Impacts of “Diabetes Theater,” a participative educational workshop for health care professionals, on participants: a patient empowerment perspective

Abstract

Introduction

Patient empowerment, as part of patient-centered care, is important in the treatment of diabetes. However, this concept is still not well-understood by healthcare professionals, because it differs substantially from traditional approaches. We developed the “Diabetes Theater” workshop to promote a better understanding of patient empowerment. The present study sought to characterize the learning experience and impact of Diabetes Theater on participants’ perceptions regarding patient empowerment.

Methods

We analyzed the data using mixed methods. Quantitative data were collected using a questionnaire with a five-item, 11-point Likert scale derived from the Diabetes Attitude Scale. The qualitative component asked the question “If you had to tell your colleagues at work two things you felt or learned at the Diabetes Theater, what would they be?” Quantitative data were analyzed using t tests, and free-text responses were analyzed using Steps for Coding and Theorization.

Results

We received 131 responses. Nurses were the most numerous respondents, followed by dietitians, physicians, and pharmacists. Scores for the five items after participation increased in the direction of promoting participants’ understanding of and attitudes toward patient empowerment compared to pre-participation. Scores for most questions increased significantly, regardless of the participants’ occupation. In their answers to the open-ended questions, participants reported that they had learned about patient empowerment.

Discussion

Diabetes Theater appears to be a useful method for healthcare professionals to accurately understand the philosophy of patient empowerment in diabetes.

Introduction

The concept of patient empowerment has developed in recent years, and is now widely considered to be important in diabetes care [1, 2]. According to this concept, the role of healthcare professionals is to empower the patient with diabetes, respecting and supporting the patient’s autonomy. The authors, Anderson et al. stated that self-care by patients accounts for a large part of the treatment of diabetes and strongly influences the outcomes of the treatment [1]. Therefore, it is important that patients themselves take the initiative to improve their care and cultivate their problem-solving abilities. In addition, healthcare professionals must provide patients with the necessary information, establish partnerships, and work together. This concept of patient empowerment is supported by healthcare professionals worldwide, especially in the United States [3]. However, some researchers have argued that the essence of patient empowerment is not fully understood by some healthcare professionals, who have traditionally learned “how to get patients to behave in ways that are desirable for their health,” using approaches that improve patient compliance and adherence rather than empowerment [4].

Programs involving theater have been reported to be effective for educating healthcare professionals. For example, Kumagai et al. [5] reported that participants’ insight into multicultural issues was deepened after engaging in a workshop involving interactive theater in a medical faculty. Participants reported that the method of combining theater with discussion in the education of medical personnel permitted them to improve not only their knowledge and skills but also their attitudes toward social issues [5]. In addition, Ünalan et al. [6] reported that medical students understood more when lectures were given using theater than when given without. Specifically, they found that students who were educated with the use of theater were able to understand the lecture content more easily and remembered it for longer [6]. Thus, the use of theater in medical education appears to make concepts easier to understand and facilitates long-term knowledge retention. In addition, the combination of theater and discussion enables the exchange of a variety of opinions and deepens understanding.

The “Diabetes Theater” workshop was developed to help healthcare professionals learn about patient empowerment in diabetes [7]. This program is a workshop-style discussion group that consists of a theater performance and discussion. The play performed is based on a scenario involving a common problem in diabetes care, such as a conflict between a medical practitioner and a patient, and the audience of healthcare professionals discusses the play to deepen their own thinking. The play was first performed at the 52nd Annual Meeting of the Japan Diabetes Society in 2009. Since then, it has been performed more than 60 times in various parts of Japan, with each play involving a different scenario. Onishi et al. [8] describe Diabetes Theater as an educational session in which the relationships between healthcare professionals and patients in the context of educating patients with diabetes are dramatized to depict the real-life interventions that are frequently performed by healthcare professionals and to make participants aware of conflicts that may arise with patients. However, according to Anderson et al., there have been few reports regarding programs in which healthcare professionals involved in diabetes care learn about patient empowerment [9]. Therefore, the purpose of the present study was to determine the impact of Diabetes Theater on participating healthcare professionals in terms of their knowledge and attitudes regarding patient empowerment.

Methods

We used a mixed-methods design for the present study and collected data using a questionnaire. The Diabetes Theater “Waiting edition” was performed at the 57th Annual Scientific Meeting of the Japan Diabetes Society in 2014. A questionnaire survey was administered to the participants in the Diabetes Theater immediately after their participation.

