Optimising Health Literacy and Access of Service Provision to Community Dwelling Older People with Diabetes Receiving Home Nursing Support

Table 5

Key themes and illustrative quotes.

Themes	Findings	Illustrative quotes
Benefits experienced during the use of diabetes education checklist	Six nurses reported that the checklist helped them keep on track with client education by focusing only on areas the client thought were necessary. Overall, the checklist appeared to be well accepted and utilised and was termed “user-friendly”	I think it was useful – in her situation I was the only one giving her the education, when lots of different nurses – where it’s good to have different ideas you sometimes end up guessing what has been covered, often re-hashing and going over time that has already been spent, making sure that you haven’t missed, whereas if doing all education, …in that conversation you realise that oh they didn’t know that, useful conversation around what do you know/ not know. (RDNS 7); I tend to use the checklist now for all my diabetes clients - this is much easier for me to tick off what they need to learn (RDNS 4)
Benefits and barriers experienced during the use of teach-back	The method was praised by most nurses ( = 7) who felt that while it had been part of their routine clinical practice for some time, participating in this intervention led to consistent and conscious use of the method during client education. Using the method more formally was seen to reinforce the importance of the teaching and learning trajectory to both clinicians and clients. The nurses () reported that using teach-back raised their awareness of the needs of clients in relation to learning such as the need to provide information in stages, use of simple terms, and being specific about actions that clients needed to undertake. The method was seen as contributing to a greater rapport with clients (). Using the method with dementia patients and other cognitively impaired patients was a challenge identified by two clinicians	I felt confident straight away to practice – was already using techniques, but the project made me more aware and made me use it more consciously and consistently (RDNS 1); I spend a lot more time asking patients what was the main thing they understood from that and encouraging them to talk back to me. Before I was more “you’ve heard the information now go and do it”. It was reinforcing to me about my teaching, she and I both enjoyed it (RDNS 2); With teach-back, I think it’s a great way to communicate with people – we say “this is what we are going to do”, not “this is what you need to do”. We work with them and get a better response all round. (RDNS 5)
Benefits and barriers experienced during the use of online library of resources	Five clinicians noted that these resources were “useful for quick answers,” “user-friendly,” and “easy to use.” However, two clinicians felt the topics were limited, and sharing the resources with clients was challenging when large/multiple documents needed to be downloaded, printed, and mailed out to clients	I use the diabetes education checklist and online resources all the time with other clients. They are good, they help keep me on track and remember what I’ve covered (RDNS 5); I used all online resources – they are written in simple language, a couple I got from the National Diabetes site, plus shopping list off the diabetes website – a very useful tool (has product names on it, much more practical) (RDNS 2); Then there is still same problem with accessing resources – large documents that have to be downloaded – we need to print them as that’s the only way I can give to people to read – not enough time in our meeting to read over again in our session, screens too small, especially if lots of sections – do people really bother to read them all? (RDNS 7)
Benefits and barriers experienced during the use of the learning styles tool	Only two nurses specifically reported using this tool; one nurse felt it made educating staff easier and was a user-friendly tool to use, while the second reported that using the tool with older clients, who had set habits, was a challenge	I used the learning styles tool initially, thought that was useful but I do that anyway (RDNS 2); The learning styles – I think that’s important, but with our kind of clients, we don’t really have the ability to do things differently. We’ll go in and talk about things – if they need resources we’ll do what we can. With the age of our clients, what they’re used to is us sitting down with them – it’s not practical to know about their learning styles (RDNS 5)
Experiences and outcomes	Two strong subthemes here were the “opportunities” and “challenges” which arose during utilisation of the intervention’s tools. There were positive reports by three nurses of clients becoming more proactive, asking more questions and showing improvements in self-management of their condition. Nurses () felt this was a result of increased knowledge, understanding, and opportunity for clients to refresh their memory on certain vital topics. In terms of changes to their own knowledge and practice, two nurses reported no changes, while five reported that the intervention provided opportunity to reflect on how education was delivered to clients and taught them to look for cues to ascertain client understanding of the content. Nurses () felt the intervention either formalised the process of information delivery, and/or provided an opportunity to check on a client’s existing knowledge, refresh knowledge, and build rapport with a client. In relation to challenges, five nurses reported that recruiting suitable clients to participate in the intervention was difficult given the large proportion from non-English speaking backgrounds. The second biggest challenge was client cognitive decline or impairment as noted by two nurses	She’s more confident to ask questions. She has had a foot wound which she has stopped looking after, so she has asked me if anything else, and I said well let’s do foot care, so we’ve done more about this and got her to a podiatrist, so definitely more proactive than previously. I’ve known her for 3 years, and this is different. (RDNS 2); Has given me an opportunity to reflect on how I deliver education and reflect back and look at what I’ve done more analytically and see that nodding the head doesn’t mean they get it…looking for objective and subjective cues about how they have learnt (RDNS 6); I found only one suitable person, because limited criteria I have many patients with non-English speaking background or cognitive decline (RDNS 3)
Critical facts and lessons learnt	Cultural and linguistic diversity was predominant amongst the target population and therefore translation and use of simple language were suggested to make the intervention more relevant (). The continuous promotion of the intervention within the organisation was advised to maintain its momentum. In terms of client behaviours, staff () felt some clients/carers may dislike being assessed/questioned on topics they had limited knowledge about. Allowing clients to learn at their own pace, educating them without impeding their confidence, and encouraging clients to be independent were suggested as vital points by clinicians (). One nurse reported that using the tools with some clients revealed cognitive issues which had not been previously identified, due to a lack of formal assessment. Finally, nurses praised the Clinical Diabetes Educators who led the project from within the home nursing service for their supportiveness, availability, and responsiveness	CNCs will need to keep promoting it. If there is no one driving it, it won’t be successful (RDNS 1); If we are going to take education seriously, we should use this method- each site in RDNS is doing something different. Not to say it’s bad but to be consistent, we need consistent methods…incorporating teach back is the first tool (RDNS 6); We don’t encourage our patients to be independent (RDNS 3); Think it is a good idea, but can see that many people would benefit from education, but not all are English speaking, so some translation required (RDNS 3); It comes with practice and being aware that everyone is at different stages, some will take longer, and need to go over and over, some people take it in quickly. Need to be really patient with people (RDNS 8)