Elizabeth Blair, MSN, PARN, BC, CDE
- How can you understand your patients’ behaviors?
- What is the emotional component?
- What lies behind a person’s choice or behavior?
- What expectations can you expect from your patients?
- How can you enhance the learning process?
- When should your patients apply what they have learned?
It is important to remember that people’s behaviors are in part the result of their attitudes about diabetes, beliefs about treatment, degrees of success with blood glucose management, and their experiences with medical care. Intervening variables such as major life events, other competing priorities (such as tension between work demands and self-care), or conflicting messages from the healthcare team or from home (e.g., lack of support from family members for nutritional recommendations) can also affect the person’s ability to follow through on goal setting. The individual may not be ready to make changes because of denial or other psychological factors or obstacles. These variables require the provider to renegotiate goals, pay attention to negative feelings about diabetes, assist in conflict resolution and actively engage that person in problem solving. To more fully understand behaviors, consider the following:
The reasons underlying most human behaviors are complex and not readily recognized by outside observers. For example, insulin omission may at first appear foolhardy to the provider but, to the young woman who is distressed about gaining weight, it makes sense because omitting insulin results in weight loss. It is important to realize that behavior is not random but is the result of a series of active choices. The healthcare provider needs to put aside judgment, inquire about what lies behind a person’s choice or behavior, and modify the treatment program and/or goals to address that person’s primary motivations.
It is important for the provider to realize that indecision, reluctance, or resistance to clinical recommendations is not uncommon. People have mixed feelings about being in control of their self-care and about needing help. People with diabetes also fear the potential of unknown side effects from medications and are not willing to completely trust current research recommendations. These issues and feelings need to be openly discussed.
Communication, trust, respect, acceptance and support are elements that help create a positive climate for people to learn and to ultimately change behaviors. It is important to respect the individual’s choices even when such decisions conflict with recommendations made by the health team member.
Each person brings expectations to the patient/provider relationship based on need, knowledge level, attitudes, preconceptions and past history. In some cases there may be unrealistic expectations of the healthcare team. This can lead to conflict and/or disappointment. For example, a person may expect that after one visit with the diabetes educator glucose levels will be perfectly controlled. The healthcare provider needs to ask that person about expectations of the visit and treatment program and if necessary clarify and negotiate realistic goals and expectations. All people with diabetes are looking for a cure for their diabetes, or at least for perfect treatment leading to perfect diabetes management. It is important to acknowledge the imperfection of available treatment modalities.
Enhancing the Learning Process
The ability of the provider and patient to relate to one another facilitates successful learning. Without warm human interest and responsive rapport, teaching can be done to patients, but may not engage them enough so that they adopt healthy self-care behaviors. The following concepts help facilitate learning:
The need to know — When people want to learn, particularly when they come to a healthcare provider on their own initiative, the success of learning is enhanced. Individuals who initiate contact for education are more likely to participate in their education. People who receive education as part of their hospital care may not have a specific agenda for learning about their diabetes. Asking a patient, "What would you like to learn?" can help you to better identify how engaged this person is in the education process. The provider must balance what people say they want to know with what they need to know.
Personal relevance — Learning is a process of assimilating or taking in new information and linking that information with existing knowledge. It is important to assess what the individual knows and has experienced in the past in order to determine a starting point. Using past experience as a platform of learning provides continuity for people and allows the healthcare team to better understand potential barriers to learning and doing. Minimize teaching of abstract and theoretical information and emphasize knowledge and skills that are tangible and that will be personally useful to the individual. A good way to begin a session is to simply ask, "What are you most concerned about?"
Self-confidence and a desire to learn — Continually reinforce the idea that one can master the skills and knowledge needed to control his or her diabetes. Simple statements like, "I know you can do it!" can help reinforce self-confidence. A person’s confidence in making and maintaining changes is predictive of success in making the change. This process is enhanced when the education program builds on a series of carefully planned successful experiences that lead to achieving short-term goals. Guide the person with poor confidence in making positive self-talk statements such as, "I can do it." Anticipate and acknowledge problems that the person might encounter as he or she begins to change behaviors.
