Nurse as Educator

Introduction
There is an increasing emphasis of the importance of the role of nurses as educators and therefore is important to have an understanding of how to implement a teaching plan in clinical practice. Education of patients and family is the professional responsibility of the nurse. The nurse should aim for the patient to achieve independence in the management of their own health. This assignment will compromise of a proposed teaching plan regarding self-administration of sub-cutaneous insulin in diabetes. It will encompass a one-to-one teaching session with a diabetic patient. The aim of the teaching plan is to provide insulin dependent diabetics with the skills and knowledge to independently control their diabetes through self-administration of sub-cutaneous insulin.

Diabetes Mellitus is a metabolic disorder characterised by disturbances of carbohydrates, fat and protein metabolism which results from defects in insulin secretion or action or both (Alexander et al. 2006). There are two categories of diabetes type 1 diabetes (insulin dependent diabetes) or type 2 (non-insulin dependent diabetes). Type 1 diabetes occur when the pancreas is no longer able to secrete insulin which usually is a condition of children or young adults representing 5- 10% of cases of diabetes (Gulanick et al. 2003). Type 2 diabetes results due to a failure of pancreatic beta cells to produce sufficient amounts of insulin usually occurring in older adults (Gulanick et al. 2003).

I selected this topic as it is extremely relevant to practice as diabetes is one of the most common chronic illnesses worldwide and is predicted to increase further in coming years. According to the Diabetes Federation of Ireland (2011) 191,000 people in Ireland have diabetes, 14,000 of these accounting for type 1 diabetes. The rational for choosing to teach self-administration of insulin was influenced by the magnitude of suffers of diabetes. According to Brod et al. (2008) over 50% of diabetics are treated with insulin whether orally or via sub-cutaneous injections. Therefore I thought this was an important skill to teach to empower individuals.

For the purpose of this assignment I will discuss the development of a teaching plan using the nursing process for the following hypothetical case study. Denis is a 53 year old man who has previously diagnosed with type 2 diabetes. Measures such as diet, exercise and oral medication proved to be ineffective in lowering his blood sugars level. It was decided that Denis was to be commenced on sub-cutaneous insulin to treat the problem. Denis already has a good understanding of diabetes but needs to be thought insulin therapy.

Assessment
The assessment process will look at aspects of the individuals learning needs to determine an appropriate teaching plan specific for the individual. Gulanick et al, (2003) states that the assessment process should determine the individuals learning needs to dictate the type and amount of information needed. Neary (2000) outlines three reasons for carrying out assessments these ascertain the following: The level of theoretical knowledge The level of practical skills Insight into attitudes
The nurse as educator completes the assessment to gain insight into patient’s prior knowledge, skills and attitudes towards their condition. This enables the nurse to establish an appropriate teaching plan.
According to Bastable (2008) assessment of the learner must include: Learning needs- what the learner needs and wants to know Readiness to learn- if the learner receptive to learning Learning styles- how the learner best learns

Learning needs are defined as gaps in knowledge that exist between a desired level of performance and the actual level of performance (Healthcare Education Association, 1985). Essentially this is the gap of what someone knows and what they need to know. To obtain this information assessment strategies are implied such as informal assessments and patient-centred assessment. Informal assessments involve conversations that take place between patients and their family with the healthcare team. The nurse as educator must rely on active listening skills and pose open- minded questions that will encourage learners to reveal information about what they perceive their learning needs to be (Bastable, 2008). According to Quinn & Hughes (2007) patient centred assessment is the individual’s self-assessment of learning needs. To allow patients to self-assess their learning needs Bastable (2008) recommends asking questions such as: What do you think your problem is? What does your illness mean to you? What results do you hope to obtain from treatment? What are your strengths and weaknesses?
These purposeful questions allow the individual to discuss and contemplate their learning needs and generates a basis for the nurse as educator.

Readiness to learn is defined as the time when the learner demonstrates an interest in learning the information necessary to maintain optimal health (Bastable, 2008). Components that must be considered are physical readiness, emotional readiness, experiential readiness and knowledge readiness. The nurse as educator should be aware of the individuals own values and beliefs when assessing their readiness to learn. According to Giger & Davidhizzar (2004) patients are unlikely to accept health education unless their values and beliefs about health and illness are respected. Other factors that should be included in determining individual’s readiness to learn are knowledge deficits or physical deficits such as hearing impairment.
Learning styles must be assessed to determine the individual’s characteristics and needs, if learning is to be effective (Hinchliff, 2004). Honey and Mumford (cited in Hinchliff 2004, pp. 73) identify four categories of learners which include activists, reflectors, theorists and pragmatics. The teaching plan must consider the learning style of the individual and develop a teaching plan that is compatible to the learners preferred style.

