Gladys developed type 2 diabetes at age 58. She was concerned when the doctor told her to go to the local diabetes education center (DEC) to learn about diabetes because she had never done well in school. In fact, she disliked school and did not want to get back into a school setting. The DEC secretary told her she would be there for about 2 hours and that she would be with a small group of people who had also just been diagnosed with diabetes.
When Gladys arrived and saw the Conversation Map on the table, she thought, “Oh, it's a game.” The educator explained that it was not a game, but rather a tool to help stimulate and focus discussion. Although the group started out very quietly, Gladys found that after the first few questions, she and the others were all interacting. She discovered that she actually did know some things about diabetes, but she also realized she learned many new things. One woman in the group lived near her, so they decided they would go for a walk together on the weekend.
At the end of 2 hours, Gladys said, “That was a nice way to learn about diabetes. I was afraid we were going to be lectured at and told what to do. I met people in the same situation and who have the same worries I do. It was good to see that I am not alone.”
Conversation Maps: What Are They?
Conversation Maps are tools used to generate discussion and encourage self-reflection and sharing of the experience of living with diabetes. They are not a game, but they do provide a visual platform to engage participants and allow them to discover facts about diabetes for themselves. Conversation Maps are usually used with small groups led by a facilitator who may be a diabetes educator. The Maps have been designed on sound educational principles. They are designed to represent surroundings that are familiar to the participants, for instance, a busy street or a park, making the discussion meaningful for the participants, an important condition for learning.1 The questions used to start a discussion ask participants to relate their understanding of or experiences with different aspects of diabetes management,thus acknowledging their past experiences and defining the base on which the ensuing discussion will build new knowledge. Perhaps more than any other learning principle, discussion leads to the presentation of useful, practical information, as most of it comes from other participants, not the educator.
The constructivist view of learning describes learning as knowledge construction; people put together knowledge by incorporating their new experiences into what they already know.2 The Maps provide people with the opportunity to share experiences with others in the same situation, and although this is not actually living the experience, it allows people to share experiences vicariously. Together the participants talk through their ideas and challenges related to managing diabetes with peers and the facilitator.
Development of Conversation Maps in Canada
The development of Conversation Maps in Canada started in 2004 after several educators saw how the Maps were used in business organizations and thought they could be adapted for use in an educational setting. These educators approached the Canadian Diabetes Association (CDA) with their idea. A team of educators selected by the CDA worked with the development company,Healthy Interactions, Inc., to develop the first Maps. Subject matter experts(SMEs) met several times with an artist-and-writer team to decide what material should be covered and to what extent in each Map. It was decided that, initially, two maps would be developed for people with type 2 diabetes,one called Starting Your Journey and the other called Continuing Your Journey.
The Maps were piloted in several DECs in different parts of the country. The results were very positive; people with diabetes were interviewed after the pilot sessions and reported that they liked learning in this manner, liked the discussion, liked sharing, and found that they learned a great deal. The educators who conducted the pilots were also interviewed after the sessions. They reported that it required different skills from those needed for traditional teaching. The role of the facilitator was to ask questions and listen to the participants discuss issues among themselves. The educators found it difficult not to jump in with the answers, to hold back and let the participants come up with answers on their own, but they said it was fun to see the interaction and witness people learning from one another. The educators reported that leading a Map session required them to have good facilitation skills, and, for most, this meant asking more questions,listening more, and talking less.
In preparation for writing this article, an e-mail was sent to educators in the author's address book; hence the comments below are from a small convenience group. The question asked was: “Re: Conversation Maps: As we have not done any research (on the Maps)... I thought I would e-mail everyone on my address book to see if anyone is using them. If you are, could you tell me for whom, how often, whether you changed your program to accommodate them,or did they fit, etc. If you have a set and have never used them, please tell me that as well... or if you didn't like them. Many thanks.” The e-mail was sent to 43 educators; a total of 15 responded (34.8%).
These comments may or may not reflect the experience of the 600 educators who were trained to use the Maps, but they probably do reflect the range of reactions (i.e., from reports of never using the Maps and not liking them, to reports of using them frequently and loving them.
The first two Conversation Maps were introduced to Canadian diabetes educators in October 2005 at the annual conference of the CDA. It was felt that educators needed training in the purpose and use of the Maps to use them as they were intended. The Maps present a new role for most educators—that of a facilitator rather than just a dispenser of facts.
