Critically analysing a teaching session which has been undertaken in practice for a child or young person.
This reflective essay explores and analyses a teaching session carried out with a young person within a paediatric nursing setting, in order to evaluate positive aspects of the session, skills involved and skills developed on the part of the nurse during the session, the effectiveness of the session, and the ways in which this activity could have been improved to better meet the needs of the client. The client chosen is a 13 year old girl with Type 1 Diabetes, who, having made the decision to become independent in her glycaemic control and in managing her condition, was admitted to the children’s ward after a hypoglycaemic episode.

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The focus of the session was on re-educating the client in good practice in self-administration of insulin. Up until the period shortly before her admission, her mother had been administering BD insulin injections before school and in the evening. The client, who shall be called Sheila for the purposes of this essay (the name has been changed to protect confidentiality), had asserted her independence and demanded to be allowed to carry out our own injections, unsupervised, but after the hypoglycaemic episode, the question was raised whether or not she was able to draw up the correct dose. Therefore, the session was set up to allow Sheila to revisit the correct procedure for drawing up and delivering the correct dose of insulin in the correct manner. Confidentiality has been maintained throughout this essay by anonymising the personnel involved, and by ensuring no identifying details are used at any point. The importance of the teaching role within paediatric nursing will be discussed in the light of this activity and experience, and some recommendations for good practice will be drawn from this.
The client chosen provides an interesting case because this is a young person who can be viewed as being in transition, between childhood and the onset of adolescence, asserting more maturity and independence in her management of her chronic condition, and so needing to be treated and interacted with in ways more similar to those usually used with adults. This presents a challenge for the paediatric nurse, because one key aspect of educating for health is to engage with the client on the appropriate level, and to avoid alienating the client (Agnew, 2005). This is a fundamental component of all nursing care, acting as both the human face of medicine and as a teacher or coach who acts to “take what is foreign and fearful to the patient and make it familiar and thus less frightening” (Benner, 1984 p 77). Approaching a young person such as Sheila requires skill in terms of using typical teaching approaches but adapting them to meet her individual needs as a person, according to her own perception of who she is and her levels of independence. Benner (1984) suggests that there is a need to use tone of voice, humour, and the nurse’s own attitudes in meeting these needs. Knowles et al (2006) state that “evidence-based, structured education is recommended for all people with diabetes; tailored to meet their personal needs and learning styles” (p 322). In this instance, planning the session required the nurse to draw upon knowledge of teaching processes and principles gleaned from her own study and research, clinical knowledge about the skill to be taught, and personal attributes which would (it was hoped), avoid patronising the client or alienating her(see Appendix for teaching plan). However, this author anticipated that there would always be some distance between nurse and client, because the nurse, no matter how skilled or capable in communication, might still represent an older authority figure to whom they might not necessarily ‘relate’ very well. Understanding this, the approach to the session was clearly and consistently hinged upon basic principles of learning, incorporating aspects of adult learning in order to attempt to be more appropriate for Sheila’s learning needs. There is some debate about the differences between learning in children and adult learning, or whether there are, indeed, any differences (Rogers, 1996).
Because of the significant health impact of Type 1 Diabetes on individuals, and consequently, on society and the state’s healthcare systems and resources, it was thought important to include in this session some of the rationales for good glycaemic control and prevention of the longer term consequences of the disease. Type 1 Diabetes, is a disorder in which beta cells of the Islets of Langerhans located within the pancreas fail to produce insulin as required by the body to regulate blood glucose, resulting in high levels of circulating glucose(Watkins, 2003). The longer-term consequences of the disorder include atherosclerosis and cardiovascular disease (Luscher et al, 2003); diabetic retinopathy (Cohen & Ayello, 2005; Guthrie and Guthrie, 2004); peripheral vascular disease, intermittent claudication and foot ulcers foot ulcers caused by impaired circulation and peripheral neuropathy(Bielby 2006; Edmonds and Foster, 2006; Lipsky et al, 2006; Guthrie and Guthrie, 2004; Bloomgarden, 2005; Soedmah-Muthu, 2006); renal disease and renal failure (Castner and Douglas, 2005); and gastrointestinal complications (Guthrie and Guthrie, 2004).
In preparation for the session, the nurse engaged in some background research, ensured that her knowledge was up to date, and reviewed the key national policy document, the National Service Framework for Diabetes published by the Department of health which underlines the need for good, ongoing health promotion and education for those with the condition (DH, 2002). Reading of research and professional literature also highlighted a wealth of information on the specifics of health promotion and education within diabetes, much of which is very applicable in this instance as it focuses on self-management of the condition (Cooper et al, 2003). While these support the transmission of information between health professional and client, so that the client becomes knowledgeable about their disorder and its management (Fox and Kilvert, 2003), there is also evidence which supports health education that actively incorporates and engages the client as a partner in the learning process as well as the control of their condition (Davis et al, 2000)
Therefore, the session was planned to initially determine Sheila’s level of knowledge and understanding, her current competence in the skill, and her ability to describe the underlying principles of the procedure. As Rogers (2002) states, “it is necessary to adapt our methods of teaching adults to the range of educational skills they possess.” (p 76). Horner et al (2000) also underline the need to improve the readability of teaching materials, and some were identified during the course of this session as being in need of improvement. Therefore, this element of the session also determined her level of understanding, reading ability and whether or not she had any difficulties such as dyslexia. It was discovered that Sheila had an above-average reading level, no special educational needs and no specific requirements other than that she was spoken to as an adult, as she reiterated on a number of occasions that she was not ‘a kid’.
