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http://tde.sagepub.com/content/39/6/811The online version of this article can be found at:

 DOI: 10.1177/0145721713504471

2013 39: 811 originally published online 30 September 2013The Diabetes EducatorRoxanne K. Vandermause

Susan E. Fleming, Angela Boyd, Miriam Ballejos, Susan A. Kynast-Gales, Charlene L. Malemute, Jill Armstrong Shultz andGoal Setting With Type 2 Diabetes: A Hermeneutic Analysis of the Experiences of Diabetes Educators

  

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Susan E. Fleming, PhD, RN

Angela Boyd

Miriam Ballejos, PhD, RD

Susan A. Kynast-Gales, PhD, RD

Charlene L. Malemute, RD

Jill Armstrong Shultz, PhD

Roxanne K. Vandermause, PhD, RN

From Washington State University, Spokane, Washington (Dr Fleming, Ms Boyd, Dr Kynast-Gales, Dr Ballejos, Ms Malemute, Dr Armstrong Shultz, Dr Vandermause).

Acknowledgments: We extend our gratitude to Dr John Roll, Associate Vice Provost; Dr Cynthia Corbett, Associate Dean of Research; and Dr Barbara Richardson, Director, Riverpoint Interprofessional Education & Research of Washington State University, Spokane for emphasizing the importance of engaging in Interprofessional research.

Correspondence to Susan E. Fleming, PhD, RN, Washington State University, PO Box 1495, Spokane, WA 99210-1495, USA (sefleming@wsu.edu).

DOI: 10.1177/0145721713504471

© 2013 The Author(s)

Purpose

The purpose of this study was to explicate and interpret common experiences of diabetes educators (DEs) with patient goal setting for patients with type 2 diabetes in diabetes education.

Methods

Transcripts (n = 10) from semi-structured interviews were analyzed using a hermeneutic phenomenological approach to more deeply explore the accounts of DEs’ goal setting with patients with type 2 diabetes.

Results

The overarching pattern that emerged was “Striking a Balance,” which subsumed 4 subthemes: Applying Theoretical-Practical Principles When Setting Goals, Identifying Idealistic-Realistic Expectations, Creating Patient-Educator–Centered Plans, and Readying-Living With Goal Setting. The pattern, “Striking a Balance,” revealed a common meaning of DEs as experiences requiring balance and nuance in goal setting with patients.

Implications

The results of this study combined with the tenets of the self-determination theory can provide the DEs with real-life exemplars and a theoretical framework to encourage

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Goal Setting With Type 2 DiabetesA Hermeneutic Analysis of the Experiences of Diabetes Educators

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their patients to self-manage, increase intrinsic motiva-tion, and improve adherence related to their lifestyle changes and glycemic control. DEs, as facilitators of change, can implement these changes with flexible and reciprocal activities with their patients. The DEs owned these activities and they are: “building the bond,” “shar-ing the session,” “readying for change,” “sending them home,” and “bringing them back.”

The prevalence of type 2 diabetes is escalat-ing and continues to be a national concern.1 The American Diabetes Association2 issued a position statement that recommends new guidelines for treating type 2 diabetes by

focusing on patient-centered care lifestyle interventions, which included modifying diet, increasing physical activity and weight loss regimen. These new guidelines are “less prescriptive than and not as algorithmic than prior guidelines” and emphasize the vital importance of meeting needs of the individualized patient.2 These new guidelines call for a better understanding of how diabetes educators and patients with type 2 diabetes share in cre-ating patient-centered care. Often, diabetes educators (DEs) are on the forefront of providing first-line defenses of self-management of glycemic control with their patients who have type 2 diabetes, as patients try to modify lifestyle behaviors. Modifications to health-related lifestyle behaviors, including self-care activities, such as taking medications, increasing physical activity, modifying diet, managing weight, alcohol reduction, and glycemic control, are not inherently gratifying or intrin-sically motivating. These modifications are often initi-ated as diabetes educators and patients join together to set goals. Setting goals and educating patients about the self-management of glycemic control in ways that are relevant, engaging, and motivating is vital for working with individuals who present with type 2 diabetes.