In the questionnaire, participants were asked to indicate their age, occupation, sex, qualifications, and the number of times they had participated in the program. In addition, they were asked to rate their attitudes regarding diabetes on the Diabetes Attitude Scale developed by the University of Michigan Diabetes Research and Training Center (University of Michigan, 1998). Five questions were selected from the Diabetes Attitude Scale and translated into Japanese, as shown in Fig. 1 [10, 11]. The number of items in the questionnaire was carefully selected in consideration of the burden on respondents. In addition, the items were selected through discussions with experts (i.e., Diabetes Theater staff), who were experienced in diabetes care and treatment guidance, comprising a multidisciplinary team.

Fig. 1.

Relationship between the questions posed and the theories identified

According to Anderson and Funnell, the Diabetes Attitude Scale has a five-factor structure [10]; the subject of questions 1–4 is “the need for special training in education” and that of question 5 is “attitudes toward patient autonomy,” as derived by factor analysis [10]. Using an 11-point Likert scale ranging from 0 to 10 for each question (0: not at all disagree, 5: neither agree nor disagree, 10: strongly agree), we investigated the attitudes of the participants in the Diabetes Theater before and after their participation. We also included the open-ended question “If you had to tell your colleagues at work two things you felt or learned at the Diabetes Theater, what would they be?”

This Diabetes Theater was conducted over 90 min. The theme was “Waiting” and the main character was a 62-year-old woman with type 2 diabetes, diagnosed 20 years ago. In the storyline of the play, the main character’s husband passed away 10 years ago and she currently lives with her divorced daughter and granddaughter. She knows that the reason for her poor blood glucose control is that she eats sweets made by her granddaughter, because she feels guilty refusing them. In Act 1, a conference with the physician, nurse, and dietician takes place, and a proactive team intervention policy is decided upon. In Act 2, the nurse makes a series of dietary and exercise suggestions, including a ban on snacking. In Act 3, the dietitian asks the patient about her feelings and thoughts, and together they work out a solution. In Act 4, the dietician and patient meet by chance at a bus stop and wait for the bus together. In the discussion between acts, the following questions were discussed: “Which of the medical professionals in the play do you most strongly identify with, and why?”, “Which aspects of each medical professional’s involvement do you agree and disagree with?”, “What was each medical professional waiting for?”, “What does ‘wait’ mean for the participants?” Participants exchanged their opinions under the facilitator’s guidance. The subject of the play was the differences in opinion between patients with diabetes and their physicians, nurses, and dietitians. Throughout this play, medical professionals were asked whether they thought it was important for them to wait until the patient realized what she needed to do to improve her condition.

SPSS v.27.0 (IBM Corp., Armonk, NY, USA) was used to analyze the quantitative data. The paired-sample t test was used to compare the scores before and after participation, and a one-way analysis of variance with Bonferroni’s post-hoc test was used to compare the responses among occupational groups (physicians, nurses, pharmacists, dieticians, and clinical laboratory technicians). P < 0.05 was considered to indicate statistical significance. The responses to the open-ended question were qualitatively analyzed using Steps for Coding and Theorization (SCAT) [12]. SCAT is a method that uses a four-step coding process to identify themes and constructs, which are then combined to create a storyline and theory. This method is applicable to the analysis of small-scale data, such as free-response questionnaires. SCAT is used to derive “theories” from the data that are collected and analyzed systematically and iteratively.

Results

There were 131 valid responses. Nurses were the most numerous respondents, followed by dietitians, physicians, and pharmacists. Most of the respondents were female, and many were in their 30 s and 40 s (Table 1).

Table 1.

Characteristics of the respondents

Variables	Overall n = 131
Age (years old)	n = 126
20–29	19 (15)
30–39	38 (30)
40–49	38 (30)
50–59	26 (21)
60–	5 (4)
Gender	n = 129
Male	15 (12)
Female	114 (88)
Occupation	n = 127
Physician	14 (11)
Nurse	65 (51)
Pharmacist	13 (10)
Dietitian	20 (16)
Laboratory technician	9 (7)
Others	6 (5)

Data were presented as the number (percentage) of respondents

Because other streams of the conference proceeded alongside the performance, the number of people who participated in the program until the end was < 400, and the questionnaire collection rate was estimated to be approximately 30%. A comparison of the scores before and after participation is shown in Table 2. There were significant increases in the scores for questions 1, 3, 4, and 5 during the performance, but not for question 2.

Table 2.

