Diabetes care has never felt under so much pressure in terms of COVID-19 and the need for face-to-face consultations to become virtual overnight during 2020. This has caused extra pressures on both people living with diabetes (PLwD) and health care professionals (HCPs), especially practice nurses. The iDEAL Diabetes Group published two consultation papers about the 360° view of both HCPs and PLwD, which detail how consultation experiences for both, taking account each perspective, can be maximised (Odiase et al, 2020; Phillips et al, 2020a).
This has never been as important as it is now as we slowly come out of the third COVID-19 lockdown in the UK, with remote working becoming the usual and perhaps new ‘norm’ for much diabetes care delivery. Diggle (2020a) has published useful guidance about effective remote diabetes care delivery and resources for HCPs to access. Additionally, Diggle and Brown (2020) have designed and published a useful flowchart about ‘How to Undertake a Remote Diabetes Review’. This article is about the style of the consultation conversation and how to deliver this to the best effect for both PLwD and the HCP virtually.
Why do consultations and conversations matter?
Consultations in healthcare practice are often described as a science; the process of gathering and extracting information in a structured manner with the aim of arriving at a care planning destination (Odiase et al, 2020). Consultation models lend their formats as recommended structure outlines to help HCPs consult most effectively with individuals (Silverman et al, 2013; Bailey, 2014). However, consultation is an art and has its impact affected by multiple co-factors, such as delivery style, communication skills, personality type, and HCP–PLwD rapport. Consultation models on the whole vary from each other in conceptual structure, ‘practitioner versus patient’ centredness, and the degree to which the focus is on the aspect of healthcare to be achieved versus the behaviours needed in the consultation (Denness, 2013; Bailey, 2014). Virtual and remote consulting has caused many HCPs to experience stress and usual face-to-face conversations with PLwD have changed in context, frequency and delivery. Diggle (2020b) published some useful self-care tips for HCPs during the COVID-19 pandemic to support themselves to manage this change.
The type of consultation and the HCP who interacts at that time with the PLwD is influential, as the context and content will differ according to the individual situation, so different styles are needed. Therefore, although there should be consistency in approach, experience and education to support consultations, recognition and discernment in the conversation are fundamental. Public Health England's, ‘Making every contact count’ (MECC, 2016) approach supports HCPs promoting early intervention and emotional support to avoid missed opportunities. MacDonald et al (2013) advocated that inexperienced HCPs often resort to ‘tick box’ consultations rather than ‘finding common ground’ consultations as advocated by Stewart et al (2014). Gathering biometric data such as Diabetes UK's (2019a) 15 Healthcare Essentials is of course important, but the nuances and human factors of the individual and their experiences living with diabetes establish their story and understanding and go far beyond this.
For virtual diabetes reviews, recognition that approaches need to reflect the situation and agreed planning of care are highlighted in Box 1.
Box 1.The context of the consultation
- New diagnosis?
- Prior to initiating an agreed treatment plan?
- Ongoing review or monitoring?
- Risk reduction?
- Conversations about complications?
- Worry about COVID-19?
- Vaccination worries
- With PLwD with cognitive decline, learning disabilities or severe mental illness?
- Age appropriate?
- Vulnerability?
- Culturally appropriate?
- People experiencing emotional distress?
- In a hurry?
- End of life?
Fear and distress
The fear that some PLwD recount from the first conversations at diagnosis can cause potential diabetes-related distress and difficulty in both accepting and engaging with their diabetes (DeGroot et al, 2019). This must be acknowledged by HCPs in their everyday encounters with PLwD, and the situation the consultation occurs in as illustrated in Box 1. Undoubtedly, diabetes can increasingly occur as a multi-morbidity as illustrated by The Richmond Group of Charities work on Multi-morbidities and care approaches in the UK (2019). HCPs need to recognise the PLwD might not be able to see the point of routine diabetes consultations, if not initiated by themselves.
If someone is newly diagnosed, especially during lockdown or as a result of a recent acute hospital admission, it will take more time to understand their diagnosis and they will need time to emotionally and psychologically absorb this into their lives. This can coincide with a multitude of competing health needs or social, family or emotional demands within their lives, especially during the pandemic (Stafford et al, 2018; Royal College of General Practitioners [RCGP], 2019). This requires HCPs to approach individual needs with understanding and using different approaches, appropriate terminology, language skills and emotional intelligence depending on each PLwD's situation, emotional wellbeing and coping skills at that point in their diabetes journey (NHS England, 2018; Odiase et al, 2020; Phillips et al, 2020a).