The self-determination theory (SDT) can provide a theoretical framework for understanding intrinsic psy-chological tenets to encourage patients to self-manage, increase intrinsic motivation, and improve adherence related to their lifestyle changes and glycemic control. Patient adherence and human behavior are the most prevalent source of disparities in health outcomes and are directly linked to self-motivation.3,4 Therefore, the SDT can provide DEs with a theoretical model to address the

ability to self-motivate, which is connected to the intrin-sic need for competence, autonomy, and psychological relatedness. Furthermore, motivation relates to the ability of patients to adhere to suggested medical regimes, such as glycemic control, when managing type 2 diabetes.

The varying experiences and training backgrounds of DEs may impact their approach to developing goals with patients. Typically, providers of diabetes education are registered dietitians (RD), registered nurses (RN), physi-cians, or other health care workers.5 The possibility exists that practitioners with these different academic backgrounds may use inherently different patient tech-niques. The common practices of diabetes educators are not clearly identified or understood.

The purpose of this study was to explicate and inter-pret common experiences of diabetes educators with patient goal setting for patients with type 2 diabetes in diabetes education. In order to understand the DE experi-ence of goal setting with patients who have type 2 diabe-tes, the authors of this article set forth to investigate the compelling stories of 10 DEs, obtained in a prior study, so that a deeper understanding and meaning could be examined.

Methodology

A hermeneutic phenomenological approach was used to analyze the experience of DEs during goal-setting ses-sions with patients with type 2 diabetes. This approach, grounded in philosophical hermeneutics,6 is intended to provide a broad, contextual, and interpretive understand-ing of experience. Texts of interview transcripts, written interpretations of transcripts, discussion summaries, and the explicated professional experiences of the researchers comprised the data analyzed in the study and used to derive findings. Such methods, detailed in the following, rely on an open and iterative review of language in vari-ous forms, assume that language is symbolic and insinu-ates meaning, and assert a sense of agreement among interpreters that findings are warranted.

Method

In 2012, a hermeneutic phenomenological analysis team was formed consisting of 2 registered dietitians, 2 registered nurses, and a third-year student in nutrition and exercise physiology. The primary objective for the team was to conduct a secondary analysis and interpret

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interview transcripts collected from a prior larger study.5,7 This current hermeneutic study provided an additional interpretation of in-depth meaning regarding “what it means to ‘be’ a diabetes educator when setting goals.” The larger study used a purposive sample of 179 diabetes educators selected from a 2008 American Association of Diabetes Educators membership listing and was intended to identify goal-setting practices via a mailed survey. The original objective of these interviews was to acquire pilot data on how DEs conduct patient assessments, education, and counseling associated with goal setting alongside patients who have type 2 diabetes. The results of this exploration contributed to the design of questionnaire items used explicitly for a survey instrument.5 Using 10 of these same transcripts, researchers met weekly or biweekly over several months to analyze and interpret the texts, using an in-depth hermeneutic phenomenological approach, which uncovered some hidden yet common human experiences discerned through the analysis.6,8,9

Sampling and Setting

The sample represented the preliminary and qualita-tive stage of a larger study.5 It consisted of a purposive convenience sampling of a diverse group (eg, RD, CDE, RN) of diabetic educators (n = 10) and was recruited from the Pacific Northwest region of the United States. They were all asked to volunteer for the original study and they accepted.

Data Collection

Data were collected via one-to-one telephone inter-views using semi-structured questions with allowances for open elaborations. Although the use of semi-structured questions is generally avoided using the hermeneutic approach applied in the analysis, the data set was suffi-cient to provide a rich dialogue for interpretation. The interviews were subsequently audio-recorded, then tran-scribed verbatim. The initial interview question presented to the participants was, “Let’s think about the diabetes education you do with patients who are about to set goals for the first time.” The participant was allowed time to answer and ascribe meaning to this question. The inter-view was also followed by several semi-structured ques-tions, such as:

1. “Are there techniques you use to assess their knowledge, attitudes, or behaviors to prepare for goal setting with a patient for the first time?”

