Volume 23, Number 2 - July 2020

Thinking Outside the Box: Incorporating Flexibility into Diabetes Education

Kristine Wright

Bsc(ed), DippAppSc(Nsg),RN CDE

Canberra Hospital

Credentialled Diabetes Educator. A/g CNC paediatric and adolescent diabetes service

Kristine is a Credentialled Diabetes Educator/ CNC with the ACT Diabetes Health Service, The Canberra Hospital; until recently the Chair for the ADEA ACT Branch and Diabetes Educator of the year for 2017. Kristine has a background in Nursing with a majority of that experience within the Emergency Department setting. Currently Kristine is working in the paediatric diabetes service, supporting children and their families.



What does it mean to think outside the box? The Collins dictionary defines it as:

“To think in a different, innovative, or original manner, especially with regard to business practices” 1.

As health professionals and diabetes educators, I believe that we consider the needs of our clients and their families when working with them. This pushes us to think creatively and be innovative in our approach.

Our ability to think creatively and innovatively in our practice can be seen in our ever-changing models of care. Our models of care should adapt to the needs of our client base in light of current research and the demand made on diabetes services by government initiatives and key stakeholders.  With the current climate we find ourselves in due to the COVID-19 pandemic, I believe that we will need to continue to be creative in our practice and possibly more so when supporting our clients in the future.

Models of care support the way in which we conduct our day to day business of providing education to those with various types of diabetes. To be innovative in our approach we need to think creatively and look to support our clients’ differing needs and learning abilities. Within the adult arm of the Canberra Health Diabetes service we required a model of care that would increase interaction and knowledge of clients with type 1 diabetes (T1D) using continuous subcutaneous insulin infusion therapy (CSII).

Model of care

Models of care are established to provide best practice care for a group of people with a particular health condition. To be successful, models of care must provide relevant care at the appropriate time with the right health team and in a place that is conducive to learning2.

With these principles in mind the development of the ‘Pre-Pump Upgrade Discussion Group’ was initiated. It became clear after conducting a pilot study in adults on insulin pump therapy attending our service, that most were not fully versed on how to use their insulin pumps3. The cross-sectional study involved the development of a new questionnaire to evaluate participants knowledge and management strategies related to insulin pump therapy. More than fifty people with type 1 diabetes aged between 17 -70 years who attended the ACT Diabetes Health (adult) Service on CSII over a 12 month period were included.

The study found that most clients did not use the ‘advance features’ in their pumps, have knowledge on how to manage sick days, or adjust their insulin pump settings based on analysis of downloaded insulin pump data although they visited their endocrinologist three or more times per year and  a diabetes educator up to twice per year3.  The multivariate logistic regression analysis indicated that better CSII management (based on how much interaction they had with their pump) equated to better glycaemic management (reduced HbA1c and frequency of hypoglycaemia). To help address this, we established a new model of care – A multidisciplinary facilitated Pre-Pump Upgrade Discussion Group for adults with T1D.

Peer led Pump Upgrade Discussion Group

Research suggests that peer led self-management education programs have a positive effect on self-management skills, confidence and health-related behaviour4. We therefore decided to trial a similar approach with our clients on CSII therapy, while also involving health professional facilitators.

The target group consisted of clients who attended the Canberra Health (adult) Diabetes Service due for an upgrade of their insulin pump. We felt this was an opportunity to capture a group of clients who had at least four years’ experience on CSII and were a cohort of people easily targeted to attend an education session. The discussion group was considered a mandatory part of the insulin pump upgrade process.

The main features of the discussion group, allowing it to be a useful model of care are:

  • The multidisciplinary approach which allows for health professionals from different disciplines (in this case diabetes educator and dietitian) to work together to provide support that addresses many aspects of diabetes management when using CSII.
  • The education group is peer led with a focus on sharing of knowledge between adults who are experienced in using CSII.
  • Providing a respectful environment in which to share knowledge and experiences.
  • Using adult learning principles.
  • Health professionals facilitate the group sessions to ensure any information shared is considered best practice.

Initial evaluation (unpublished), completed at the conclusion of the new group, was overwhelmingly positive. When asked what they liked most about the group, participants reported that they enjoyed:

  • the sharing of experiences and talking to other pump users
  • the informal and relaxed style of the group/open discussion
  • learning new things
  • the opportunity to reinforce their knowledge with real world learning instead of textbook teaching

Further to this, participants unanimously found that the group was conducted in a format conducive to their learning and 70 percent felt that their diabetes management strategies may change as a result of attending the group. Most clients acknowledged that they hadn’t really wanted to attend an extra appointment but found that the session was conducted in a way that was valuable. It allowed for an update of their knowledge when dealing with food choices, sick day management, exercise, travel, adjustment of insulin settings and other areas of diabetes management in an environment that was non-judgemental or threatening. By using a discussion group format, health professionals were able to respond more effectively to the needs of this client group, which will hopefully empower the participants to be more engaged in the self-management of their diabetes.


With the advent of new CSII devices, we anticipate that different topics and messages will be delivered in future groups. However, the underlying concept of sharing information and ensuring that best practice advice is provided in peer led education groups facilitated by multidisciplinary health professional teams will continue to be valuable.



Think outside the box definition and meaning | Collins English Dictionary [Internet]. Collinsdictionary.com. 2020 [cited 29 March 2020]. Available from: https://www.collinsdictionary.com/dictionary/english/think-outside-the-box


Type 2 Diabetes: Model of Care tool Kit [Internet]. Sydney: The National Association of Diabetes Centres and the Australian Diabetes Society; 2019 [cited 29 March 2020]. Available from: https://diabetessociety.com.au/documents/MOC-with-links.pdf


Wen, W., Frampton, R., Wright, K., Fattore, S., Shadbolt, B. and Perampalam, S., 2015. A pilot study of factors associated with glycaemic control in adults with Type 1 diabetes mellitus on insulin pump therapy. Diabetic Medicine, 33(2), pp.231-234.


Harvey P, Petkov J, Misan G, Fuller J, Battersby M, Cayetano T et al. Self-management  support and training for patients with chronic and complex conditions improves health-related behaviour and health outcomes. Australian Health Review [Internet]. 2008 [cited 29 March 2020];32(2):330. Available from: http://file:///Users/admin/Desktop/Kristine/CSIRO%20PUBLISHING%20%7C%20Australian%20Health%20Review.webarchive

Other Articles in this Edition