Question

Mr. Jones, a newly diagnosed diabetic, has been a loyal patient of the ABC Physician Practice for many years. His blood sugar levels are very unstable so he is in the office today. His wife speaks with you privately to tell you he is not following his diet and refuses to exercise daily. She is concerned, but doesn’t want you to tell Dr. Foster because she knows her husband will be very angry with her. How would you handle the situation

Answer 1

It is not easy for any person to hear that he / she has diabetes. Diabetes is a disease that cannot be cured. It has to be taken care of every day. People who have diabetes must make some important changes in their lives. To stay healthy, they must learn how to monitor and control their blood sugar levels. People who don’t control their blood sugar levels can develop serious health problems, such as blindness, nerve damage, and kidney failure. But there are things you can do to help your loved one who has diabetes.

Teaching patients to take their prescribed medications correctly may be as important as the medication itself because, without a good understanding, patients may take it incorrectly, with poor outcomes.

Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in the insulin secretion, insulin action, or both. The chronic hyperglycemia of diabetes is associated with long-term macro- and microvascular damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels. Without insulin, the food we eat, broken down into simple forms of glucose, can’t enter the cells of the body and remains in the bloodstream. After a meal, glucose levels in the body rise, which triggers insulin to be released from the beta cells of the pancreas. Glucose levels in the blood fall as glucose moves into the cells, where it is used for energy production to fuel the body. Extra glucose in the blood can be stored in fat and skeletal muscle tissue. Glucose stored in the liver becomes glycogen.

When the body doesn’t produce any insulin (type 1 diabetes) or has a sluggish or resistant response to insulin (type 2 diabetes), chronic hyperglycemia develops; this is known as diabetes mellitus. The term diabetes means “to siphon through,” which refers to the loss of urine as the body attempts to rid itself of the excess glucose and pulls water along with it. The term mellitus was added years later; it means “sweet” or “honey,” referring to the glucose in the urine.

A diabetes educator can ensure effective education by following the activities
A Analyze the learner
S State the objectives
S Select appropriate teaching methods
U Use effective instructional materials
R Require learner performance
E Evaluate the learning

Analyze the Learner
“Analyze the learner” means looking at the patient’s language ability, age, ethnicity, food preferences, gender, and learning style. People of different ages learn differently. We don’t teach a child or adolescent the same way we teach adults. Children need concrete examples to which they can relate, and do well with role play and games, for example. Adults can generally learn by references and analogies. Geriatric patients may need a different approach based on physical limitations such as hearing or vision. Do not assume people who “look like you” are the same as you! With the growing diversity in our country, people come from a large variety of backgrounds with cultural norms that impact their health; these may include food preferences and even adoption of complementary and alternative therapies. Simply asking people open-ended questions like “What do you typically eat for daily meals?” will provide valuable information to help you guide them toward healthier choices. Long gone are the days when we would give the same standardized ADA 1800-calorie diet handout to everyone. The patient often threw away the seemingly irrelevant pamphlet. Gender differences are important to consider when teaching a patient about healthcare needs and management of a chronic disease. Women are generally motivated by social relationships and may thrive in a group class. Men, however, are often motivated by task completion and may prefer a one-to-one teaching session so they can be finished and leave. You can ask them how they prefer to learn new information: by reading, watching a video, seeing a demonstration, or learning by a hands-on approach. Based on their preference you can create a more effective presentation of the needed material. The saying “The more neurons that fire together, wire together” helps us remember that our brains require repetition of information to “hard wire” it, no matter the style.

State the Objectives
There are so many topics that need to be taught regarding diabetes management that it can feel overwhelming to both the clinician and the patient. Before teaching a patient with diabetes, clarify the goal of the learning session. Stating “We’re going to talk about diabetes” isn’t as clear as “You are going to learn how to test your blood sugar daily with this meter” or “You are going to learn how to use an insulin pen to give yourself the medicine your provider ordered.” Notice both sentences focused on what the learner was going to be able to do at the end of the training, rather than what the teacher was going to do. People need to be able to come away from a teaching or training session with the ability to do something that will make a positive impact on their health, and not to just learn academic concepts. Behavior change is the focus of learning sessions in healthcare. Many times the objective of the learning session is given by the prescribing clinician, it may be learning about insulin devices or counting carbs. If you are the one choosing the topic and don’t know what to teach, ask the patient what they need or want to learn first. Adult learners are generally task-oriented and already know what they want to learn.

Select Appropriate Teaching Methods
Selecting appropriate teaching methods depends on what you have already discovered about your learner’s preferences. The methods of teaching include auditory, visual, one-on-one, group classes, and so on. If a person with diabetes seems interested in a group class, find out your local resources and where you can refer them. If a person says that they prefer private teaching, then schedule that if possible. The following list shows many different methods that could be used for teaching about diabetes: Audiovisual, Case Study, Computer resources, Conference, Demonstration, E-learning, Group discussion, Gaming, Lecture, One-to-one, Reading, Return demonstration, Role playing, Simulation, Technology, Telecommunications, Workshop etc.

Use Effective Instructional Materials
In addition to selecting appropriate teaching methods, using effective instructional materials is important to creating an effective teaching experience for the patient. If you found, for example, that your learner prefers to learn by watching videos, then a pamphlet may be useless unless it summarizes information from the video. If patients disclose they can’t read well in English, then other teaching methods need to be chosen. Written instructional methods can be extremely helpful but they must be written at a fifth-grade reading level and without medical jargon. Using pictures can be helpful for those with limited English proficiency. Pharmaceutical representatives often offer diabetes education materials, generally free of cost. The following list identifies some of the many instructional materials available for diabetes: Anatomical models, Charts, Demonstration materials, Displays, Food models, Graphs, Handouts, Pamphlets, Posters, Puzzles, Videos etc.

Require Learner Performance
Learning for knowledge’s sake alone may not effect the actual behaviors needed to improve physical health. Notice that, within this course, each module identifies a learning objective. Knowledge becomes powerful when it prepares you to improve action toward a desired goal. The four domains of learning depicted earlier include affective (emotional), behavioral (ability to adopt new behaviors), cognitive (knowledge), and psychomotor (physical ability). As a diabetes educator you will choose some combination of these to achieve the goal of improved patient outcomes.

Evaluate the Learning
Evaluating the learning experience is important to ascertain whether your explanation was effective. Simply asking “You understand, right?” won’t elicit honest feedback. Many people will say yes just to save face for both their sake and yours. Cultural norms in many Asian cultures demand that patients nod a polite yes even if they don’t understand. In fact, many people don’t want to admit they didn’t understand. Asking them to state back what you said, or requiring them to do a repeat demonstration after your instruction, will give you a better assessment of their learning. You may see holes in their understanding, which you can then fill. Asking patients to teach you is a good way to assess their understanding. Generally if someone can teach correctly, then they know. Asking open-ended questions after your instruction is also helpful: “Explain to me how insulin works in your body,” or “Tell me how you may know if your blood sugar is getting too low.