2. “How do you know when a patient is ready to move from receiving information about diet to taking action to change dietary behaviors for better diabetes control?”

3. “In general, what kind of conversation between you and the patient results in the patient setting a goal?”

4. “Can you give an example of how a patient set a dietary goal and worked with you to bring it to an implementation stage?”

5. “What strategies do you use with patients who have not had satisfactory outcomes with their diet or meal action plan?”

Data Analysis

A hermeneutic phenomenological analysis was con-ducted as transcripts were read and interpreted. The anal-ysis of these texts gleans from the work of Martin Heidegger and Hans Gadamer, where by nature the interpre-tations are reflective and circular.10 Researchers carefully read each transcript and brought written interpretations to bimonthly meetings, reading and discussing the interpre-tations with one another. A comprehensive collection of notes was generated, adding to the data. In this study an all-encompassing pattern emerged as the themes were formed (see Table 1). Initially, rudimentary themes emerged and were discussed and modified, keeping closely to the text and representing the common experi-ences of diabetes educators. The iterative process con-sisted of naming the themes, which were then revised and renamed. Each member of the analysis team brought to the discussion their own ideas and professional experi-ences working with patients. Unwarranted interpretations were challenged during the process. Furthermore, the intention of this analysis is that the reader will continue to interpret the text.6,10

Validity of the findings were established through examining the primary and secondary criteria. The pri-mary criteria of credibility, authenticity, criticality, and integrity were examined against the findings. Credibility questions if the results of the research reflect the experi-ence of the participants or the context in a believable way. Authenticity illuminates delicate differences in the voices of all participants. Criticality answers whether the research process displays evidence of critical appraisal. Finally, integrity answers whether the research reflects recursive and recurring checks of validity as well as humble presentation of findings.11 The secondary criteria of explicitness, vividness, creativity, thoroughness, con-gruence, and sensitivity were used to construct the expli-cation that follows.11

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Results

Results revealed a constitutive pattern called Striking a Balance. This pattern subsumed several overlapping themes: Applying Theoretical-Practical Principles When Setting Goals, Identifying Idealistic-Realistic Expectations, Creating Patient-Educator–Centered Plans, and Readying-Living With Goal Setting. While each DE shared their unique insight of a typical goal-setting session, their tran-scripts were analyzed across texts to allow for interpreta-tion that built from one to the next, creating an overall understanding of the shared experience. It is from the lan-guage, emphasis on technique, and overall content that these themes emerged.

Pattern: Striking a Balance

While each diabetes educator had a unique practice style that became visible through the text, the transcripts

together flowed like an unraveling story, constructing the idea of Striking a Balance, as DEs related their practice with goal setting. Some DEs openly disclosed their struggles and frustration with misunderstanding delinea-tion of patient/practitioner roles, difficulties of lifestyle change, or patient nonadherence with treatment recom-mendations. As a whole, the DEs acted as facilitators throughout the sessions as patients relied on them to assist in the construction of achievable goals. One practi-tioner discussed the difficulty of aiming low in goal set-ting in an effort to balance sensitivity to the patient’s circumstance with the need to improve outcome and establish rapport.

Lifestyle change is hard and I wanna be their friend and help them, and if I come off hard core I’ll be one of those nasty dieticians they don’t wanna see again. So I really am sometimes a little too gentle. I’d rather have

Table 1

Pattern, Themes, and Exemplars Related to Diabetes Educators Setting Goals

Pattern Themes Exemplarsa

Striking a Balance Applying Theoretical-Practical When Setting Goals

“And so we can make little tiny goals. Sometimes we don’t even have goals the first few times, it’s just they’re getting comfortable talking to me. And they’re thinking about it, like you said, the stages of change.”

Identifying Idealistic-Realistic Expectations

“I typically will use their goal whether it’s weight loss or better glycemic control, and walk them through their day, and their routine, and how they cook or eat out . . . try and just talk ’em through a scenario so that they’re using the knowledge that I’ve given them to incorporate into their day to meet their goal . . . take them mentally through different scenarios on how they can implement changes or information in meeting their goal.”