Planning
The teaching plan allows for the identification and development of resources and strategies that the nurse as educator will need to use. Planning how you are going to teach is vital to avoid omitting vital elements of the teaching session and ensures all necessary information is included (Quinn, 2000). The establishment of the teaching plan should be a joint effort with the nurse patient and family. Teaching is most effective when the objectives of patient and nurse are in agreement (Bastable, 2008). Involving patient and family in establishing goals and in planning teaching strategies promotes their co-operation in the implementation of the teaching plan (Smeltzer et al, 2008).

For the development of a teaching plan it is imperative to draw on different types of subject knowledge. Subject knowledge is the amount and organisation of knowledge in the teachers mind which include key facts, concepts, principles and explanatory frameworks (Shulman & Grossman, 1988). The key facts to be included in the teaching plan involved the pathophysiology of diabetes and hyper/hypoglycaemia. The concepts encompassed the learning goals and intended outcomes while the principles of effectively controlling diabetes were outlined.

Learning theories are another aspect that must be considered when developing a teaching plan. The Cognitive learning theory was chosen as an appropriate approach to this particular teaching plan. The cognitive theory is based on the individual’s cognition involving their perception, thought, memory and ways of processing and structuring information (Bastable, 2007). It focuses on changing the individual thoughts process to allow for new understanding and insights. This learning theory is effective as it focuses on the learners thought process. Gagne et al. (1992) identify the elements needed for the cognitive learning: Gain the learner’s attention Inform the learner of the objectives and expectations Stimulate the learner’s recall of prior knowledge Present information Provide guidance to facilitate the learners understanding Have the learner demonstrate the information or skill Give feedback to the learner Assess the learner’s performance Work to enhance retention and transfer through application of varied practice
The following steps were guiding principles for the development of a teaching plan (see appendix) and were applied throughout to facilitate cognitive learning.

The principles of adult learning are also a consideration when developing a teaching plan. According to Quinn (2000) adult learning should imply the following: Learning occurs as a result of individuals own effort The teacher and learner treat each other as equals in the teaching and learning process The teaching method is patient-centred The individual accepts responsibility for their own learning.
The nurse as educator should encourage these principles to ensure the individual is being pro-active in their learning. The teaching plan incorporated these principles allowing participant to actively participate in the learning process. The teaching method was particularly patient-centred as it accustomed to meet the individual’s specific needs.

When developing the teaching plan a number of different learning theories were considered including the behaviourist learning theory. This theory involved the learner being passive in the learning process and learning is dependent on input from others (Hinchliff, 2004). The behaviourist theory involves two forms of learning classical conditioning and operant conditioning. This theory suggests that learning is dependent on the interaction with the contextual circumstance (Quinn, 2000). I disregarded this theory after further research as Bastable (2008) raised the issue that this is a teacher- centred model in which the learner is easily manipulated raising ethical questions about individual’s ideas of desirable behaviour. When developing a teaching plan it is important to be aware of possible barriers to teaching or learning to maximise chances of successful learning. Factors such as denial, depression or anxiety are identified as barriers to individuals participating in their own care (Valentine, 2000). If this is recognised the nurse can overcome these issues and facilitate effective learning. The problem should be discussed with the individual and treated appropriately and sensitively.

When planning a teaching session it is important to be organised and use effective time management skills. The nurse as educator should establish a suitable time with the patient and other staff members. Quiet times during the middle of the day may be must appropriate for conducting teaching sessions to avoid disruptions or the nurse having to abandon the session. The nurse should organise a suitable environment for learning and insure all related materials and resources are available.

Implementation
When the teaching plan is developed it is now time to implement the plan. The nurse as educator must deliver the information in an appropriate manner. According to Smeltzer et al. (2008) for effective learning the teacher must use appropriate language that the individual can understand and relate to. Simply avoid using medical terms and explain the condition using comprehendible language.

To keep the learner interested during the session the nurse as educator should use visual aids and encourage active participation in the session. Use appropriate teaching and internet resources if appropriate along with encouraging individual to participate actively in learning (Smeltzer et al. 2008). Using a variety of teaching aids promotes retention of information. Visual aids and practising psychomotor skills achieve better retention of learning than continuous teacher transmission (Quinn, 2000). During the implementation of the teaching plan diagrams were used along with the individual practising sub-cutaneous injections.

While implementing a teaching plan it is vital to keep the learner motivated to facilitate effective learning. Motivation is described as a willingness of the learner to embrace learning, with readiness as evidence of motivation (Redman, 2007). To aid with motivating the individual throughout the session the following factors were considered that can facilitate or block learning (Bastable, 2008): Personal Attributes- physical, developmental and psychological components Environmental influences- physical and attitudinal climate Learner relationship system- significant others, family and teacher- learner interaction.
Maslow’s Hierarchy of needs was also considered in promoting motivation for learning this involved promoting a suitable, safe and welcoming environment where the student is valued and respected and their individual needs are met.

