Читать книгу Patient Education: You Can Do It! - Ginger Kanzer-Lewis - Страница 15

Let’s discuss my favorite subject: adult education.

Malcolm Knowles is considered the father of the adult education movement in the United States. He was an amazing man, and in his book The Adult Learner: A Neglected Species,⁵ he makes an incredible statement. He wrote, “We know more about how animals (especially rodents and pigeons) learn than how children learn: and we know more about how children learn than how adults learn.” He wrote this over 30 years ago, and we have learned a great deal during that period of time, but it remains amazing to me that we find educators everywhere who are still treating adult people as slightly moronic 6-year-olds.

He said that the reason that adults have difficulty learning is that they are taught by people who are either experts in their subjects and don’t know how to teach or by teachers who were trained to teach children and not adults.

Have you ever been a college student who was treated as if you were a child? Did you resent it? I will give you an example. I am a diploma graduate in nursing, so I had to go back to college and take the same courses that I took in nursing school. It had been decided that nurses who were educated off college campuses would not receive academic credit for those courses, so I was taking anatomy and physiology again, and I am skinning a cat 10 years after I skinned the first one. Now, we get to final examination time, and I am well prepared. I was sure that “the eye” would be on the final exam because the professor had spent six weeks on the eye and two weeks on the heart. I prepared well and if given a model of the eye, or a diagram, could accurately identify all of the components. Great. I need an A because I am a nurse and compulsive. The night of the exam arrives, and I open the exam, and it says, “draw and label a diagram of the eye.” I raise my hand and the professor comes over for my question. I stated my concern that I do not draw well, and if I draw an eye, he will not recognize the components and will deduct points. He said to just draw an eye. I told him that this was not an art class and if he gave me a diagram I would label it absolutely accurately. He said just draw it, and you will not lose points. I wrote on my paper, “I will not accept any deduction in points because of this poor art work. This is not an art class.” I had him sign it. I got an A on my eye.

Think about what you ask patients to do, how you ask them to do it, and their treatment as adults.

Andragogy means adult education, versus pedagogy, or the teaching of children. It stems from the Greek word aner, meaning man as distinguished from boy, and was originally used by the educators in Yugoslavia. It is rarely found in dictionaries, which drives many of my colleagues crazy when they try to validate adult education methodology.

I started my first diabetes education program in 1972 when I was Director of Staff Development in a hospital in New Hampshire. The nursing staff came to me for help with inpatients who had been diagnosed with diabetes. We had few materials in those days to help us teach patients. There was a tear sheet on oral medications and a small booklet from Eli Lilly and Company about insulin. Patient education was a new idea in the Northeast, and pioneers like the Joslin Diabetes Center were doing groundbreaking work. If you were not in the “diabetes world,” you really did not know what was happening in other parts of the country, and many of us were operating in the dark.

I started teaching patients with handmade materials, and it took me over a year to develop a manual to give to “diabetic patients.” Before you think I was an idiot, please remember that I was operating in the adult education world 10 years before I finally enrolled in Harvard for a master’s degree in Education. Dr. Knowles had not even written his book on adult education. I took my beautiful new manual to a newly diagnosed patient one day and told her to read the book and she would know everything about diabetes. No assessment, or even a conversation. I returned the next day and asked her what she had learned. She responded, in French, that she could not read or speak English. I had given her this beautiful book, and it was worth nothing. I had not taken the time to find out who this woman was and what she needed from me.

Let’s think about the adult learner. Adults will learn what they want to learn, when they want to learn it, and your job is to facilitate that learning experience. We are talking about changing behaviors. Change is always frightening, and when you are talking about life and death issues, it can be so frightening that it is paralyzing.

When dealing with adults, the terms relevant and validating are so important. The first rule of adult education is: Don’t teach junk! If I don’t need to know it and it will not impact my life, do not teach it to me. Adults do not have time in their lives and minds for unnecessary information. Your job is to find out what is relevant to each individual and give him or her that information.

Consider adult education a partnership with another individual who is on an equal plane with you. He may have less, or more, education than you have, but he brings to the partnership life-long learning experience that may help or hinder the learning process. He may be an expert in another field and need more scientific data from you than most people require. Your assessment will help you determine his learning needs. I give my patients permission to disagree with me on the importance of certain actions that I expect from people with diabetes.

Here is an example on the topic of exercise. I encourage every person to increase their physical activity level when diagnosed with diabetes, but I have to be realistic. Here is a person, perhaps 55 years of age, who has never done physical activity as an adult. It is unreasonable for me to expect her to join a gym and start being active just because I suggest it. I need to convince her of the need for more movement and help her find a reasonable activity. I hate to exercise, but I really love to dance. Does that make sense? I actually state that to my patients, and we talk about alternatives. Adults need to analyze information and synthesize it with their lifestyle.

Several years ago, my husband Jack went to the doctor after being diagnosed with type 2 diabetes. My husband is an interesting man. He is the biggest pain in the neck I ever met but an amazing man. You need to know that we live on a boat in the Florida Keys, and we worked hard all our lives to be able to do this. Jack had emergency angioplasty, and I told him in the recovery room that he was fine and that I had called the boat dealer and ordered the boat we had been debating about when the doctor told me that he was going to be fine. After such a close call, I was not going to chance waiting any longer to buy the boat. Now, that boat means everything to Jack. Our doctor told him that he now had to lose 50 pounds and start exercising. Jack said “no.” The doctor repeated that it is essential that he lose 50 pounds and exercise. Jack asked the doctor, a great friend of ours who has kept us both alive longer than we ever expected, what part of the word “no” did he not understand. Then the doctor said, “You know, Jack, if you don’t take care of yourself, you’re going to drop dead, and I know three guys who are perfect for Ginger.” Jack said, “Great, she’ll be comfortable and fine.” I am sitting there with smoke coming out of my ears, but I didn’t say a word until we got in the car. Then I clued him in. “If you don’t care who is going to be sleeping with me, I want you to think about who is going to be driving your boat.” He lost 30 pounds and started walking two miles a day. His A1C is 6%, and he will probably outlive me. The message is to talk to adults about what is important to them. Read Chapter 6 on motivation.

Oermann⁶ and Bell⁷ discuss some important variables in adult education:

readiness to learn

past experiences

health status

environmental stimuli

anxiety level

developmental stage

practice session length

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 be divided into two sections: verbal and nonverbal.

Verbal communication includes anything that uses language or words. It can be spoken, written, or sung. English is the hardest language of all because there are so many definitions for simple words. Here’s an example of a simple word that can mean many things.

Fast can mean speed, quick, hurry. It can also mean not move at all as in hold fast.