Creating Patient-Educator–Centered Plans

“‘How Do You Want to Learn’ assessment sheet that is filled out and it asks about if they like ‘by watching, by listening, by reading printed material,’ or a combination of those things. So I’ll usually look at that, or if I don’t look at that I’ll directly ask the patient how do they like to learn.”

Readying-Living With Goal Setting

“‘Okay, I wanna start walking.’ Okay, great. And in Alaska we have a lot of barriers. ‘What is your plan for winter?’ Um, ‘Well, my so-and-so friend relative likes to mall walk. I will go to the mall with them.’ Okay, ‘When are you gonna do that, on which days of the week?’”

“I think the easiest way you know is just if they’re following what you tell ’em to do, or what you suggest they do. If they’re motivated enough. Or if they repeat things back to you so that you can tell that they’ve caught on to what you’re saying.”

aExemplars represent hundreds of experiences revealed in the data.

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that and maybe in three or four appointments they make some really great goals, rather than losing ’em after the first appointment. (Transcript No. 6)

The DE implies that this compromise is an effort to establish a relationship with the patient as means to meet the goal of long-term diabetes self-management. This necessity to strike a balance is justified by her experi-ence, “So, I don’t know if I’m a typical dietician these days . . . I’ve been doing this for seven years, diabetes stuff” (Transcript No. 6), and there is an awareness that this balance is a conscious effort, something she brings up throughout the interview.

It became evident that goal setting is multifaceted, and each patient counseling session can fall in a new place on the different spectrums of goal setting. Striking a Balance suggests a spectrum of interventions and activities, through which the DE moves during the goal-setting process, adjusting to the needs of the patient and circumstances.

Theme: Applying Theoretical-Practical Principles When Setting Goals

A DE is equipped with a toolbox of theories when they enter a patient counseling session, but ultimately the application in practice is determined by the practitioner as the session develops. Theories, models, and aforemen-tioned tools are provided to allow a practitioner to adapt to the individual needs of patients. Each of the DEs inter-viewed described various theories and frameworks acquired from their professional education. Some of them listed numerous models and protocols, detailing their use, while others made looser references to educational theory. Each transcript demonstrated a variation on the use of the stages of change (SOC) model, which is used to determine the proper goal intervention based on the patient’s level of readiness to make behavioral changes.

The practitioners found unique ways to assess a patient’s SOC, sometimes using a “ruler of change” (Transcript No. 10) or a “scale of 1-10” to let the patient assess their own SOC. Thus, the SOC model appears to be known broadly, if understood variously. For some DEs, the SOC assessment ultimately brought on an action in goal setting. If the practitioner’s interpretation of the model was used in a way that applied interventions only when they perceived the patient as ready or willing to change, then the session could conclude with goal set-ting. Alternatively, some practitioners applied interven-tions to all stages identified in the model, including

precontemplation and contemplation changes. Thus, understanding the SOC model did not necessarily trans-late to standardization of practice. The approach of prac-titioners was evident in their assessment. Language in some of the transcripts revealed an underlying tone that implied desperation for patient initiative.

Some of the interviews contained more explanation of theory and few exemplars of application, while others focused on the interaction in theoretical styles.

So we actually put together a really wonderful diabetes workbook using all these tools I’m talking about. The stages of change, the empowerment model, the smart goals, a lot of these things. And we have a workbook where they actually can, if it’s a patient that is literate enough and would find it useful. (Transcript No. 1)

At times, educators appeared to be cluttered with tools, with focus on the materials of their education and little description of the value of interaction with the patient to generate goals. “The goal setting really has to be according to what they’re able to make, not what I sit and tell them” (Transcript No. 3). This excerpt suggests the DE distinguishes her own model of care from the techniques she uses, indicating a more judgment-based approach using protocol than evidence-based approach using frameworks.

The varying styles of theory applied to practice dem-onstrated that practitioners differ in their abilities to bal-ance of understanding theory and actual goal setting for diabetes management. “When we come to the end of the class, and we talked about goal setting and what smart goals are, of something that is specific, and measured, and time-stamped, and why it’s important to have goals to change behavior” (Transcript No. 2). The DE, even if educated about practice standards, applies knowledge-able understandings uniquely. Thus, there is an element of practice application that is distinct from theoretical knowledge.

