Oermann6 and Bell7 discuss some important variables in adult education:
Learning does not exist in a vacuum. Adults seldom live in this world completely alone, and their environment and support system often is the main determinant of whether the patient succeeds or fails in his or her learning experience.
We need to make what we do relevant to them and purposeful in their lives. It upsets me terribly when a patient says that he keeps a log of his daily blood sugars and takes them to his doctor at each visit but it is never looked at or used for pattern management. How can we ask patients to do things that are meaningless?
Here is an example of a patient problem. Jack (another Jack) was in my outpatient class and attended with his wife. He is a charming, delightful man who just happens to look just like Santa Claus, beard and all. We get to the point in the class where the pharmacist is teaching the class, and she explains that you pick up the insulin bottle and roll it gently because you don’t want to damage the insulin or get bubbles in the bottle. Jack states that he shakes his insulin all the time. This gentleman has been in our hospital system for two years. He has not been to class before but he has been in ICU, the outpatient medical clinic, the emergency room, and on the medical surgical units during the previous two years. I ask him, “Do you mean you leave the bubbles in? How do you get them out before you inject yourself?” He says he draws the insulin up and always gets bubbles and just injects them into his abdomen. I asked him to show me his abdomen, and he is covered with bubbles under his skin: crepitus. The man was injecting the insulin with “bubbles” into his skin. It now occurs to me why his blood sugar is out of control: He never gets the same dose of insulin. Every injection is different depending on how much air is in the syringe. My question is for the health care providers who cared for him in the previous two years. Who validated that this man was capable of giving himself injections?
So, we taught Jack the proper technique and validated that he could do it correctly. At this point, I had major concerns and arranged for Jack to call me every day for the next week with his blood sugars. I wanted to make sure that he avoids hypoglycemia, as he is now getting the correct dose of insulin.
I also had to perform a quality improvement review and investigate the root causes of this major problem. Why was the staff giving the patients their injections instead of supervising the patients’ self-administration? The reply was ludicrous: they knew that diabetics had to give their shots at home so they did it for them in the hospital to give them a rest. They eat at home too but we don’t just feed everyone in the hospital to give them a rest.
It is not valuable for health care providers to do tasks for patients that the patients need to learn to do for themselves. Adults need to practice psychomotor skills in front of people who can validate the correctness of the task before they practice it incorrectly at home.
My granddaughter broke her leg, and they told her “no bathing or swimming this month.” It was July, and she was upset and angry. They showed her how to wrap her cast, which enabled her to shower, but it was not good enough for Tara. She was a teenager at the time and ticked off that her summer was being ruined. She had been told not to swim or bathe, but no one had said anything about not lying on a lawn chair and holding the garden hose over her head to cool off on a hot summer day. The cast started to smell, and when we noticed green things starting to grow out of the cast, it was time for a visit to the orthopedic specialist for a cast change. We had not explained the ramifications or alternatives; we just told her what to do and expected her to follow orders. Adults do not follow orders well. I really have no right to insinuate that teenagers are adult people, but I try.
You need to ask people what they are willing to do to survive. How hard are they willing to work, and what are they willing to learn? If we teach them survival skills, they do much better than if we ask them to learn everything about diabetes immediately. A great little book was developed by the Metropolitan New York Association of Diabetes Educators8 that really helps define what people with diabetes need to learn.
I have had patients tell me that they are not ready for this process. They cannot handle the stress, and they are frightened or in denial. The most difficult thing I ever wrote in a chart is that the patient is uneducable. I would not write that now. Instead, I might say that the person is uneducable at this time and define the barriers. I would then make a referral to another health care provider in the community and notify the primary care physician of the problems and obstacles. I would also make sure to contact the patient in the future and check on his or her state of mind and motivational status.
When I worked in the hospital, I was notified if one of my patients arrived in the emergency department in crisis. There might be a person with a blood sugar of 500 or 700 mg/dl. And I would ask the person, “Why is your blood sugar so high?” Everyone would be running around doing diagnostic tests, CAT scans, blood work, and blood cultures, and I am talking to the person. There are only a few reasons that a blood sugar would be that high. The person did not take her medications, she ate everything in sight, she has an infection, or something unusual is going on in her life. So I ask them. In one episode, the person went to a wedding and drank everything available. His daughter was getting married, and he decided to take the day off from being a diabetic. He never got to eat all day, but everyone gave him a drink to celebrate. Sounds like fun to me but not too clever. Hyper- or hypoglycemia is not a fun experience.
The most important part of adult learning is accurate, clear, concise communication. This is the hardest thing we do as adults, and it is not something we learn in school. Unless you chose a communication course in college, it is never part of your academic life. Yet, all teaching is communication.
Communication is the act of transferring an idea or message, for the purpose of eliciting a response. Most of us just talk. We send words and ideas into the atmosphere and hope that someone will catch the message out there and pay attention.
To say that you are communicating assumes that what you are saying requires some response. The response does not have to be verbal. A person can nod or just change his or her affect, and you know that he or she has received the message. One-way communication is so often the way people are taught. Think about a huge lecture hall where students sit, listen to the professor, and take notes. The only way teachers find out if the message got through is at the time of final exams when a test score is supposed to tell them how successfully they were educating. That may be acceptable, but I cannot imagine anyone accepting it as an adult education method. Adults need an opportunity to analyze information and adapt it to their own lives.
Communication can