COVID-19 has caused much fear and some delay in accessing health care due to misunderstandings of services being reduced or indeed closed. Cultural misunderstandings in communities have also created barriers that as HCPs we need to be aware of and ensure we remain accessible to local communities. Sadly, for example, late presentations of PLwD with foot ulceration or infections have led to increased delayed admissions, avoidable amputations and increased avoidable mortality (Robbie et al, 2020), therefore the necessity to ACT NOW is never more apparent (Edmonds et al, 2020; Phillips et al, 2020b).
People with diabetes
Each PLwD is the expert in their life and their experience of living with diabetes. Language Matters (NHS England, 2018) and the nuances of non-verbal communication can be lost in virtual consultations, where non-verbal cues cannot be read. The words we use as HCPs are of vital significance to each PLwD, never more so than via telephone consultations. Every PLwD should be given access to diabetes self-management education, sick day advice (Stewart, 2021) and individual or group behaviour change support via appropriate digital offerings depending on their preferences.
Mixed understanding of how COVID-19 might affect PLwD has caused additional fears and stressors, as has inconsistent understanding around whether PLwD need to shield or not. This has placed further burden on HCPs fielding frightened enquiries daily within their practices and giving clear consistent messages about PLwD being generally classed as clinically vulnerable and at moderate risk (NHS UK, 2021).
Effective self-management education
During lockdowns, social distancing and pandemic situations, self-management education has never been more important. For PLwD who lack access to mobile technologies, then printed reading materials or DVDs can offer suitable solutions – these can be accessed free of charge from Diabetes UK (https://shop.diabetes.org.uk/collections/information-for-your-patients). Ultimately the individual is responsible for their own self-management with support and partnership with their HCP (Skinner et al, 2003; McDonald et al, 2013; Bailey, 2014). Therefore, reaching out to enable people to carry on coping with the unremitting demands of their diabetes is of vital importance.
Learning to live with diabetes is like learning to drive – we all need lessons to drive safety and gain the knowledge and license to be a safe driver. Learning to live with diabetes and make self-management decisions safely also requires effective education similar to driving lessons – this knowledge cannot just be assimilated into an individual's life and life choices without appropriate support and access to resources.
Conversations with a purpose
Every consultation is a conversation of opportunity to share knowledge and understanding with the PLwD and HCP, working in partnership to explore the person's informational and support needs. The HCP can gain an increased depth of understanding of the individual.
PLwD are diagnosed and live with a complex, demanding and relentless condition (Doherty et al, 2012; Lhussier et al, 2013). It is imperative that every contact counts and every virtual and face-to-face consultation has meaning for the PLwD to maximise the benefit for the individual and their circumstances. Remote support and access can increase accessibility, especially using digital options such as WhatsApp, Skype, text messaging, email and remote chat features of digital systems. This has never been more apparent during repeated lockdowns. Hendrieckx et al (2020) have published ‘Ten top tips’ for person-centred consultations. These are a useful tool kit to support conversations with a purpose.
Language has influence and meaning, but this can be misunderstood without visual non-verbal cues. The language, tailored with cultural awareness and competence, used in the consultation conversations needs to be personalised to the individuals' requirements, health literacy, learning style and reflect Language Matters (NHS England, 2018). Conversely, many PLwD have previously reported experiencing stigma, judgement, labelling, disablement and discrimination in some consultations with some HCPs. This can be due to lack of knowledge or training of the HCP, inexperience, misunderstanding of the HCP as regards their role in the consultation, attitude, or stress, unawareness, fatigue or even burnout in the HCP (Egan et al, 2018).
Depending on the PLwD’ individual situation (Box 1), for example at diagnosis or during annual reviews, this is where language used can potentially have the greatest impact on emotional distress and fear (Quandt et al, 2014; Papaspurou et al, 2015) depending on the PLwDs' understanding, health beliefs and experience of diabetes. This offers an opportunity for HCPs to be a motivator to change attitudes and behaviours to improve outcomes that can be generated within the PLwD’ sphere, rather than a decision made for them by the HCP. Embedding this approach into every HCP–PLwD consultation conversation means that the decision to make any changes is intrinsically motivated to enable the individual to take ownership of their diabetes care, which is a positive for effective self-management, rather than being extrinsically motivated based on fear of negative diabetes outcomes or to please the HCP (Skinner et al, 2003; Odiase et al, 2020; Phillips et al, 2020a). PLwD need to be encouraged and enabled to be involved in every decision using language that is understood (NHS England, 2018) and paraphrasing techniques to ensure understanding; this reflects ‘no decision about me, without me’ (Department of Health, 2012).