Theme: Identifying Idealistic-Realistic Expectations

It appears that the goal-setting objective is complex, as are the expectations of what those goals represent. The practitioner and the patient may walk into the office with opposing expectations for the outcome of the session, leading to a shift in responsibility to make those changes attainable.

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Sometimes it’s encouragement, the tool that’s just kind of walking through what they currently are doing, and just talking about some possible changes, and then sometimes that gives ’em some ideas and then they can, they’ll springboard from that, or they’ll pick some of the ideas that I’ve kind of talked about. What I’m trying to do is kind of see how they can set goals, how they can make small goals, and still meet their goal of change. ’Cause a lot of ’em come in with the idea that they have to change everything, right now, and they can’t do anything they like, or eat anything they like. Does that make sense? (Transcript No. 7)

Several DEs conveyed the need to moderate patients’ excessively high expectations that might be likely to result in failure to attain their goals. This is an important part of the practitioner-patient relationship, as the DE must be compassionate but still focused on the task of bringing about beneficial change. This sensitivity and compassion are evident on execution of the process, as demonstrated in the following:

We talk about how hard or easy it was to implement the changes, what some of the barriers were that they are conscientious of, we try and look at alternative strate-gies. For instance, if the carb counting didn’t work, then I’ll talk about something that might be a little easier for them like label reading, or Plate Method, or something, you know, that’s a little less involved, and I try to be realistic with people. A lot of times they feel they’re unsuccessful because they’re not able to imple-ment changes a hundred percent of the time, and I just try and really remind them that that’s not necessarily realistic. (Transcript No. 5)

The practitioner may understand that idealistic goals are not achievable, and therefore have to consider what may “just do” for that patient to make them more comfortable in their self-management. Striking a balance between/among what the patient perceives as the “right thing to do,” the ideal health model, and ultimately what a person is capable of changing in their life is a necessary practice illuminated in the study, one that requires particular skill.

Theme: Creating Patient-Educator–Centered Plans

Today, patient-centered care dominates diabetes edu-cation and lifestyle counseling.5 For a DE to guide a patient through the goal-setting process, with limited time to come to understand the patient, the practitioner in

many ways has to leap into the practitioner-patient rela-tionship with a sense of focus on the patient’s medical care. Through interpretation of the transcripts, as practitioner-patient relationships were revealed, it became clear that needs of patients were being weighed by practitioners whose agenda was to balance supporting the patient against achievement of a particular health goal. Some transcripts revealed a practitioner’s agenda for a given outcome by which to measure the success of the session. One practitioner was so enthused by the process of help-ing patients to reach their goals, the research team was moved by the excitement conveyed in the response.

I: Can you give me just an example of how a patient set a dietary goal and then worked with you to bring it to implementation?

R: Oh my. Okay, boy, there’s several, I don’t know where to start! (chuckles) Oh, oh boy, oh boy, let’s see. Okay, I can think of a face, brings a lot of joy to me, and this couple, the husband’s diabetic and the wife has weight management issues, and they try to work on small things such as eliminating the weekend overeating on desserts. And so they worked on that for a while. And the husband, you know, who has diabetes, was not checking his blood sugar daily, and he began to check it a couple times a week . . . beaming smiles, feeling just so elated about making those changes with the ice (cream), overeating on the weekends, checking the blood sugar more often, he also limited his portions at dinner time to one, and worked on his lunch—changing from fast food to like a Lean Cuisine . . . they did the goals slowly, they also went through our diabetes education classes as well, and just were real positive, gave us a lot of positive feedback. (Transcript No. 4)

The previous transcript demonstrates how educator-patient interaction may be implemented by making sub-tle lifestyle changes that align with the needs of the patient. Individualized education is personally tailored for each patient “to incorporate into their day to meet their goal” (Transcript No. 5). Often DEs formatted their patient counseling sessions in response to their client’s needs, whether it is more dietary education or by what the client expresses as a need.

