S Kalra, B Kalra
S Kalra, B Kalra. A Good Diabetes Cousellor ‘Cares’: Soft Skills In Diabetes Counselling. The Internet Journal of Health. 2009 Volume 11 Number 1.
Counseling is an integral part of diabetes management, and impacts the success of therapy in one way or the other. Many authors have reported the beneficial effect of diabetes education on various aspects of clinical care (1,2).
Quality Of Counselling
Keeping this in mind, many countries have developed efficient system for training and registration of qualified educators. Regulatory and advisory bodies such as the American Association of Diabetics Educators and the Diabetes Education Study Group (Europe) monitor the quality of education by recommending minimal/optimal guidelines which centers try to follow.
Many countries, however, lag behind. While most diabetologists in underserved countries have accepted the need for focused diabetic counselors, they are hampered by the lack of qualified staff. This means that anyone who is ‘willing’ or ‘available’, whether a clinical nurse or a dietician, is taken as a diabetes care team member. He or she is taught a few rudimentary facts of diabetes, and given the label of educator.
Surprisingly, this approach works most of the time! But just as clinical mistakes (misdiagnosis or mismanagement) lead to hard casualties (avoidable morbidity, mortality); counseling mistakes lead to soft casualties.
Soft causalities include examples such as patient not following a suggested therapeutic intervention or refusing to initiate insulin. At times, counseling mistakes lead to financial causalities: the patient decides to go doctor-shopping; to the doctor next door! These mishaps are what diabetologists worry about most of all!
Hard Skills In Counselling
One way of minimizing these mistakes is to ensure efficient and effective diabetes counseling. Initial and continuing medical education, as well as aggressive ‘on-the-job’ training, is necessary to teach hard skills to educators and counselors.
Hard skills include the basic scientific knowledge or competence levels required to run a counseling service, e.g. dietetics, insulin adjustment.
Soft Skills In Counselling
The limiting factor, however, in counselling efficiency, is transfer of knowledge from educator to patient, in a way that the patient accepts it, follows it, and internalizes it.
The way by which this transfer is done efficiently and smoothly is through use of soft skills (3).
A few attributes are essential to the success of a high quality counselling service. The acronym CARES has been coined at Bharti Hospital, Karnal to list these properties that a counsellor needs to internalize (Table 1).
These attributes are discussed in detail below. They include, under five ‘labels’, most of the soft skills necessary for counselling. The use of ‘labels’ helps in teaching them to one’s staff, in assessing the quality of soft skills, and in using them as bench marks for improvement in counsellor behaviour.
C: Confident Competence
Scientific competence is a pre-requisite for any counsellor. He or she should know his or her subject in detail, and should remain in touch with the latest developments in the field.
The art, however, lies in conveying this competency (hard skill) with confidence (soft skill). A positive body language (direct eye contact, warm smile, straight back, open arms, forward leaning posture) radiates strength and security from the counsellor to the patient. A friendly, resonant voice with pitch modulation, along with non-verbal gestures completes the picture of confidence.
This type of counselling will be more successful than a scientifically loaded, jargon-filled lecture by an ‘academic-looking’ educator who mumbles the words while looking out through the window or while trying to stifle yawns.
Confidence should not be confused with boasting, e.g. “I just returned from the AADC conference” is not as good-sounding as “I’ve just updated my knowledge on pregnancy”.
A : Accessible Authenticity
Effective counsellors must be accessible. Patients shy away from ‘superior’ educators who maintain an aloof or distant manner They feel more comfortable with normal-looking, normal- behaving health care professional from a similar cultural background.
An open-door policy is preferable, in which an OPD client or indoor patient can meet the educator any time to discuss his or her problems and concerns.
Authenticity is a soft skill, which means genuineness, trustfulness, honesty. If the counsellor smiles, it should be full of warmth, if he or she frowns, it must be as actual response to some stimulus, or the non-verbal equivalent of a ‘diplomatic confrontation’
In case, the educator happens to yawn, he or she should apologize, mentioning the reason for yawning, and clarifying that it is not a sign of boredom.
The diabetics care provider should be able to convey her humanness and concern to the patient. The diabetic should not feel that he or she is being treated as an assembly- line product.
R: Reciprocal Respect
No relationship can be successful if the emotions in it are not reciprocal. For example, a one-sided love affair will always end in tragedy.
The counsellor-patient relationship is no exception. Mutual respect is essential if this relationship is to be effective. There is little point in spending energy on counselling a patient if he does not respect or appreciate the educator, because of age, gender, socioeconomic status or ethnicity. It is better, then, to defer detailed counselling until the patient has gained confidence in the health care setup.
Similarly, the counsellor, through his or her body language, should convey respect for the patient. Behavior should neither be arrogant, nor should it be deferential.
Age-specific and gender-specific body language should be used to convey a sense of professionalism, tempered with caring for the diabetic. The patient should not feel that he or she is looked down upon as an ignoramus. He or she should feel that he or she is in charge of his disease, and its treatment. The counsellor should come across as an equal partner in the fight against diabetes, who is willing to ‘listen actively’ and not a one who wants to force his or her views upon the patient.
E : Expressive Empathy
S: Straightforward Simplicity
Diabetes counselling is a neglected science in many countries. But, the soft skills necessary for counselling are even more neglected in virtually every part of the world. This leads to a lot of easily avoidable psychological and physical morbidity (4).
Is it because soft skills are not written in books? Or are difficult to attain? Even more difficult to teach? And very difficult to assess? If so, it gives us even more reason to work harder at this field of diabetes management. We must ensure that we and our educators equip ourselves with this knowledge, so that we can communicate properly with our patients and help them in their fight against diabetes.
This paper has tried to set a framework of soft skills which can be used for teaching, assessment and further improvement of counselling services throughout the world.