The HCP can achieve this by ensuring the PLwD feels in control of their decisions and self-management plans discussed in the virtual consultation, especially when setting targets using tools such as Diabetes UK's (2019b) Information Prescriptions in General Practice. Motivating care and creating a different future for the PLwD is a unique art and skill that experienced HCPs apply, and this can be endorsed by engaging with SMARTER (Specific, Measurable, Attainable, Realistic, Timely, Ethical and Resources) individualised objectives in care planning (Klinkner et al, 2017). When these are not applied effectively, as can occur when a lack of communication occurs, PLwD might experience dissatisfaction or feel they were not listened to, that the HCP was too busy and did not have the time for them to express their fears, or that the agenda of the consultation was designed to meet the HCPs needs and not those of the PLwD (Lafata et al, 2013).
Promoting emotional wellbeing
Acknowledging the individual as part of the consultation conversation is of immense importance. Emotional wellbeing and psychological concerns can hinder individual self-expression of their fears or concerns and influence self-management (Doherty et al, 2020). The importance of emotional health needs to be acknowledged and explored in each consultation by each HCP. Krejany and Jiwa (2019) suggested that using person-centred, directed goal setting with each PLwD can help people engage and understand their agreed therapeutic targets in their diabetes care journey. Virtual consultations can hinder the individual's voice being heard. HCPs need to be mindful of each PLwDs lived experiences, capacity, choice, abilities, emotional health and readiness to make changes if required and acknowledge and respect these challenges (Diabetes UK, 2019c).
The person-centred, individualised approach needs to hear and listen to each PLwD, to respect their situation, experience and fears, and acknowledge their journey and autonomy (Diabetes UK, 2019d). Therapeutic targets cannot be the only driver in each consultation and as Krejany and Jiwa (2019) acknowledged, the ‘lived experience’ of diabetes – where their diabetes fits within their life experiences – is of paramount consideration. Current fears about COVID-19 have heightened the vulnerability of individuals (Mertens et al, 2020).
Power of language
Different styles of consultation affect outcomes and the emotional response of the PLwD. Dickinson (2017) recognised that PLwD are exposed to the language HCPs use both in spoken and written form and those words may contribute to an already stressful illness experience.
The global recognition of the language used in diabetes care and management in recent years (Speight et al, 2012, Kyle et al, 2014; Dickinson et al, 2017) has advocated for HCPs to adopt and evolve their language in the UK clinical setting (NHS England, 2018). While HCPs are encouraged to embrace an encouragement model for delivering education and care, frequently the language being used in diabetes care and education is not always consistent with that approach (Dickinson, 2017). The spoken and written words HCPs use contribute to the context in which people live with and manage their diabetes. Through context, people create meaning (Fleishman, 1999; Marrero et al, 2013); therefore, negative words can lead to negative meaning.
Conclusion
The power of language and emotional wellbeing are equally applicable to the HCP and currently due to extreme work pressures, excessive workloads, frequent and rapid changes to practice, deployment, frequent changes in governmental guidance and workload fatigue, feeling undervalued can be a common occurrence, in a previously enjoyable pre-pandemic work environment. Never has it been as important for all HCPs to look after themselves, as by doing so they can look after others to best effect.
Useful resources:
- Sources of information and education for people with diabetes to support remote consulting. https://www.diabetesonthenet.com/journals/issue/617/article-details/glance-factsheet-sources-information-and-education-people-diabetes-support-remote-consulting
- Ten tips for more effective and satisfying clinical consultations. https://www.diabetesonthenet.com/journals/issue/616/article-details/ten-tips-more-effective-and-satisfying-clinical-consultations
- Printed reading materials from Diabetes UK for those without access to mobile technologies. https://shop.diabetes.org.uk/collections/information-for-your-patients
KEY POINTS:
- Consultation is an art and has its impact affected by multiple co-factors, such as delivery style, communication skills, personality type, and health care professional (HCP)–person living with diabetes (PLwD) rapport
- Virtual and remote consulting has caused many HCPs to experience stress and usual face-to-face conversations with PLwD have changed in context, frequency and delivery
- The nuances of non-verbal communication can be lost in virtual consultations, where non-verbal cues cannot be read. The words we use as HCPs are of vital significance to each PLwD, never more so than via telephone consultations
- The person-centred, individualised approach needs to hear and listen to each PLwD, to respect their situation, experience, fears and acknowledge their journey and autonomy
CPD reflective practice:
- How has the move to virtual consultations changed your communication with people living with diabetes (PLwD)? Has face-to-face communication also been affected?
- How can the language used in consultations affect the PLwDs' self-management?
- How have people newly diagnosed with diabetes during the COVID-19 pandemic been affected? Could you modify your communication style to help better support them?