The learning approach taken was what Hinchliff (2004) describes as a constructivist approach, which, based on cognitive and humanistic learning theories, places the most importance on “self awareness, and the individual’s understanding of the processes involved in his or her own learning” (p 65). Hinchliff (2004) discusses Bloom’s (1972) learning domains, and this teaching session was designed to affect all three domains, cognitive, psychomotor, and affective. In relation to the cognitive domain, the aim was to reinforce and introduce knowledge. Psychomotor skills relate to the practical ability to administer insulin, and affective domain refers to the initiation of a process of attitude formation, wherein the nurse was hoping to help Sheila form a positive, proactive attitude to self-management of her condition.
Further reading uncovered information on tailored educational programmes for children with diabetes to encourage appropriate self-care and management of their condition, based on pre-existing adult courses which exist in the UK but are of limited value for children (Knowles et al, 2006). Knowles et al (2006) carried out a study to adapt the adult Dose Adjustment For Normal Eating (DAFNE) course to design a skills training course, for children aged 11–16 yr, focusing on self-management skills within an intensive insulin regime. While this kind of approach would have been ideal for Sheila, a little research into facilities available local to the client showed no provision of this kind, or similar, targeted at her age group, which this author believed was a failing of local provision. This is a key point in the lifespan of a young person with a chronic condition, and at the least such young people need age-appropriate health education activities (Knowles et al, 2006). However, this study has yet to be validated by a planned larger multicentre trial (Knowles et al, 2006).
Viklund et al (2007) carried out a six month randomised controlled trial of a patient education empowerment programme, with teenagers with diabetes, but found after their trial that this empowerment programme made no difference on outcomes related to glycaemic control or empowerment. Their conclusion was that there should continue to be parental involvement in educational programmes and in management of self-care and ongoing control in diabetes in teenagers (Viklund et al, 2007). This might suggest that this session should have included some parental involvement, or should have made reference to ongoing parental involvement, because it supports anecdotal evidence that the author has gleaned from practice, wherein nurses rarely ‘trust’ teenagers to manage their diabetes appropriately themselves. Murphy et al (2007) describe a ‘family-centred’ diabetes education programme which was successfully integrated into paediatric diabetes care in one location, with potential benefits on parental involvement and glycaemic control. In all three of these cited studies, multidisciplinary involvement was a feature of the programme (Knowles et al, 2006; Murphy et al, 2007; Viklund et al, 2007). This suggests that there should be programmes which provide ongoing, family-oriented support, but this author still feels that the particular needs of teenagers may need something else, something indefinable as yet, but something which still supports their sense of self and emerging adult identity, fosters independence but also helps ensure proper management of the condition. This takes us to the issue of resources, and the lack of them, but if there were more, good quality research in this area, it might provide the leverage for more resources to be mobilised to meet the needs of this client group.
Sheila evaluated the session well, but the author was left with the feeling that there was no certainty that the client would take on this new learning and that her glycaemic control would improve. Having addressed issues from the point of view of diabetes, and of the needs of teenagers with this condition, the author can only conclude that the session was well designed and incorporated patient-centred, established educational techniques, but that these techniques are not necessarily the optimal way to educate and support teenagers with Type 1 Diabetes. The literature has shed a light on some potential approaches to this, but the evidence is still insufficient to fully change practice. However, Sheila was able to demonstrate correct technique, discuss the rationale for the technique, and discuss with some confidence her management and control of her condition, and the prevention of longer-term complications. A more multidisciplinary approach would perhaps be needed to address the emotional and psychological elements of her learning and development needs in the future.
References
Agnew, T (2005) Words of wisdom. Nursing Standard 20(6),pp24-26
Anderson, B. (2005) The art of empowerment : stories and strategies for diabetes educators New York: American Diabetes Association.
Anthony, S., Odgers, T. & Kelly, W. (2004) Health promotion and health education about diabetes mellitus. Journal of the Royal Society for the Promotion of Health. 124 (2) 70-3
Benner, P. (1984) From Novice to Expert: Excellence and Power in Clinical Nursing Practice London: Addison-Wesley Publishers.
Bielby, A. (2006) Understanding foot ulceration in patients with diabetes. Nursing Standard. 20(32). pp. 57-67.
Bloomgarden, Z.T. (2006) Cardiovascular Disease Diabetes Care 20 (5) 1160-1166.
Castner, D. Douglas, C. (2006) Now onstage: chronic kidney disease. Nursing. 35(12). pp. 58-64.
Cohen, A. Ayello, E. (2005) Diabetes has taken a toll on your patient’s vision: how can you help?. Nursing. 35(5). pp. 44-7.
Cooper, H.C., Booth, K. and Gill, G. (2003) Patients’ perspectives on diabetes health care education. Health Education Research 18 (2) 191-206.
Court, S. and Lamb, B. (1997) Childhood and Adolescent Diabetes London: John Wiley.
DAFNE Study Group (2002) Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. British Medical Journal 325:746–9
Davies, K. (2006) What is effective intervention? Using theories of health promotion. British Journal of Nursing15 (5) 252-256.
Department of Health (2002) National Service Framework for Diabetes Available from www.doh.gov.uk Accessed 25-7-08.
Edmonds, M. Foster, A. (2006) Diabetic foot ulcers. BMJ. 332(7538). pp. 407-10.
Fox, C. and Kilvert, A. (2003) Intensive education for lifestyle change in diabetes. BMJ 327 1120-1121.
Guthrie, R.A. & Guthrie, D.W. (2004) Pathophysiology of Diabetes Mellitus. Critical Care Nursing Quarterly 27 (2) 113-125.
Hinchliff, S. (Ed)(2004) The Practitioner as teacher 3rd Ed London: Balliere Tindall
Knowles, J., Waller, H., Eiser, C. et al (2006) The development of an innovative education curriculum for 11–16 yr old children with type 1 diabetes mellitus (T1DM) Pediatric Diabetes 7 (6) 322-328.
Luscher, T.F., Creager, M.A., Beckman, J.A. and Cosentino, F. 2003 Diabetes and vascular disease: pathophysiology, clinical consequences and medical therapy: part II. Circulation 108 1655-1661.
Murphy, H.R., Wadham, C., Rayman, G. and Skinner, T.C. (2007) Approaches to integrating paediatric diabetes care and structured education: experiences from the Families, Adolescents, and Children’s Teamwork Study (FACTS) Diabetic Medicine 24 (1) 1261-1268.
Northam, E. Todd, S. Cameron, F. (2006) Interventions to promote optimal health outcomes in children with Type 1 diabetes – are they effective? Diabetic Medicine. 23(2). pp. 113-21
Reece, I. & Walker S.(2003) Teaching, Training and Learning. Tyne & Weir: Business Education Publishers Ltd.
Rogers, A. (2002) Teaching Adults 3rd Ed Buckinghamshire: OU Press
Soedmah-Muthu, S.S., Fuller, J.H., Mulner, H.E. et al (2006) High risk of cardiovascular disease in patients with type 1 Diabetes in the UK. Diabetes Care 20 (4) 798-804.
Viklund, G., Ortqvist, E. and Wikblad, K. (2007) Assessment of an empowerment education programme. A randomized study in teenagers with diabetes Diabetic Medicine 24 (5) 550-556.
Watkins, P.J. (2003) ABC of Diabetes (Fifth edition). London: BMJ Publishing Group.
Appendix