Active learning — People will acquire and retain knowledge and skills better if they are given opportunities to be active participants in the learning process rather than passive recipients of information (such as reading or lecture). Engaging an individual in a conversation about the topic area, having them set their own goals around important key concepts that are relevant or encouraging interaction with others in a group setting help promote active learning.
Apply learning immediately — People will retain knowledge and skills longer if they have opportunities for frequent application and repetition. Encourage "homework" assignments, such as looking for a particular food label, so the person can apply new knowledge. Having opportunities to practice what one has learned not only reinforces the concepts, but also promotes mastery of the material.
Keep it simple and short — Deliver only one or two main messages at a time. Staging the learning and setting priorities will enhance the learning. Remember the K.I.S.S. principle of education, "Keep It Short and Simple." When a person accomplishes a measurable, small goal (and that goal is acknowledged), self-confidence will increase, increasing the likelihood that other goals will be successfully met.
Weight control is a good example for goal setting. The initial goal should not be pounds lost, but perhaps keeping a food diary for 3 days or controlling portions during the after-dinner hours.
Adjust the pace — People usually do not learn at a constant rate. The pace of education and goal setting may need to be adjusted to accommodate variations in people’s ability to absorb and retain information. Be prepared to adjust your goals for each person to match his or her readiness to learn. When people are ill, it makes learning and retention of material much more difficult. Be sensitive to the physical as well as psychological effects of illness on motivation and learning.
Make it an enjoyable experience — A warm smile and a good sense of humor on the part of the provider can go a long way in enhancing learning. Think about your patients as "customers." If they don’t find the education session enjoyable, they will not want to hear more or come back.
Review, reinforce and repeat — Learning is enhanced when it is practiced and reviewed. Not only do repetition and review help to solidify understanding, they provide opportunities for success and building confidence. Having the person practice and review information provides valuable feedback about the areas that may be problematic for him or her.
People forget what they have learned as time passes. Level of education, profession, or the length of time living with diabetes does not necessarily correlate with knowledge of diabetes. Core diabetes knowledge and skills should be reviewed and updated on an annual basis.
The following management areas should be reviewed annually:
- Blood glucose monitoring technique and schedule
- The use of and interpretation of monitoring results
- Medication dosing and schedule
- Meal planning
- Hypoglycemia plan and practices
- Sick-day plan
- Foot care
Educational materials — Use of written materials, handouts, discussion or other educational interactions can be used to refresh diabetes selfcare knowledge. Learning is enhanced when it is fun, personally relevant, necessary, interactive, goal-oriented, short and repetitive. Written patient education materials or audiovisual aids such as videotapes, should enhance but not replace individualized attention from a healthcare provider. Patient education videos can be a helpful way to "teach" basic diabetes information. Here are a few tips for enhancing the use of patient education materials:
- Make sure the print size and reading level is appropriate for your patient. Ask him or her: "Do you need glasses to see this better?" Use a non-threatening approach to identify a reading or vision problem.
- Personalize the written piece by writing the following on it: your name, phone number, the person’s name and date.
- Use a colored pen or highlighted marker when reviewing a tool with the person you are instructing. Have him or her use the marker to circle or underline key information.
- Encourage the person you are teaching to write down his or her own behavioral goals as well as follow-up plan.
Group vs. individual teaching sessions — Traditionally, education has been conducted in individual sessions. Studies, however, have shown that group sessions are at least as effective as individual educational sessions. In the current healthcare climate of cost-containment, group sessions can provide effective education in a cost-effective format.
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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Please Note: Reasonable measures have been taken to ensure the accuracy of the information presented herein. However, drug information may change at any time and without notice and all readers are cautioned to consult the manufacturer’s packaging inserts before prescribing medication. Joslin Diabetes Center cannot ensure the safety or efficacy of any product described in this book.
Professionals must use their own professional medical judgment, training and experience and should not rely solely on the information provided in this book to make recommendations to patients with regard to nutrition or exercise or to prescribe medications.
This book is not intended to encourage the treatment of illness, disease or any other medical problem by the layperson. Any application of the recommendations set forth in the following pages is at the reader’s discretion and sole risk. Laypersons are strongly advised to consult a physician or other healthcare professional before altering or undertaking any exercise or nutritional program or before taking any medication referred to in this book.