Elizabeth Blair, MSN, PARN, BC, CDE
- What different learning styles do children and adults have?
- How can life experiences be used as part of the learning process?
- What are the challenges of educating older adults?
- How can the power of self-confidence be used to teach?
- What are the strategies for preventing relapses?
As a life-long chronic condition, diabetes requires ongoing care as people with this condition progress from childhood, to adolescence, to adulthood and to the older adult. The needs and life demands of each of these populations are rich and varied. Each population has different learning styles. Children and adolescents can benefit from visits with a pediatric diabetes educator.
Educating children about their diabetes involves not only educating the child, but educating family members as well. Early in the course of care, it is important to identify which adult is primarily responsible for the care of the child. The primary caregiver may be the mother, father, grandparents or other.
The most important concept in childhood diabetes education is understanding the developmental level of the patient. Childhood is a time rich in cognitive, emotional, and physical growth and changes. It is important to be attuned to the developmental level of the child so that the healthcare team can connect in meaningful ways. Moreover, the way children learn about their diabetes and the ways to assist in their self-care can have important positive effects on their self-care as adults. Diabetes education in childhood plays an important role in both the short and long-term care of the person with diabetes.
Following, are four concepts for teaching children:
- Make it developmentally relevant. Based on the age and demonstrated competencies of each child, adjust teaching strategies to the strengths and capabilities of that child. For example, when teaching blood glucose monitoring to a 5 year old, you can engage the child by letting her choose which finger will be used for the test, but you should actually instruct the parents. For a 13 year old, the parents would observe while the teenager receives the instructions and demonstrates skills. Teaching tools can include dolls, plastic foods, puzzles, and, for older children, games.
- Make it enjoyable. Children, like adults, learn best when they are engaged in what they are doing and when it is fun. Open communication about the experience of diabetes coupled with smiles can turn a potentially frightening visit with the healthcare team into a great learning opportunity. Additionally, using multiple teaching aides such as games, examples and rewards will increase the "fun" factor.
- Make it concrete. Abstract thinking normally develops during late childhood and early adolescence. As with adults, making examples and teaching aids as concrete as possible will ensure that a complex idea is understood.
- Provide positive reinforcement. Children are best motivated when they are told they are doing well. Using simple behavioral aids such as stickers for a job well done gives children the emotional boost they need to continue to accomplish simple as well as complex self-care tasks.
Adolescents, almost by definition, are undergoing a time of physical, emotional and social transition as they mature beyond childhood into young adulthood. This period poses special physical challenges for blood glucose control and heightened social and emotional pressures as adolescents move away from their families and toward peer relationships. Several concepts are important when working with adolescent patients/learners:
- Developmental relevance – There is considerable variability in the emotional and cognitive maturity of adolescents. Negotiating roles for self-care behaviors between family members and adolescents based on the cognitive and emotional maturity of the adolescent creates a more successful diabetes management plan.
Teens also need an opportunity for frank discussions about some of the most pressing topics of this developmental period: drugs, alcohol, dating and sex. None of these topics can be raised without a trusting, supportive relationship. Exploring how teens manage diabetes around these issues will be more meaningful to them and increase their willingness to listen and learn if the discussion is presented in an honest, open, nonjudgmental forum.
- Engage in conversation – Adolescence can be a time of shyness or awkwardness, especially when it comes to visits with a doctor or other healthcare provider. Engage the adolescent in a dialogue about what diabetes means to him or her, difficulties in balancing diabetes self-care with peer relationships, or the impact of physical changes on insulin administration, self-monitoring, or meal planning. Ask questions! Listen not only to the words the teen uses, but also pay attention to his or her body language and emotional responses. The more actively the adolescent is involved, the greater the chances are of using the information you impart. Confidentiality between teen and provider must be emphasized. Spend part of a visit alone with the teen. Having a parent in the room will alter the educational process. If a parent is part of an education intervention, a teen may feel less committed to listening. End a visit by including parents in the wrap-up so that they are informed.
- Make the learning experience enjoyable. Vary the way the information is conveyed as well as the context. Diabetes camps, science clubs, and teen support groups can provide important access to learning self-care skills in a fun and engaging way. Be sensitive to modes of education that may feel too "condescending" to the maturity level of your adolescent patient.
With the benefit of maturity, most adult learners are capable of advanced skills in reading, listening, focusing attention on relevant tasks, problem solving and assimilating information. Tap into these traits by noting these four characteristics of adult learners:
- Self-direction – Adult learners can be self-directed in teaching themselves beyond the patient education session. Provide adult patients with the resources and tools they will need to continue their own efforts at education. Resources such as support groups, reading lists, and relevant organizations (e.g., American Diabetes Association) can be valuable tools to the adult learner.
- Problem orientation – Discussing concrete, realistic problems that are easily applicable to each individual are excellent teaching strategies for all ages. Adults in particular are well acquainted with problem solving. Giving homework such as case histories or situations for people to solve, promotes greater assimilation of material and useful problem solving techniques that can be applied quickly.
