Armed with an understanding of diabetes and what motivates people to change, it is necessary to know how to teach effectively in order to help patients achieve favorable outcomes. The determinants of learning can be addressed by answering the who, what, when, where, and how of teaching people with diabetes (Redman, 2004).

Who, What, Where, When, and Why

The who includes who you are teaching and, hopefully, family members. Parents of children with type 1 diabetes especially need education and support. Although there is no actual type 3 classification of diabetes, family members who care for a patient with diabetes have coined the term for themselves. Their lives are touched directly as they care for a family member with diabetes even though they don’t have diabetes themselves. It is important to involve the family members who may be buying and preparing food and/or administering medication. There is a very real phenomenon of diabetes burnout, and caregivers also experience this and need support.

Deciding what needs to be taught may be easy if it is prescribed—such education for insulin injection or blood glucose monitoring—however, most topics are up to the diabetes educator. You must decide between the nice-to-know and the need-to-know. Because formal diabetes education may be limited by insurance companies to a maximum of ten hours in the first year, teach first survival skills such as basic physiology and medication administration. Long-term goals and special topics such as eating during the holidays, travel, and cooking ideas should be chosen after essentials such as weight loss and blood glucose monitoring. All topics must be in accordance with the ADA national standards for DSME.

Topics such as the use of alternative therapies should be limited if there is no position statement from the ADA. For example, patients will want to know if they should be taking cinnamon pills or chromium or cactus pear because they read about it on the Internet or heard it from a friend. Unless the ADA has endorsed such products, you need to tell the patient that they are not approved. Patients will highly value your opinion as a healthcare professional so you must be careful what you say about vitamins, complementary therapies, and practices not validated by evidence-based medicine.

Stay with the seven approved topics and interventions for diabetes management:

• Weight loss
• Medications
• Diet
• Exercise
• Monitoring
• Mental health and stress management
• Self- management strategies
• Avoidance of complications

A simple way to remember this are the “seven daily MnMs,” which include:

• M   Mass reduction (weight loss)
• M   Movement (exercise)
• M   Meal Planning (diet)
• M   Monitoring (blood glucose, weight, lipids, blood pressure, etc)
• M   Medications
• N   No complications (avoiding hypoglycemia, DKA and HKS)
• M   Mental Health

Make sure your patient understands you are not advocating eating M&Ms to manage their diabetes! Once you know this is understood, the seven daily MnMs is a “sweet” way to remember the daily strategies recommended by the ADA to control daily blood glucose levels and overall diabetes. The use of mnemonics and acrostics help some people remember action items.

How to teach is grounded in understanding basic principles of teaching. As mentioned earlier in this module, you can ASSURE effective teaching by analyzing the learner’s unique needs, stating the objectives for a teaching session, selecting appropriate teaching methods, using effective instructional materials, requiring learner performance, and then evaluating the learning.

Where diabetes education takes place includes both healthcare settings and non-healthcare settings such as the home. Because time and insurance coverage may limit the formal teaching, referring patients to public libraries, community support groups, the Internet, and diabetes organizations can expand their learning resources.

When diabetes education can begin depends on the physical and emotional readiness of the learner. Acute settings such as an emergency department may not be ideal for diabetes education, especially when the patient is in pain or discomfort; however, initial seeds may be planted as patients become newly motivated to avoid acute diabetic emergencies. Other factors that may impact a patient’s readiness to learn include their state of fear, open vs. closed dialog, sense of safety or perceived threat to self, and discussing realistic or unrealistic goals. Telling an obese patient to lose 20 pounds may be unrealistic and overwhelming to the patient and close the patient off to any future discussions. Discovering what is of most interest to the patient is key. Discussing erectile dysfunction may actually become the right motivator to get a man interested in testing his blood sugar.

Just as children want to know the “why” of parental rules, many people with diabetes want to know why they are being given certain medications and prescriptions. Again, being able to explain the pathophysiology to them in a manner they understand can help them make connections with the prescribed regimen. The overall goal of diabetes self-management education is to help patients live as full and healthy a life as possible within their limitations.