A core group of experienced educators were trained as trainers and a 2-hour class was developed and offered in cities across the country. The response from educators was better than expected. Within weeks of the postcard invitation being mailed, ∼ 600 of a possible 2,000 educators had signed up for training. In early 2006, ∼ 600 nurses, dietitians, pharmacists, and other health care professionals were trained and given Maps to use in their education settings.
Why Training Is Necessary
When using the Maps, educators' role changes to one of a facilitator. The Maps work best when patients answer each others' questions and work through a topic from their own perspective. Educators are there to ensure that information shared within the group is correct and that the solutions arrived at are within the context of the experience of the people attending. In the words of educators,
As a facilitator, it was hard to restrain myself from giving the correct information right off the bat instead of letting the group work through the different stations in their own way. It was interesting to hear the points that they brought up, as I did not always anticipate just what they were thinking. (Educator L.H., via e-mail, 16 October 2007)
As the educator, it was hard not to jump in with advice and to hang back and see what the participants were able to come up with. (Educator D.G.,via e-mail, 17 October 2007)
After using them several times (Maps), my personal opinion is that they can be a great tool for review and to initiate discussion, but they need to be used by a skilled facilitator and experienced diabetes educator. I think our last team had a problem because they are new educators currently sticking close to the lesson plans. When a client asked questions outside the box,which the Map stimulates you to do, they had difficulty retracking. (Educator G.M., via e-mail, 24 October 2007)
Some educators have commented on how the facilitator role changed their own outlook or the response of patients.
I found it professionally rewarding to interact with the RD [registered dietitian] during the session to see their perspective as well as feel valued for my role as the RN [registered nurse]. The role of the educators as facilitators builds further trust in the client/health care professional relationship, which I have seen bring about perhaps questions that they might not have asked in a different setting (e.g., individual session). (Educator J.G., via e-mail, 16 October 2007)
Integration Into Practice
Approximately 8 months after the training, a 40-question survey was e-mailed to 568 educators who had completed the training. No incentives were offered for completion. The response rate was 21% with 9 of the 10 Canadian provinces represented. Forty-five percent of those answering said they had used the Maps. About half the respondents were nurses, one-third were dietitians, and the rest were pharmacists or other health care professionals.
When asked about their overall satisfaction with the Conversation Maps, 92%of educators using the Maps reported being satisfied or very satisfied. Eighty-seven percent rated their patients' overall experience as good or excellent, and 88% rated their overall experience facilitating as good or excellent. Eighty-five percent reported that the Conversation Maps made group teaching more interactive and engaging. Ninety percent felt that their patients were able to incorporate the information in the Conversation Maps into their diabetes management.
They have been most helpful with those clients who have had diabetes for 3–5 years and for those of long standing with diabetes. The sharing is a joy to behold. It can meet the adult education needs in real time, as the session takes place. For those who have shared, I have seen a buildup of confidence as they relate their ability to control what they can, sharing what works and what doesn't work. (Educator J.G., via e-mail, 16 October 2007)
I really enjoyed the interaction the tool facilitated and thought it was of great use in that setting. Many of our clients had attended groupprogramming in the past. It built on their existing knowledge and really drew out the crowd, including someone who couldn't read. The classes really took on a life of their own. I used it in place of my What is [Diabetes]?session. (Educator K.T., via e-mail, 16 October 2007)
Most certainly I have seen those clients who have perhaps gotten“stuck” in the place they are with their diabetes look at their diabetes from a different perspective because of something someone at the session has disclosed. (Educator J.G., via e-mail, 16 October 2007)
More than half of the educators (60%) had integrated the Maps into their current programs. Twenty-seven percent were creating new programs based on the Conversation Maps.
Following is an example of how the Maps have been integrated into an existing program.
In the K—program, we have incorporated them into two classes. In our initial education series (two classes), we use them in class 1.We also use them in our follow-up groups. These are for clients who would like a refresher session or just need a general update. We have three sites in our program and run the initial classes four times a month. The follow-up groups occur monthly. We selected them as tools that fit our program needs and move the clinicians away from didactic group sessions. (Educator J.E., via e-mail, 15 October 2007)
For the last year or more, I have been using the Conversation Map at both [local centers]. We find that the Maps promote discussion between individuals. It also allows for more efficient use of time and the center gets a “bigger bang for their buck.” (Educator L.C., via e-mail, 16 October 2007)
Two Years After Launch
There have been no further surveys or research conducted on use of the Conversation Maps in Canada since October 2006. Of the nearly 1,000 Maps distributed, we do not know how many are being used or how many are sitting in cupboards. Anecdotally from those who are using the Maps, there have been some negatives as well as many positives.