Scores for each of the questions before and after the performance

Question	1	2	3	4	5
Pre score	8.05	8.12	8.02	8.51	6.16
Post score	9.13	8.39	9.05	9.38	7.44
Pre/post differences	1.08	0.26	1.03	0.87	1.28
p value	< 0.05	0.08	< 0.05	< 0.05	< 0.05

One-way analysis of variance was used to compare the pre/post differences among the occupational groups for each question: p = 0.50 for item 1, p = 0.12 for item 2, p = 0.11 for item 3, p = 0.02 for item 4, and p = 0.15 for item 5. For item 4, Bonferroni’s multiple comparison test showed that significant differences existed between physicians and laboratory technicians, nurses and laboratory technicians, and dietitians and laboratory technicians.

Eighty-six participants responded to the open-ended question (nine physicians, 43 nurses, 10 pharmacists, 12 dietitians, six clinical laboratory technicians, and six other healthcare professionals). Qualitative analysis of the free-text responses using SCAT yielded the following theories: (1) healthcare professionals should improve their communication skills to facilitate interactive communication; (2) Healthcare professionals should provide medical care at the patient’s pace while trying to match the patient’s goals; (3) Healthcare professionals provide information and advice, but ultimately follow the patient’s decision-making process; (4) Healthcare professionals should help improve the patient’s understanding and wait for the patient to make a decision; and (5) Healthcare professionals should share information at conferences to communicate with other healthcare professionals (Table 3). Q1 and Q3 were related to (1), Q4 to (2), and Q5 to (3) and (4) (Fig. 1).

Table 3.

Typical comments for each theory on the free-text field

(1) Healthcare professionals should improve their communication skills to facilitate interactive communication

Communication is important to get the patient's thoughts and feelings out. (nurse in her 20 s)

One-way communication is not good. (nurse in her 40 s)

Healthcare professionals need to learn various communication skills. (laboratory technician in her 50 s)

(2) Healthcare professionals should provide medical care at the patient’s pace while trying to match the patient’s goals

Healthcare professionals should adjust to the patient's pace and wait. (nurse in her 30 s)

I came to the new realization that the goals of my patients do not have to be the same. (dietitian in her 30 s)

(3) Healthcare professionals provide information and advice, but ultimately follow the patient’s decision-making process

Do not impose your ideas on the patient. (nurse in her 30 s)

Allow the patient to decide, so that he/she can set goals. (nurse in her 20 s)

(4) Healthcare professionals should help improve the patient’s understanding and wait for the patient to make a decision

The patient has the right to make decisions, and healthcare professionals need to wait. (nurse in her 30 s)

It is crucial to wait for the timing when the patient thinks he/she can do something, while at the same time, it is also crucial to draw out the "can-do" power from the patient. (nurse in her 20 s)

(5) Healthcare professionals should share information at conferences, for example, and communicate with other healthcare professionals

Sharing information among team members is essential. (dietitian in her 30 s)

How can we organize a conference that allows people to have the same perspective on how they are feeling and what they are feeling? (psychologist in his 30 s)

Discussion

In the present study, we found that Diabetes Theater exerted a positive learning impact on participants’ perceptions of patient empowerment. The results revealed three main findings. First, we consider the impact of the Diabetes Theater. The Kirkpatrick model is sometimes used to evaluate the impact of educational programs [13] (Table 4). This model reflects the characteristics of medical education. Significant increases in the scores were identified for almost all of the items on the questionnaire. Therefore, the participants were considered to be in Step 2 “Learning” [14].

Table 4.

Kirkpatrick’s model

Step1-Reaction	How well did the conferees like the program?
Step2-Learning	What principles, facts, and techniques were learned?
Step3-Behavior	What changes in job behavior resulted from the program?
Step4-Results	What were the tangible results of the program in terms of reduced cost, improved quality, improved quantity, etc.?

Second, the content of most of the questions was included in the theories created on the basis of the qualitative data analysis. The questions were all related to patient empowerment, but in the theories, the participants wrote about what they felt and what they learned. These contributions suggest that the participants in the Diabetes Theater may have learned about patient empowerment, which was the purpose of the program. Third, there was little difference in the learning experienced by participants in each occupation category. This implies that Diabetes Theater was an effective means of learning for all types of healthcare professionals.