They’re very motivated and so they find that their time’s more usefully spent talking about new things and so I try and always allow them the opportunity to voice what they wanna get out of the session. (Transcript No. 5)

The DEs can be instrumental in assisting the client envi-sion the commitment to the program in a very realistic and practical way, which represents the patient’s desires.

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“Can you see yourself going home and using this?” Or, “Is this something that you think you can use maybe for dinner tonight? Is this something that you’re willing to practice or see yourself practicing?” (Transcript No. 5)

Using encouragement and reinforcement encourages the patient to make changes and monitor their own progress. Goal setting, in this example, is patient-centered, specifi-cally requiring patient recognition of needs, verbaliza-tion of goals, affirmation of benefits by the educator, and implementation with tools, Although the DE refers often to “providing” information to the patient, she retains a supportive role and allows the patient to take ownership of and responsibility for their health and healthcare.

Theme: Readying-Living with Goal Setting

One of the more prominent difficulties with the goal-setting process is the need for the DE to assess the patient’s readiness for change. This process involves assessing the patient’s verbal as well as nonverbal cues, which can convey the patient’s readiness to make changes and modifications to their current lifestyle.

You know a lot of it is just interpreting, even non-vocal indications from the patient. If they are acting interested in the information, if they are engaged in the conversa-tion, if they’re making eye contact, or if they’re, you know, arms folded and sitting back and not, not seeming to be very receptive. (Transcript No. 5)

All of the DEs worked at talking with patients as a dia-logic exchange to bring forth the patients’ needs and desires into the plan while assessing their readiness for change. A good example of this is when a DE responded how she knew when a patient was ready for change:

Mostly they tell me . . . “Do you have any questions?” . . . they almost always do. So I will just sit and relax with them, and usually provide some handout material . . . towards the end of our session. I’ll say words like “We covered healthy eating and checking blood sugars today. What goal would you like to set on that informa-tion?” . . . it’s really individual and patient-driven—the goals . . . some patients say “I don’t have any today” and I just gotta go with that.” (Transcript No. 6)

With transcript 3, the DE responds to the opening ques-tion about “what information?” she collects with, “That one’s kind of a hard one.” This seems like a surprising

response but then the participant goes on to describe a process of assessment that is less concrete than some of the others initially described. She brings in an element of intuition or the like, saying:

Basically it’s just talking with them, asking them ques-tions, kind of getting a feel for what they understand, what they do not understand. And then basically you sort of get a feel if they say they’re not willing to do this or that, basically kind of helping them to see how different health behaviors will help them to change their diabetes, improve it, and see what the patient is willing to make changes to do. The goal setting really has to be according to what they’re able to make, not what I sit and tell them. (Transcript No. 3)

The previous dialogue brings a finale to setting goals and assessing readiness with patients who have type 2 diabe-tes. The DE is seen more as a facilitator of change to be there when their patients express their readiness to move forward and take the next step, which often includes modifications to their current lifestyle that the patient can live with.

Discussion

The results from this analysis raise new insights about the phenomenon of goal setting with patients. Phenomenological interpretation of the transcripts of interviews with DEs raises new insights into the experi-ence of practitioners in goal setting with patients. Practitioners interact with their patients through applica-tion of theoretical knowledge and tools gleaned from pro-fessional education as well as through shared consciousness of life as it is experienced. In the process of goal setting, practitioners navigate the need to “Striking a Balance” between professional obligation to provide effective diabetes education and compassionate interper-sonal facilitation of patient self-efficacy to set and achieve goals that they and their patients liked. The inter-actions between DEs and their patients involved recipro-cal and flexible activities, such as “building the bond,” “sharing the session,” “readying for change,” “sending them home,” and “bringing them back” (see Table 2). These activities seemed to be “owned” by the practitio-ners that described them through experiential accounts of practical wisdom that is not standardized or explicitly taught in educational settings. This practical wisdom, though manifested in the analysis of these accounts, was

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expressed differently than the recitation of theoretical understandings or use of particular models and tools. Such understandings should resonate with DEs and influ-ence clinical practice by raising questions about how theoretical and physiological knowledge is applied to everyday life situations.

