking Relatives/partners What to bring (monitoring equipment, insulin, questionnaires, etc) etc. Explain examples of letters are provided in Centre Manual. Centre Manual Flipchart and pens DAFNE T01.002, Version 12 July

223 DEP DAFNE Pre-course Appointment Exercise John Smith Dob Type 1 diabetes since age 9 At annual review 5 months ago: Background diabetic retinopathy Reduced sensation (monofilament) in both feet HbA1c 74mmol/mol (8.9%) Creatinine 110 umol/l Cholesterol 4.6 mmol/l BP 128/72 Weight 82kg Currently on: Humulin I 30 units at bedtime Humulin S 8 units at breakfast, 12 units at lunch, 20 units at tea. Atorvastatin and Lisinopril Has hypoglycaemia unawareness and has had 2 severe hypos in the past year. Has discussed insulin pump therapy with Consultant. DAFNE T01.002, Version 12 July

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252 EQ-5D Pre/Post Course* (delete where applicable) DAFNE No /.. Health Questionnaire (English version for the UK) (validated for use in Eire) DAFNE T01.002, Version 12 July

253 By placing a tick in one box in each group below, please indicate which statements best describe your own health state today. Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed DAFNE T01.002, Version 12 July

254 Best imaginable health state To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked Worst imaginable health state DAFNE T01.002, Version 12 July

255 We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today. Your own health state today DAFNE T01.002, Version 12 July

256 Because all replies are anonymous, it will help us to understand your answers better if we have a little background data from everyone, as covered in the following questions. 1. Have you experienced serious illness? Yes No in you yourself in your family in caring for others PLEASE TICK APPROPRIATE BOXES 2. What is your age in years? 3. Are you: Male Female 4. Are you: a current smoker an ex-smoker a never smoker PLEASE TICK APPROPRIATE BOX PLEASE TICK APPROPRIATE BOX 5. Do you now, or did you ever, work in Yes No health or social services? If so, in what capacity?... PLEASE TICK APPROPRIATE BOX 6. Which of the following best describes your main activity? in employment or self employment retired housework student seeking work other (please specify) Did your education continue after Yes No the minimum school leaving age? PLEASE TICK APPROPRIATE BOX 8. Do you have a Degree or equivalent Yes No professional qualification? 9. If you know your postcode, would you please write it here PLEASE TICK APPROPRIATE BOX PLEASE TICK APPROPRIATE BOX DAFNE T01.002, Version 12 July

257 Problem Areas in Diabetes (PAID) Questionnaire Pre/Post Course* (delete where applicable) DAFNE No /.. INSTRUCTIONS: Which of the following diabetes issues are currently a problem for you? Circle the number that gives the best answer for you. Please provide an answer for each question. Not having clear and concrete goals for your diabetes care? Feeling discouraged with your diabetes treatment plan? Feeling scared when you think about living with diabetes? Uncomfortable social situations related to your diabetes care (eg people telling you what to eat)? Feelings of deprivation regarding food and meals? Feeling depressed when you think about living with diabetes? Not knowing if your mood or feelings are related to your diabetes? Not a problem Minor problem Moderate problem Somewhat serious problem Serious problem Feeling overwhelmed by your diabetes? Worrying about low blood sugar reactions? Feeling angry when you think about living with diabetes? Feeling constantly concerned about food and eating? Worrying about the future and the possibility of serious complications? Feelings of guilt or anxiety when you get off track with your diabetes management? Not accepting your diabetes? Feeling unsatisfied with your diabetes physician? Feeling that diabetes is taking up too much of your mental and physical energy every day? Feeling alone with your diabetes? Feeling that your friends and family are not supportive of your diabetes management efforts? Coping with complications of diabetes? Feeling burned out by the constant effort needed to manage diabetes? 1999 Joslin Diabetes Center DAFNE T01.002, Version 12 July

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