MAGORZATA BERNAS

HOW WE EDUCATE PATIENTS WITH DIABETES

MELLITUS: GENERAL, METHODOLOGICAL AND
ETHICAL PRINCIPLES OF THE INNOVATIVE
THERAPEUTIC EDUCATION
Department of Diabetology, Endokrynology, II Med. Faculty,
Warsaw Medical University

JAK REALIZUJEMY EDUKACJ TERAPEUTYCZN OSB Z CUKRZYC:

OGLNE, METODOLOGICZNE I SPOECZNO-ETYCZNE ZASADY
INNOWACYJNEJ TERAPEUTYCZNEJ EDUKACJI
Klinika Diabetologii, Endokrynologii i Chorb Wewntrznych, II Wydz. Lekarski
Warszawski Uniwersytet Medyczny

SUMMARY. Therapeutic education of diabetic patients has to be approached as the basic, structural and functional component of the holistic
diabetological care. It enables the physician and the patient to cooperate in an effective manner-together they are stonger. The significance
of the term of diabetological education goes beyond the stereotypic meaning. It embraces the knowledge, emotional motivation, antidepressive psychotherapy, social stimulation and creates the proper level of adherence and compliance.
Such aims require the specialistic, medical teachers and also proper interrelation between educational team members. Practice of education
has to be based on proper organization and plan. It should also be subjected to objective assessments.
Key words Diabetes mellitus, diabetes therapeutic education, therapeutic motivation, medical pedagogies.
STRESZCZENIE. Edukacja terapeutyczna osb z cukrzyc stanowi podstawowy, stay, strukturalny i czynnociowy skadnik opieki diabetologicznej. Powinna mie holistyczny charakter. Daje moliwo lepszej komunikacji i wsppracy lekarza z pacjentem razem s silniejsi.
Znaczenie pojcia terapeutyczna edukacja wykracza poza stereotypowe okrelenie edukacja. Obejmuje wiedz, emocjonaln motywacj,
przeciwdepresyjn psychoterapi, aktywacj spoeczn tworzy wyszy poziom zrozumienia metod leczenia oraz ich stosowania.
Takie cechy edukacji terapeutycznej wymagaj stosowania profesjonalnych metod oraz pogbionym relacjom miedzy medycznym nauczycielem i pacjentem oraz midzy pacjentami. Praktyka edukacji musi si wic opiera o systemow organizacj i plan. Powinna podlega okresowej ocenie skutecznoci.
Sowa kluczowe Cukrzyca, edukacja terapeutyczna, motywacja terapeutyczna, pedagogika medyczna.

INTRODUCTION
Diabetes mellitus education for self-control and even
more for self-care, besides the universalistic character,
contains many local and regional influences. Presentation
of this problem accordingly to the Warsaw and Polish

experience may serve as a good example of this two-dimensional image The local components of the diabetes mellitus
education are suitable for cross-cultural comparison as well
as for the exchange of experience and ideas (1, 2, 3, 4)
In this area the emphasis should be put on:
1 the working definition of the diabetes mellitus education;

Medycyna Metaboliczna, 2016, tom XX, nr 4

www.medycyna-metaboliczna.pl

19

2 organization of the diabetes care delivery in general;

3 local, specific medical potential and conditions in
Warsaw and the experience in innovative educational
activities;
4 special programmes and teaching approach in the form
of a Diabetic School;
5 of local experience in the domaine of the construction
of the programme and action in
General meaning and influence of such premisions, medical and special, pedagogic aims, programmes and practical logistics of personalistic diabetic, therapeutic education
form a special communication between physician and patient, increase adherence and compliance (5, 6, 7)
What do we mean by diabetes mellitus education?
In Poland the tradition of the education in chronic diseases has long history It has begun many years ago with
philosophical concept of the personality and related to the
personality, spiritual force of motivation called by K Twardowski polish philosopher of this time-fiat It means
I should do the meaningful, rational use from my life
potential In Poland also the work of Victor E Frankl, an
Austrian psychiatrist and philosopher, creator of so many
important reflections related to the human existence, to
the human spiritual needs and drives and to the sense of
meaningful life and creative personality as opposed to the
only biological and reductionist idea of man This attitude
was named logotherapeutics In this particular term the
word loges means rather understanding, rationalization or education Many polish followers of VE Frankl
as Florian Znaniecki, Maria Ossowska, Z.J. Lipowski, Jan
azowski have development the idea of the logotherapeutics of Victor E Frank into a working concept of a creative
education in chronic diseases, based on the priority of building the motivation and enriching the personality This
concept became a moving force in the activities of Polish