It is difficult to say why some have had a negative experience using the Maps without actually being there to watch the interaction. One wonders if perhaps they did not assume the role of facilitator or perhaps had misgivings that were inadvertently communicated to the participants and therefore influenced their participation.
We realized that it didn't “fit” our basic program; for one thing, we would have had to change our whole curriculum to include it, and we also know that at a first visit people are not always comfortable about discussion as a learning mode. A second try met with a group that just wouldn't open up, possibly for fear that they would be showing their ignorance. (Educator C.L., via e-mail, 15 October 2007)
Perhaps some negative comments stem from a problem with structure and a reluctance to revisit program design to integrate the Maps.
We were all excited to use them and loved the idea. Then under new management, we ended up redoing all of our classes into short modules—after that process, we lost momentum to use the Maps. We know they are a great idea and certainly have their place in diabetes education. You got me thinking we should be revisiting this. (Educator D.P., via e-mail,17 October 2007)
... my bias is that I have a better comfort level using traditional methods. (Educator C.P., via e-mail, 17 October 2007)
Other negative impressions may have been the result of simply not having room for such a group discussion in some settings, such as a pharmacy, or that the groups are just too big.
I have a set, but I don't do a lot of group teaching, plus I don't have the space to use them properly either. (Educator A.K., via e-mail, 15 October 2007)
Perhaps one of the most limiting factors of these Maps, and the predominant issue at our center here, is that the size of the audience must be limited in order for all clients to see/read the Map and engage in it simultaneously. We teach groups of eight registered clients, each of whom can bring a guest as well, taking group size up to 16. I find the Maps are ideal for no more than approximately six people at a time. (Educator M.C., via e-mail, 17 October 2007)
In October 2007, two more Maps were launched to Canadian educators: the first for people starting or recently starting insulin, and the second for children age 9–12 years and covering acceptance of diabetes in the family and how to tell friends, neighbors, and other key people in a child's life.
In March 2007, we trialed the Insulin Conversation Map and I found this to be my best Map experience of all. Despite this, however, we have not yet changed program scheduling here to enable use of this Map, as clients on insulin continue to see educators individually (old habits die hard?).(Educator M.C., via e-mail, 17 October 2007)
There has been a good deal of excitement about the Maps in Canada. However,for the Conversation Maps to continue to be used, it will be necessary to collect some evidence of their value in the education process. Other than at the very beginning, there has been no formal collection of feedback from patients who have been through Map sessions. Studies of this nature are needed to show that the Maps have a place in educators' toolbox. Traditional education methods will, of course, continue. However, new approaches are needed that will help educators see the value of integrating different methods into their programs to best meet the needs of their patients.
Conversation Maps in the United States
Based on the positive experience in Canada, the American Diabetes Association (ADA) and Healthy Interactions, Inc., launched a series of five U.S. Diabetes Conversation Maps at the ADA Annual Meeting and Scientific Sessions in June 2007. The U.S. Maps were adapted from the Canadian Maps by diabetes nurse and dietitian educator experts and a person who has diabetes. The five U.S. Maps cover the following topics:
Diabetes and Healthy Eating
Blood Glucose Monitoring
Natural Course of Diabetes
The revisions are consistent with ADA guidelines and address behavioral and psychosocial issues, as well as clinical content.
The plan is to train U.S. educators during the next 3 years. This effort will also include a website to support health care professionals who have been trained to use the Maps and a website for patients and their family members who have experienced a U.S. Conversation Map education session. Training is available free of charge, and educators who attend the training will receive copies of the Maps. More information about training is available on the Healthy Interactions website(www.healthyi.com).
Anne B. Belton, RN, BA, CDE, is a diabetes education consultant working independently in Calgary, Alberta, Canada.
Note of disclosure: Ms. Belton is an SME for the development of the Conversation Maps in Canada and has received honoraria for serving in that role and for speaking engagements related to the Maps development process from Healthy Interactions, Inc.