I chose a one-to-method of teaching as it was most suitable for this teaching plan as it involves delivering information specifically designed to meet the needs of an individual learner (Bastable, 2008). Experiential learning was most suitable in the delivery of much of the information, a degree of lecturing was also used. Experiential learning is doing rather than listening to information. According to Quinn (2000) the key characteristics of this form of learning is active learner involvement, a degree of interaction, measures of autonomy and flexibility along with a high degree of relevance. This approach was suitable for the implementation of this teaching plan as the learner was involved in completing physical skills regarding their care.

Assessment and documentation
Assessment and evaluation are often used interchangeably (Hinchliff, 2004) but there are significant differences. The assessment measures student learning which is achieved as a result of a learning situation while evaluation is a series of activities that are designed to measure the effectiveness of the teaching system as a whole (Ellington et al. 1993).

The assessment is the collection of data on which to base the evaluation and is descriptive and objective (Hinchliff, 2004). The assessment strategies I have chosen are questions and answers, interviews and observations (see appendix). These strategies allow for the collection of data to determine if learning was successful. Assessments are learning experiences that can enhance content understanding and promote the skills of the individual.

Evaluation
The evaluation of the teaching process determines if goals have been achieved. According to Hinchliff (2004) evaluation is the process of making judgements and decisions about achievements, expectations and the effectiveness of the plan. To establish an evaluation tool I used the following steps outlined by Smeltzer et al. (2008): Collect object data Determine if goals were achieved Include patient, family, significant others in evaluation Identify alterations that need to be made to the teaching plan Make referrals to appropriate sources after discharge Continue all steps of the teaching process
The main goal of the evaluation is to determine elements that can be changed to improve the teaching plan. The evaluation tool I used was a questionnaire to determine if the individual achieved the learning outcomes and if they were content with the material that was covered (see appendix).
Evaluation is not the final step in the teaching process but the beginning of a new assessment, the information gathered in the evaluation process should modify a new teaching plan to improve learning outcomes (Smeltzer et al. 2008). The nurse as educator should constantly be striving to improve teaching and learning within the clinical environment.

Conclusion
To conclude this teaching planned discussed the important aspects to consider when generating a teaching plan. Concepts of this teaching plan can be used to develop teaching plans regarding any clinical topic for education. This assignment was helpful to furthering my knowledge in the importance of the nurse as educator and I will implement such teaching plans in practice.

References
Alexander M. ,Fawcett J. & Runciman P.(Ed.) (2006) Nursing Practice Hospital and Home. 3rd edn. Churchill Livingstone Elsevier, London.
Bastable S.B. (2008) Nurse as Educator: Principles of Teaching and Learning for Nursing Practice. 3rd edn. Jones and Bartlett Publishers, London.
Brod M., Kongs J.H., Lessard H & Christensen T.L. (2008) Psychological insulin resistance: patient beliefs and implications for diabetes management. Qual Life Res, (Electronic) 18, 23-32, Available at: http://download.springer.com/static/pdf/428/art%253A10.1007%252Fs11136-008-9419-1.pdf?auth66=1354981682_157e4d3bf5f678115300cba8dd162690&ext=.pdf (Accessed 6 December 2012).
Diabetes Federation of Ireland (2011) Diabetes Action. (Internet) Available at: http://www.diabetesaction.ie/diabetes-in-ireland (Accessed 6 December 2012).
Ellington H., Percival F & Race P. (1993). Handbook of Educational technology. 3rd edn. English National Board for Nursing, London.
Giger J. N & Davidhizar R. E (2004) Transcultural Nursing: Assessment and Intervention.4th ed. St Louis, Mosby.
Gulanick M., Myers J., Klopp., A., Galanes S & Puzas M. (2003) Nursing Care Plans.5th edn. St. Louis, Mosby.
Healthcare Education Association. (1985) Managing Hospital Education. Laguna Niguel.
Hinchliff S. (Ed.) (2004) The Practitioner as Teacher. 3rd edn. Elseveir, Philadelphia.
Neary M. (2000) Teaching, Assessing and Evaluation for Clinical Competence: A Practical Guide for Practitioners and teachers. Nelson Thornes, Cheltenham.
Quinn F. M. (2000) The Principles and Practice of Nurse Education, 4th edn. Nelson Thornes, Cheltenham.
Quinn F. M & Hughes S. J. (2007) Principles and Practice of Nurse Education, 5th edn. Nelson Thornes, Cheltenham.
Redman B. K. (2007) The Practice of Patient Education: A case study approach. 10th edn. St. Louis, Mosby.
Shulman and Grossman (1988) Knowledge Growth in Teaching: a final report to the
Spencer Foundation. Stanford, CA, Stanford University.
Smeltzer S.C., Bare B.G., Hinkle J.L & Cheever K.H. (2008) Textbook of Medical- Surgical Nursing . 11th edn. Lippincott Williams & Wilkins, Philadelphia.