Union of Blind and Polish Association of Deaf-Mute since almost 80 years and is now the important tendency of
teaching of educators in Warsaw School of Special Pedagogics and in diabetological care institutions at Warsaw
University and at Warsaw Medical University.
The general pedagogical base of actual diabetes mellitus education in Warsaw is also under strong influence of
these humanistic and personalistic concepts (7, 8).

HOLISTIC, DIABETES MELLITUS CARE AND

GOOD QUALITY OF LIFE OF THE PERSON WITH
DIABETES MELLITUS.
The therapeutic education should be aimed at re-shaping
the personality of the patient, at enforcing the psychosocial
mechanisms of positive motivation and at changing the
behaviour Diabetes mellitus is a disease, which concerns
all aspects of the diabetic patient life: it creates so called
diabetic life It is necessary for him to construct a new,
rational style of life (tab 1)
After such transformation patient plays a role of the
full-right partner of the treating team Therefore he must
transforms his illness, his pains into meaningfull life, into
new values and in new behavior Clinical and biochemical
parameters are not the only important dimensions of life
One could observe in difficult external conditions, during
fast social and economical changes that even the hierarchy of basic human values may suffer The diabetologist
thinks, that the health and life belong automatically to the
highest human values It may however not be the case
Such negative from the medical point of view, attitude may
be sensitive only to behavioral education, to the influence
of the above mentioned psychosocial methods Such psychological approach makes the patient more resistant to
the critical, external stresses (9, 10, 11)

Tab. 1. Possible effects of holistic therapeutic education and patient motivation improving the quality of diabetological care.
Diabetologia edukacyjna
PATIENT

motivation, psychosocial factors

change in behavior
knowledge
skills
autonomy

MEDICAL

highest degree of possible metabolic correction

near normoglycemia
secondary and teriary prevention of complications
minimal side-effects of therapy
improvement in individual
performance

ECONOMICAL

decrease of hospitalization, morbidity, mortality

increase of social and professional efficency

20

Medycyna Metaboliczna, 2016, tom XX, nr 4

www.medycyna-metaboliczna.pl

PATIENT ACTIVE PARTICIPANT IN THE

THERAPEUTIC PROCESS
Management of diabetes mellitus is based on the cooperative actions of both - the medical team and the patient
supported by family or friends The patient is the main object of therapeutic activity, he plays the role of the partner,
because in the systematic and long-term way materializes
the nutrition recommendations and the rules of the healthy
life-style, the daily home blood glucose monitoring and adaptation, respectively, the dosage of hypoglycemic drugs
This gives the chance of the more effective prevention of
acute and chronic complications of diabetes mellitus Therefore patient should be sufficiently prepared by the professional, intensive and complex therapeutic education for
the performing such a partnership Therapeutic education
in diabetes mellitus comprised the transmission of the
knowledge and skills and - in the same time - the formation of motivation and the empowerment of personality
for better coping with the stress of the chronic disease
In these activities the professional approach is necessary
They should be structurised and materialized accordingly
to the rules of the specific pedagogics for disabled and
patient - oriented social support To achieve such goals
several technics and methods could be assessed as well as
many organizational and psychological solutions System
of the structurised, intensive and psychosocially oriented
therapeutic education creates the chance to the achieving
better results of therapy, better prevention of the complications and better quality of life.