Patient Education Plan

Self-administration of Insulin

Lesson Aims:

To support Sheila to develop the skills and knowledge to demonstrate competence in the independent self-administration of Insulin.
To reinforce health promotion principles and information regarding long-term management and control of her Diabetes and the prevention of later-life health complications.

Learning Outcomes – at the end of the session the client should:

Be able to describe, discuss and demonstrate the principles of correct drawing up of accurate doses of insulin as prescribed in her own regimen.
Be able to competently self-administer insulin with correct technique, and describe the rationale for this technique
Be able to discuss ongoing glycaemic control and prevention of later life complications of Diabets.

Activity

Method and Rationale

Determine Sheila’s current level of knowledge.
Determine Sheila’s reading level and identify any specific learning needs or difficulties (eg dyslexia)

Discussion
This allows for the identification of Sheila’s needs, and allows the nurse to set the tone and establish a relationship with Sheila.
Provision can be made for specific needs such as augmented or specialist reading materials.

Sheila to demonstrate drawing up technique
Nurse to demonstrate drawing up technique

Demonstration/discussion with supporting information/leaflets.
Drawing comparisons between the two techniques should allow the client to identify whether her own practice matches that of the nurse/teacher.
Discussion of this will draw out underlying knowledge and principles.
Written information will reinforce learning.

Review and demonstrate correct administration technique

Discussion/Demonstration
Discussion allows the nurse to identify gaps in knowledge and skill and address these in a responsive, flexible manner.

Review knowledge of disease management and prevention of complications and identify further learning needs

Discussion
Provide a rationale and potential motivation to maintain good glycaemic control.
Plan to meet further learning needs either immediately or in future sessions, perhaps involving the multi-disciplinary team.

Gain client feedback

To evaluate effectiveness of teaching session in client’s own words.