Scenario 3: Negativity

In this video the educator is facilitating a session in which the group share their DAFNE diaries. In this session individuals are reflecting on their own application of DAFNE principles of CP estimation and insulin dose adjustment. They are looking for patterns in their Glucose to help them problem solve, make decisions and action plan for any changes they would like to make. The session is key to the DAFNE course and provides opportunities for modelling, mastery, reflection, experimentation and peer learning.

Activity 13: Negativity

Timing: 20 minutes

Part 1

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WOMAN
Nice cuppa.
[SIDE CONVERSATION]
OLGA
[voiceover] God, this is a waste of time. Yesterday was useless. I was just high all day and not in a good way. I don't think she can help me. This approach just seems daft.
EDUCATOR
Hello again, everyone. Shall we get straight back into it? OK, Olga, so before we look at your diary, would you like to just remind us of your action plan from last night?
OLGA
Look, yesterday was horrendous. I told you this wouldn't work. I was high all day. I mean, I know you mean well, but it's just pointless.
EDUCATOR
OK, I'm sorry to hear that. Could you just remind me what it was you said you would try last night?
OLGA
Well, we said if I was going to have supper, I should have some insulin with it.
EDUCATOR
OK, I think there was something else as well. What was that?
OLGA
OK, so we said I would check the BG in the night. I did, and it's just as bad in the morning. I mean, this is why I need a pump. It's just not working for me.
EDUCATOR
OK, so you're not happy with the numbers. What does everyone else think?
FRED
They look all right to me. They're not that bad. Better than mine, anyway. Apart from the 18 in the morning, they're all really steady.
OLGA
But then it went up overnight.
EDUCATOR
OK, well it sounds like that's the part of the day that you'd like to focus on for now. Shall we have a little look and see what's happening? Olga, can you please talk us through what happened between 10:30 last night and breakfast time this morning?
OLGA
OK, at 10:30 I checked, and they were 10.5. I had two CPs and took two units of insulin. I set the alarm at 3:30, 13.5. And this morning, 15, nightmare.
EDUCATOR
OK, so based on previous experience, what's a positive about your BG overnight? What hasn't happened since Monday?
OLGA
Well, I haven't had a hypo. But that doesn't mean I won't. I know how this happens.
EDUCATOR
So a positive is that you're using insulin in a new way. And, so far, you haven't had a hypo overnight this week. Looking at supper, what were the CPs there?
OLGA
Well, same as the night before. I had milk and biscuits, and they were the same.
EDUCATOR
And how did you work out the CPs for that?
OLGA
OK, I looked at the packet, 10 carbs. That's one CP. My glass of milk was a half pint, so that's half. I rounded it up to two, two CPs.
EDUCATOR
OK, so you rounded it up by half a CP. And how did it feel taking QA with supper?
OLGA
Well, odd. I've always eaten before to stop my BG dropping overnight.
EDUCATOR
Way back, we used to tell everyone to eat supper. That's quite a common thing to do. Who else, here, still does this?
FRED
I did. Then yesterday, when we talked about how insulin works, I thought, perhaps, I don't need to anymore. Maybe you don't either.
OLGA
Well, you're you, and I'm me. And everyone's different.
EDUCATOR
You're right, everyone is different. And that's why we need to work out what the right amount of insulin is for each individual person. That's why the course takes five days. So Olga, you've been trying lots of different things since Monday. So perhaps some of the things that were happening before might not be happening now. Did your BG drop overnight?
OLGA
No, it went up.
EDUCATOR
So what used to happen isn't happening at the moment. Thinking about the effect one CP has on BG, if you had those CPs without QA, what would happen to your BG?
OLGA
Well, it could have been even higher by this morning, maybe even 20, I suppose.
EDUCATOR
OK, so looking at what did happen, what do you think caused the rise?
OLGA
Well, I'm not sure. You tell me.
EDUCATOR
Fred, you mentioned yesterday's session on insulin. What do you think?
FRED
Well, if that was me, I'd think maybe my basal insulin wasn't high enough. The QA I'd take with supper would last about four hours we said. So by then, that's gone. So we've just got the BI working then.
EDUCATOR
And what does everybody else think?
[AFFIRMATIVE REACTIONS]
OLGA
So, QA with supper finished about 2:30. It's risen anyway despite the QA and rises even more by breakfast.
EDUCATOR
OK, so if we look at the stepwise approach in the workbook, Olga's identified the problem. Her BG is rising overnight. What about the other causes, Olga?
OLGA
Nope, no carbs, no alcohol. I didn't fancy taking extra as well as carbs, and my sites are OK.
EDUCATOR
OK, and do you think there's a pattern over 48 hours?
OLGA
Well, I suppose there is. It went up on Monday night as well.
STEVE
Yes, but you had two CPs without QA. That could've put you up by six.
EDUCATOR
OK, and what could help you decide that your BI at bedtime, you needed to change?
OLGA
OK, I suppose I could do the same again – have QA with my supper or just not have supper. I suppose I don't need it to keep my BG up. Oh dear, 3:00 a.m. again to do my checks, great.
EDUCATOR
And what does everyone else think?
[AFFIRMATIVE REACTIONS]
EDUCATOR
OK, Olga, it sounds like you've come up with an action plan for tonight. You just jot that down in your diary, and we might come back to it later. So your plan is to check the BI you take before bedtime by doing a 3:00 a.m. check. How do you think the changes you make are going to help you achieve your goal?
OLGA
Look, my goal is to get a pump. I really don't see how this is going to help.
EDUCATOR
OK, so we talked a little bit about pumps yesterday. When you use a pump, you still have to check that your basal insulin is right by doing checks through the night. The way we use insulin at DAFNE is very similar, so this may well help you in the future. Thank you very much, Olga.
Fred, shall we move on to your diary next?
End transcript
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Which educator behaviours can you observe to manage the challenging behaviour, focus on the positives and involve the group?

If you need to refresh your memory about educator behaviours refer to ‘Educator behaviours that demonstrate the DAFNE philosophy [Tip: hold Ctrl and click a link to open it in a new tab. (Hide tip)] ’, which is available in the resources area

Record your observations in your workshop pack.

Reflect on what you have observed. What will be different for you when you are in the room delivering face-to-face DAFNE courses? What might you have done differently? Record your reflections in your workshop pack.

Bring your observations and reflections to the workshop. You will have an opportunity to discuss them there.

Teaching tip

As in Remote DAFNE, for many people with type 1 diabetes, a face-to-face DAFNE course is the first opportunity they have had to spend time with a group of people who share their experience of living with type 1 diabetes. There can therefore be a strong need to share.

Some educators feel that the time allocated to deliver DAFNE sessions is longer than that required to deliver the content. Remember: session delivery is not just about covering the content. It is about allowing people to share their experiences, and to support and learn from each other.

Many people with type 1 diabetes have maintained a level of Glucose management that they find acceptable with little support or input from healthcare professionals. Presenting them with a new way of managing their Glucose can seem like a criticism of past practices. People can be afraid to change what they perceive has worked for them for a long time. You may find face-to-face facilitation more challenging because the feeling and emotions of group members may have a more direct effect on the group, on you, and on the atmosphere in the room.

A non-judgemental approach is key to keeping teaching of DAFNE principles neutral and not personal. It is important to explain that DAFNE is just a different set of tools for managing Glucose. As in all areas of life, innovation gives us choices that have associated benefits. Trying a different approach is not a one-way process – they can always go back.

Scenario 2: Talkativeness

Summary