AIMS AND FORMS OF THERAPEUTIC

PEDAGOGICS
Among the most important aims of therapeutic
education in diabetes mellitus one should list: transfer of
knowledge and skills pertinent to rational, active self-care
in the close harmony with the psychosocial empowerment
and the increase of the capacity in social competition This
approach is able to create the patient-centred motivation
and compliance (11, 12, 13)
As the general result of therapeutic education the patient
becomes more autonomic and more socially active
Therapeutic education in diabetes mellitus could be divided into several forms suitable tor different types of patients It should be, based also on psychological diagnosis
In the same time therapeutic education should exploit all
methodological, pedagogic achievements in specialized
education of adults (14, 15, 16, 17)
Diabetes mellitus in all its forms and phases enforces the
new, adaptive changes in whole life aspects of the patient
They have predominathy intensive character
The psychoemotional, social and biological tolerance
of the pathological stresses is surrended to the hard and

real life testing The hope for good, planned quality of

life decreases The task of the physician is to diagnose
and to control, in an individual, personalistic way all these
disturbances and even more to create the new life aims and
values helping the patient to find a new way of life.
The physician must to ask himself and the patient - how
in the new, morbid situation create positive for therapy
and life quality outcomes? How to mobilize the patient
psychological, social and behavioral strength for reaching
the optimal aims of therapy?
In this was the personalistic diabetes care is formed by
the embedded into physician actions therapeutic and psychosocial education
The next step is to utilize for these purposes the principles and methods of the innovative, medical pedagogics
including both - personalistic, individual approach and the
school of patients (18, 19, 20)

EMPOWERMENT AND MOTIVATION OF THE

INDIVIDUAL PATIENT
Therapeutic education in diabetes mellitus is aimed not
only on knowledge and skills formation but should also
offer a psycho-social support It should be therefore individualized in the relation not only to the type of diabetes
mellitus and therapy but also adjusted to the psycho-social
characteristics of the patients (15, 19)
One may divide the forms of therapeutic education into:
a) individual - aimed at special, individual problems of the
patient and b) collective 6-10-persons in groups
The teaching is performed by the team composed of
physicians, nurses, psychologist, dietetitian and a pedagogue Such a team may create an long-lasting motivation
In the practical programmes it forms also the chance for
empowerment and fortification of the psycho-social, competitive abilites of the patient

CONCLUSIONS - SUGGESTIONS
Accordingly to discussed assumptions one could define
the diabetes mellitus education as seen from the Warsaw
perspective by 6 obligations or tasks one it has to assure:
1 educational and psychosocial diagnosis enabling the holistic - it means personalistic, behavioral and technical
teaching,
2 positive motivation (the force of fiat of Twardowski),
truly existing contact of the patient with himself and
other people, construction of the creative attitude to the
potential new life values, which patient has to acquire,
3 increase of the psychosocial resistance to stresses by
enabling the patient to understand the mechanisms of
his disease and to copying with the handicaps,
4 counteraction to the anxiety, psychoemotional fatigue, depression, loosing the feeling of the sense of life, frustration,

Medycyna Metaboliczna, 2016, tom XX, nr 4

www.medycyna-metaboliczna.pl

21

5 equipment of the patient with all necessary, knowledge

and skills for self - control of his diabetes mellitus, and
for the prevention or treatment of complications,
6 convinction of the patient, that he is able to fullfil his
social role, to obtain the good quality of the individual
life, the sufficient level of autonomy, to eliminate the
external and internal discrimination
It is felt, that the holistic-educational and psychosocial
way of educating the diabetic patient, based on the personalistic approach, objective evaluation of teaching results
and continuous, educational engagement of the patient
combined with social support may substantially help to
increase the quality of therapy and life