- Using experience — Adults learn better when their own experiences are incorporated into education. Using the individual’s frame of reference increases understanding of concepts and the relevance of new information. Use analogies from work or hobbies to help incorporate information.
- Participation in the learning process – Active participation in the learning process not only enhances understanding of the material, but also engages the individual to use the information right away.
Older adults present a diverse and unique set of developmental and social needs. Older adults face greater challenges due to an increased number and frequency of illnesses, the increased demands of self-care, the need for multiple medications, changes in social interactions (or isolation), and differing expectations about the utility of self-care efforts. While some older adults have multiple medical issues and cognitive impairment, others are very capable of incorporating complex and necessary self-care tasks into their daily regimen. An individualized teaching plan drawing on the strength of the older adult will help meet the needs of such diversity. Consider the following when working with the elderly:
- Co-morbid health issues — Older adults frequently present with additional medical conditions that require on-going professional care and self-care. Such co-morbid healthcare issues may make it even more burdensome to learn about or follow diabetes management principles. Be aware of how diabetes education can overlap or contradict self-care recommendations for other conditions. Integrate and prioritize teaching objectives to cover the diabetes and other medical information most essential to the patient. Be mindful of the use of other medications so that interactions can be avoided.
- Sensory changes — Identify and clearly communicate physical challenges to other team members. For people with low vision, use larger print and black ink on white paper to make written materials easier to see. For people with impaired hearing, an individual appointment in a quiet location rather than a group session may enhance understanding.
- Need for the opportunity to practice self-care behaviors – Research has found that many older adults are highly motivated to learn about their diabetes. Taking advantage of such motivation allows them to practice what they have learned during educational sessions. Observing skills gives the healthcare team an opportunity to assess cognitive ability and pace, literacy, and perceived ability to perform tasks appropriately.
- The power of self-confidence – A common misperception of older adults is that "you can’t teach an old dog new tricks." It is important to dispel such myths among healthcare professionals and patients alike by presenting material in a relevant and confidence-building way. Older people bring a lifetime of experiences with them. Draw on their ability to adapt and meet challenges.
- Need for sensitivity to social and financial issues – Limited social support and financial resources play an important role in the continued success of self-care behaviors. Access to family members, food preparation, financial resources, and medications may pose important daily challenges for an older person. Discuss financial constraints that may impact self-care. Referral to a social worker may be appropriate so that older adults get connected to relevant agencies and programs.
Strategies for Relapse
Even with all these tools and strategies, behavior change and lifestyle maintenance are fundamentally difficult. Feeling discouraged, "burned out" or hassled by diabetes is common among people with newly diagnosed and long-duration diabetes alike. Reversing course and reverting to old patterns of behavior or old habits of self-care is a common phenomenon.
Relapse is usually defined as a period of time when an individual stops behavior change and returns to familiar habits of the past. While feelings of failure are common for both providers and patients, relapse is not a return to a previous state. Whenever an individual has worked to make any kind of change, he or she will retain the knowledge and experience from that attempt, regardless of the ultimate outcome. For example, an individual who returns to smoking after quitting for 6 months has learned more about the strategies that work and don’t work. Whether the individual continues to smoke or tries to quit smoking again, she will be able to use her experience as a tool the next time she wants to make a change.
Relapse is a natural part of change. It is estimated that most patients will relapse at least three times while attempting to make a behavioral change. Relapse is most common during high-risk or high-stress situations such as:
- physical illness
- emotional stress
- changes in routine (e.g., eating out)
- social situations (e.g., hanging out with friends)
- special occasions (e.g., holidays)
- boredom or burn-out
- negative feedback or lack of positive reinforcement.
The healthcare provider should discuss the potential for relapse with the patient. Discussing the potential for relapse can help anticipate challenges as well as have consider possible solutions ahead of time.
Diabetes education is not a one-time experience where everything can be learned at once. Diabetes is a chronic illness, and because people change physically and emotionally over time, the skills and knowledge that they need to engage in the best self-care will also change. To be most effective, education needs to be tailored to the individual.
Diabetes self-management education begins as a relationship between the healthcare team and the person with diabetes. While providing this care the diabetes team weaves sensitivity, curiosity, and compassion into the interaction as behavioral goals are jointly decided and barriers to change are anticipated. Both the healthcare provider and the person with diabetes are part of an ongoing learning process that may span several developmental periods of life and require a continuous flow of new information. Thus, providers and patients have an opportunity to be dynamic and thoughtful in their teaching. Ultimately, the role of the healthcare team is to help each person with diabetes develop self-care and problem solving skills so that he or she can be as independent as possible and achieve positive health outcomes.
Copyright © 2010 by Joslin Diabetes Center. All rights reserved. Reprinted with permission. Neither this book nor any part thereof may be reproduced or distributed in any form or by any means without permission in writing from Joslin. Note: Joslin does not endorse products or services.
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