In general, we found that participating healthcare professionals changed their responses in the intended direction, reflecting greater knowledge regarding patient empowerment. A possible reason for the lack of a significant change in responses to question 2 is that the participants may have already been practicing this kind of behavior with their patients to some extent before participating in the program; therefore, their participation may not have had a significant additional impact concerning this question. It is possible that significant differences were only found between physicians and laboratory technicians, nurses and laboratory technicians, and dieticians and laboratory technicians in responses to question 4, because laboratory technicians had less experience in this area, which involves goal setting with patients during routine consultations [15–17]. A possible reason for the lower pre- and post-scores for question 5 compared with those for the other questions is the potential impact of the “socially desirable answers” bias. This is a bias, whereby respondents themselves have already recalled answers that are considered to be socially desirable and will respond to the more desirable answer even if it differs from their own opinion. However, it is difficult for this bias to explain the significant increase in scores of question 5 after the play; thus, we speculate that this increase in scores is likely to reflect an impact of the Diabetes Theater.

This study was conducted 9 years ago. During this time, trends in diabetes patient education have changed, and empowerment-based patient education programs have become prevalent in the US [3]. In Japan, a section on “empowerment” has been introduced in the Japanese Clinical Practice Guideline for Diabetes 2016 [18]. Therefore, it is possible that a similar study conducted more recently would yield different results. However, we believe that there is still a demand for Diabetes Theater activities, which continue to be held at national medical societies, including online at the 12th Annual Conference of Japan Primary Care Association in 2021 [19] and at the 66th Annual Scientific Meeting of the Japan Diabetes Society in 2023 [20]. In future, it may be necessary to reexamine the value and significance of Diabetes Theater and its current impact on healthcare professionals. In doing so, it may be possible to reformulate the Diabetes Theater in a more compelling form that incorporates the issues facing diabetes care today, and contribute to improving the knowledge and attitudes of healthcare professionals regarding patient empowerment in the current context.

The present study had several limitations. First, although we found that the workshop changed the thinking of the healthcare professionals who attended, we did not investigate whether this resulted in a long-term change. According to Ünalan et al., education through theater not only aids understanding [6], but also facilitates long-term memory. However, it remains to be determined whether the effects of the performance on healthcare professionals’ understanding persisted over time. Second, we did not assess whether the subsequent behavior of healthcare professionals when examining patients was changed. Thus, step 2 of Kirkpatrick’s model was achieved, but we did not determine whether steps 3 or 4 were achieved. Patients treated by oncologists who had participated in a communication skills training program were previously shown to be more satisfied with the care they received, whereas those treated by other oncologists were more depressed [21]. It is necessary to examine whether there is a similar impact in the Diabetes Theater. Third, because the respondents to this questionnaire remained present until the end of the session, it is possible that they tended to be healthcare professionals with a particular interest in patient education. Fourth, in this study, participants were asked to respond after participating in Diabetes Theater regarding their status both before and after participation. In this case, there may be a “bias regarding the measurement of change” on the basis of the implicit theory of change. This may have led respondents to believe that they must have an increased understanding of each element of patient empowerment after participating in Diabetes Theater compared with their pre-participation status. Fifth, the analysis of free-text responses was carried out independently of the content analysis of the question items. However, the question items and free-text sections were answered at the same time. It is, therefore, possible that the results of the analysis partially coincided with each other because of mutual influences at the stage of filling in the questionnaire. Sixth, it is unclear whether similar results would be obtained using other scenarios or with different participating medical personnel. Therefore, further studies will be needed to evaluate the results obtained with different participants, or when the scenario or number of participants differs. Finally, the Japanese version of the questionnaire was not previously validated.

Conclusion

The impacts of the Diabetes Theater workshop were studied using a questionnaire and a mixed-methods model. We found that participants’ understanding and attitudes changed in a direction that was consistent with the philosophy of patient empowerment after participation in the theater program. Therefore, Diabetes Theater was found to be a useful method for healthcare professionals involved in diabetes treatment to deepen their understanding of patient empowerment.

Author contributions

KO designed the study, and KO and RA analyzed the data. All of the authors were involved in the interpretation of the data and the writing of the manuscript.

Data availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available, because they contain information that could compromise research participant privacy.

Declarations

Conflict of interest

Kentaro Okazaki, Mina Suematu and Noriyuki Takahashi declare that their past (KO) and current (MS and NT) affiliations were established by donations from Aichi Prefecture and Nagoya City, Japan.

Ethical standards

The provision of answers to the questions was not compulsory and the questionnaires were completed anonymously. Therefore, it was determined that there was no need for an ethics review of the study. However, the purpose of the study was explained both in writing and verbally, and the participants were assumed to have consented to their involvement by answering the questions and submitting the questionnaire.