Concepts from the SDT may help to further interpret our results by conjoining the SDT and its tenets, which can increase intrinsic motivation and may result in improved adherence related to lifestyle changes and gly-cemic control. The SDT has 3 main tenets, which are autonomy, competence, and relatedness.4 Autonomy is associated with the tendency to self-manage and self-organize, which is a fundamental skill needed to acquire the ability to attain glycemic control. Diabetes educators can promote autonomous behaviors through empowering their patients with knowledge and skills needed to achieve their relevant goals. Competence is related to one’s ability to adapt to new cognitive and motor skills, which can confront new health-related challenges such as the onset of type 2 diabetes. DEs can strengthen com-petency as they offer praise and authentic feedback of their patients’ newly acquired skills or tools. Relatedness is the tendency to connect to one’s own group. Often, patients with type 2 diabetes lack the technical expertise to attain glycemic control and look to DEs for assistance.

DEs who can offer their patients a sense of being respected, understood, and cared for can strengthen their relationship and build trust.12 Autonomy, competence, and relatedness are fundamental principles, which can increase intrinsic motivation, promote long-term adher-ence, and build a stalwart relationship between the DEs and the patient with type 2 diabetes.

The National Standards for Diabetes Management Education (DSME) can provide DEs strategies using models and evidence-based education, which can aid DEs in providing their patients with diabetes self- management support.13 DEs are facilitators and offer the first-line defenses of initiating patient-centered education and lifestyle modifications, which are key in achieving glycemic control for individuals with type 2 diabetes. A well-educated, motivated patient can engage in the self-management of their diabetes and prevent further dete-rioration of their health such as comorbidities and preventable complications as stroke, heart disease, kid-ney failure, and increased costs.13,14

Dialogic exemplars from DEs are presented to repre-sent the patterns and themes of this study (see Table 1). However, it is important for the reader to recognize that these excerpts represent hundreds of experiences, which led to the interpretive findings. These findings are not intended to be scientifically generalized to groups, but

Table 2

Suggested Clinical Implications for Setting Goals With Patients With Type 2 Diabetes

Supportive Activity Suggested Clinical Implications

Building a bond •• Listen attentively and respond to body cues•• Strengthen your relationship and build trust•• Empower your patient with new skills and knowledge

Sharing the session •• Promote autonomy•• Understand their learning style•• Negotiate expectations

Readying for change •• Offer praise and authentic feedback•• Implement changes that can meet their goals•• Facilitate lifestyle modifications

Sending them home •• Promote goals that are mutual, realistic, and time sensitive•• Offer your patient a sense of being cared for•• Encourage them to self-organize their care

Bringing them back •• Welcome them back•• Recognize their achievements•• Evaluate their competence

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they should resonate with DEs and diabetes health care professionals in ways that increase understanding and affect future practice and experience. This study pro-vided a contemporary view of DEs setting goals with their patients and can increase our awareness of this distinct process.

Limitations

The narrow geographical pool from which participants were sought limits this study. A more diversified sample could provide additional insights influenced by location, including area practice standards, demographic charac-teristics of patients, and sociocultural backgrounds of educators. From a methodological standpoint, the inter-views were first intended to gather data for a larger quan-titative study and not for interpretive analysis, limiting the possibilities that might have come from longer, more unstructured interview conversations. The need for future research is warranted.

Conclusion

In this study of experiences of DEs setting goals with patients with type 2 diabetes, it was found that Striking a Balance is a common practice and that educators differ in their skills and abilities as well as in how they apply pro-fessional understandings. Their experiences include Applying Theoretical-Practical Principles When Setting Goals, Identifying Idealistic-Realistic Expectations, Creating Patient-Educator–Centered Plans, and Readying-Living With goal setting. Individual practitioners, as facili-tators of change, manifest these interactive styles according to their unique circumstance as they join with their patients to set goals. These practices should be acknowledged in patient-centered educational and practice settings to better understand their manifestations and the relationship

between theory and practice where intrinsic motivation is enhanced and long-term adherence is achieved.

References

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