BIBLIOGRAPHY
1 American Association of Diabetes Educators: Quality
Improvement in Diabetes Education, AADE, Chicago,
2005
2 American Association of Diabetes Educators (AADE),
The Art and Science of Diabetes Self-management
Education, Mensing C (red nacz), publ AADE, Chicago, 2006
3 Assal JP: Traitement des maladies de longue dure:
de la phase aigue au stade de chronicit Ency Med
Chir. 25-005-A-10 Pary, Elsevier, 1996.
4 Bauman Z.: Ponowoczesno jako rdo cierpie,
Wyd Sic!, Warszawa, 2000
5 Bernas M.: Socjologia cukrzycy, rozdz. w: Idea
i praktyka nowego podejcia do edukacji zdrowotnej
i promocji zdrowia, Osiska H., Przewocka I. (red.),
wyd. Pol. Tow. Owiaty Zdrowotnej, Warszawa, 2011.
6 Bloomgarden ZT, Karmally W, Metzger MJ i wsp:
Randomized, controlled trial of diabetic patient
education Improved knowledge without improved
metabolic status Diabetes Care, 1987, 10
7 Czech A.: Profesjonalna edukacja terapeutyczna
w chorobach przewlekych cele, metody, programy,
ocena korzyci na podstawie dowiadczenia w optymalnej opiece diabetologicznej, rozdz. w Idea i praktyka nowego podejcia do edukacji zdrowotnej i promocji zdrowia, Osiska H., Przewocka I. (red.), wyd.
Pol. Tow. Owiaty Zdrowotnej, Warszawa, 2011.
8 Czech A.: Poradnik dla Pacjentw z cukrzyc typu 2,
wyd. Tow. Edukacji Terapeutycznej, Warszawa, 2011.

22

9 DAFNE Study Group. Training in flexible, intensive

insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal
eating (DAFNE) randomized controlled trial BMJ,
2002, 325, 746-749
10 Dortier J.F.: Peut-on motive autrui? Sciences Humaines, 1999, 92, 110-111
11 Education Therapeutique du Patient Organisation
Mondiale de la Sant Bureau Regional pour 1`Europe, Copenhague Programme de formation continue
pour professionnels de soins dans le domaine de la
prevention des maladies chroniques Recommandations d`un groupe de travail de 1`OMS, 1998
12 Fayers P.M., Machin D.: Quality of Life assessment,
analysis and interpretation, J Wiley and Sons, Chichester, 2000
13 Lacroix A., Assal J.Ph: Therapeutic education of Patients, wyd. 2, rekomendacja EASD, Ed. Viget, Pary
2003
14 Tato J.: Cukrzyca nauczanie samoopieki, Wyd.
Naukowe PWN, Warszawa, 1995
15 Tato J.: Filozofia w medycynie, Wyd. lekarskie
PZWL, 2003.
16 Tato J., Czech A., Bernas M.: Diabetologia kliniczna, Wyd. lekarskie PZWL, Warszawa, 2008.
17 Tato J., Czech A.: Podrcznik samokontroli cukrzycy, Wyd. lekarskie PZWL, Warszawa, 2008.
18 Tato J., Czech A.: Historia bada i leczenia cukrzycy, Wyd. Medyczne Termedia, Pozna, 2011.
19 Till E.E.: La motivation, une construction progressive Science Humaines, 1997, hors serie 19, 71-75
20 Peyrot M, Rubin RR, Lauritzen T i wsp.: Psychological problems and barriers for improved diabetes
management: results of the cross-national Diabetes
Study Attitudes, Wishes and Needs (DAWN) Study,
Diabetic Med, 2005, 2, 1379
Adres do korespondencji
Magorzata Bernas
Klinika Diabetologii, Endokrynologii i Chorb Wewntrznych,
II Wydz. Lekarski WUM,
Mazowiecki Szpital Brdnowski
03-242 Warszawa
ul Kondratowicza 8
mw.bernas@interia.eu

Medycyna Metaboliczna, 2016, tom XX, nr 4

www.medycyna-metaboliczna.pl