One overarching strategy to achieve this is through controlling chronic hyperglycemia. Once patients understand the overall goal, monitoring their blood sugar levels throughout the day can give them feedback on the effects of exercise and food on their body. The goal is self-management, and information is key to being able to make adjustments. Blood glucose monitoring or insulin is no longer the enemy, but rather the tool to help them achieve better health.

How to teach effectively has been the overall question this continuing education course attempts to answer. Strategies discussed have included:

• Understand learning styles
• Understand learning principles for patients’ ages
• Understand motivation and compliance factors
• Adjust teaching for cultural preferences
• Control flow of time and pacing
• Identify purpose of teaching session
• Require learner to take an action
• Organize the material
• Be prepared
• Have a sense of humor
• Be flexible and adjust the teaching as needed

General principles of effective teaching include being prepared with the material you may need. Give positive feedback and reinforcement rather than chastisement. Always demonstrate an attitude of respect and compassion. After teaching a concept, allow patients to rephrase it in their own words to evaluate understanding. Be flexible when the patient asks questions about a topic you may not have planned for. Sometimes a patient may ask general questions until gaining confidence in you and then the deeper questions of sexual dysfunction or eating disorders may surface.

Creating a Lesson Plan

Creating a plan for effective teaching begins with identifying the overall purpose of the teaching session. Writing your plan down helps focus on the overall goal and the topic for learning. What are the learning objectives you want your patient to achieve? Outline the related content to identify the topics you will need to cover, including the realistic time it will take to cover the material. Choose the materials and instructional resources you will use and how you will evaluate the learning.

The following table shows how you may outline a simple lesson plan to teach about blood glucose monitoring.

Even though your lesson plan was perfectly organized and delivered, the patient may have a less than impressive retention or understanding of the information you presented. There are many factors that influence learning. Environmental elements may affect the learning experience (eg, temperature, noise). If the environment isn’t conducive to learning, you may need to reschedule or return at a different time. Simply ask your patient “Is this a good time for you to discuss this?”

Emotional elements impact learning (eg, depression, readiness for change, fear). A patient who is anxious while waiting for a test result may not be ready for a lecture on weight loss. Social issues such as family dynamics can impact learning. Support or lack of support from family members or loved ones can change the learning experience. A man who doesn’t feel supported by his wife may reject a learning session and stay in denial or anger. Physical condition can impact patients’ learning if they are in pain or tired. It’s generally not a positive experience to try to teach someone who is waiting for a pain medication or who keeps falling asleep from anesthesia. Ideally the planets will align and make all the elements perfect while you have the opportunity to teach about diabetes; however, reality is that you probably will need to teach in small segments of time based on the patient’s preference and not your own schedule.

Even cultural values impact the learning experience. While teaching a Spanish-speaking woman about diabetes, a bilingual nurse was surprised when the patient stated “Si Dios quiere” (If God wants it) when asked “Would you like to learn more about how to monitor your blood sugar?” Even though there wasn’t a language barrier, the deeper barrier was the belief system of the patient that God is in charge and she had no power to control her blood sugar levels. When confronted with a wall of resistance, endeavor to identify the barriers you are facing.

Other special considerations are patients with low literacy, attention deficit disorder, or mental illness. For more effective teaching with these persons consider the following strategies:

• Personalize all messages.
• Repetition is key.
• Use concrete illustrations.
• Allow hands-on learning.
• Be sensitive to word usage.
• Identify family members to assist.
• Word check for readability.
• Provide education in short time segments.
• Identify 1 to 2 main messages.
• Allow patients to teach back to clarify understanding.

Teaching all there is to know about diabetes is a daunting task—and unrealistic. Being able to connect your patient with reputable resources supports the patient’s ability to become a lifelong learner with diabetes. Self-management education means you do not have to be the sole person to educate about diabetes, which is a relief. Look at the Resources at the end of this course for many options for you and your patient.