Background
The sense of a restrictive diet and the need for good glycaemic control prompted the team at Torbay to look into structured education programmes such as DAFNE and BERTIE. By observing the BERTIE team and programme and having the information consolidated at an Insulin pump training course, the team developed the TIFA programme. The first course commenced in November 2002 and we now run six courses a year.
Objectives
The aim of the TIFA course is to educate, in a small group, people with Type 1 diabetes. There are general educational components focussing on complications, illness, travel and life style, but the main focus is on carbohydrate counting and the matching of insulin dose to food intake and activity. This approach is to allow people with diabetes to choose to eat as normally as possible while maintaining good glycaemic control.
Service Provided
Whilst following the format of the BERTIE programme, the TIFA programme also offers an Introductory session. This enables participants to meet prior to starting the programme, establish their needs and wish list and expectations of the programme. It is also the time for completing the administrative elements of the course and checking participants’ equipment. The educators also work with participants to set the boundaries for the group, and stress issues such as confidentiality and the flexible nature of the course.
In order to be considered for the course potential participants must:
1. Be able to attend sessions, be motivated and willing to learn about their diabetes.
2. Be willing to monitoring their blood glucose levels at least 4 times a day.
3. Be on, or willing to change to, insulin at least four times a day.
The programme then runs for 1 two hourly, and four, four hourly sessions held once weekly over consecutive weeks. It was decided to run the sessions in a hotel as this is a neutral setting. Sessions comprise of skills learning regarding carbohydrate counting and insulin adjustment along with basic education on issues such as hypos, travel and complications. Participants set their own goals for the course and then explore whether they have met them on the final session, the people attending are made aware that they can leave / talk at the end if anything discussed has made them uncomfortable.
Homework is set, and agreed up on, at the end of each session this helps to consolidate the learning of areas covered. This homework usually takes the form of filling in food diaries, using correction doses for hyperglycaemia and practicing changing ratios when participating in physical activity.
Educators are trained in adult teaching methods – out of the members of the TIFA team two educators have completed the City and Guilds 730 Adult Education teaching course, one the ENB 928, one has completed the postgraduate Certificate in Education Each course would have at least one of these members participating.
The curriculum is based on the core content, agreed upon by the Type 1 Education Network.; carbohydrate counting and insulin adjustment, revision of diabetes management and how insulin works, hypoglycaemia and hyperglycaemic management, managing exercise as well as travelling and the complications of diabetes. These areas are backed up and worked through by using the Type 1 Education Network workbook which is issued to all participants at the start of each course. It can then be used as a reference for them in the future.
At six weeks the participants come back as a group to discuss any areas that may have been a success, and share these experiences with the group, and/ or discuss areas that might be causing them a problem. They are invited again at three months for the same and to meet the participants of the current programme running, at what will be week two of that course. This gives new participants the chance to speak to those who have been through the programme already and this can help allay fears and support the new groups learning.
At 6 and 12 months, after participating in TIFA, people are asked to repeat the questionnaires and have their bloods taken for the collection of the audit data. They also attend a normal clinic appointment with their diabetes care team in order to further discuss the results, their daily management of their diabetes and any areas that they may wish to further improve.
Annually, at a hotel all previous participants of the year are invited to a refresher session with relatives and friends, with quizzes and games designed to cover what had been learnt that year.
Evaluation
At present the TIFA programme collects its own audit data which has as agreed by the Type 1 Education Group (TEIN) this consists of 2 validated questionnaires, the HAD (Hospital Anxiety and Depression scale) and the PAID (Problem Areas In Diabetes) also general clinical data such as HbA1c, cholesterol levels, kidney function etc.
To date these clinical findings have shown an overall mean reduction in HbA1c of -0.44% which is statistically significant to the value of p<0.01.
The other area that has been anecdotally reported by the participants is an improvement in quality of life. We have recorded comments such as:
“Improved my knowledge of food / eat what I want with out being out of control or feeling guilty.”
“Feel confident to go for a walk alone for the first time since having diabetes”.
“Can now cope with my insulin in different situations / stopped having hypos / feel updated.”
“Now my sugars aren’t swinging all over the place I can focus on my life / control of sugars.”
“Knowing I’m not alone/ comparing notes and meeting other people with diabetes.”
“Has made me assess my life and helped me accept my diabetes.”
At present quality assurance is undertaken internally by peer review but again the programme is working towards formal external quality assurance with the Type 1 Education Network group.
Learning
A support group has arisen as a result of the TIFA programme. They have called them selves the TIFA Graduates. They have a monthly informal meeting in a local public house. This group is continuing to grow and these members act as a resource for the ongoing courses as well as the annual update sessions. Through the teaching of the other members of the local Diabetes Team, all have become more aware of carbohydrate quantities in relation to insulin doses. It also acts as one of the educational building blocks required for people transferring from multiple insulin injection to insulin pump therapy