Valentine V. (2000) Educational Strategies at Diagnosis and Beyond, or Diabetes, Type 2, and What to Do. Diabetes Spectrum, (Electronic) 13(4), 197, Available at: http://journal.diabetes.org/diabetesspectrum/00v13n4/page197.asp (Accessed 6 December 2012).

Appendices
Teaching Plan
Subject: Diabetes
Topic: Self-administration of subcutaneous insulin
Target Audience: Newly diagnosed diabetic
Duration of lesson: 15 minutes

Previous Knowledge and Experience of Condition:
This teaching plan is based on an individual who has a basic knowledge of the pathophysiology of diabetes. They have an understanding of the rationale for insulin administration.
This lesson will rely on their previous knowledge of their condition to further their participation in the management of their diabetes.

Aims: To develop individuals knowledge of diabetes and become independent in its management

Objectives: To be aware of signs and symptoms of hyperglycaemia and hypoglycaemia To be competent in checking blood sugars To be aware of actions to take if blood sugars are undesirable To administer insulin safely and effectively
Organisation of learning: Time | Content and Development | Method | Rationale | Learner Activity | Assessment | 2mins | Re-cap on knowledge of diabetes | Direct Questioning | Identify previous knowledge | Direct answering of question | Verbal feedback to identify prior learning | 2mins | Introduce to session. Aims and learning outcomes. | Teacher transmission | Highlights structure of lesson | Listening with opportunity to ask questions | Identifies prior knowledge | 3mins | Development 1 Question knowledge: -What are signs and symptoms of hyper/hypoglycaemia? -What actions to take if undesirable? -Discuss checking blood sugars? -Discuss administration of blood sugar? | Teacher transmission with direct questioning | Assess understanding. Provide feedback | Listening and answering questions | Assessment of knowledge. | 5mins | Development 2 Demonstrate checking blood sugars and rationale. | Teacher demonstration Learner performs skill | Enhances transmission of information by using tangible equipment. | Demonstrating skill and questioning. | Allows visual assessment. | 2mins | Development 3 Identify injection sites. Identify sub-cutaneous tissue on diagrams. | Teacher transmission with direct questioning. Diagrams of subcutaneous tissue | Visualisation aids retention of learning. | Listening with opportunity to question | Allows assessment of prior knowledge | 5mins | Skills video demonstrating administration of sub-cutaneous injections | Watch audio with direct questioning | Demonstration enhances transmission of information. | Watching, listening and questioning where appropriate | Verbal feedback | 3mins | Learner performs sub-cutaneous injection under direct supervision | Learning performs skill encouragement from teacher | Given opportunity to practice psychomotor skill in safe environment | Performs skill and listens for instructions | Allows visual assessment of skill | 3mins | Discussion of sharp disposal and insulin storage | Teacher transmission and direct questioning | Reinforces learning allows teacher expand on subject further | Listens and asks questions | Assessment of knowledge | 2mins | Re-cap on what is learned | Teacher transmission | Reinforces lesson content and signposts end of lesson | Any questions about content | Allows assessment of what has been learnt and retained during the session |

Assessment Strategy Assessment Tool | Description | Example | Questions and answers (orally) | Allows teacher to assess individual on previous knowledge and understanding. | Questions and answers regarding diabetes | Observations | Teacher observes learner performing skills | Performing blood glucose checks. Administering insulin injections | Interviews | Informal interviews to determine individuals perception of their condition | Open informal discussions with individual and family. |
Evaluation Tool
Circle the number to indicate your level of agreement/disagreement with each of the aspects of course design.
1= Strongly Agree
2=Agree
3= Neutral
4=Disagree
5=Strongly Disagree
Section A
1. The session content met my needs. 1 2 3 4 5
2. Length of the session was adequate 1 2 3 4 5
3. What did you like most about the session?

4. What specific things did you like least about the course?

5. If the course was repeated, what would you change?

Section B
1 .Increased Understanding of diabetes 12345
2 .Aware of signs and symptoms hypo/hyperglycemia 12345
3. Competent in checking blood sugars 1 2 3 4 5
4. Awareness of actions to take if BSL undesirable 1 2 3 45
5. Competent in administering sub-cutaneous insulin 1 2 3 4 5
6. Knowledgeable of safe practice 1 2 3 4 5
7. Knowledge of sharps disposal12 3 4 5

Section C
1 Content was presented in an organized manner12345
2. Content was presented clearly and effectively 12345
3. Educator was responsive to questions/comments12345
4. Teaching aids were used effectively12345
5. Teaching style was effective12345
6. Content met stated objectives12345

Overall I would rate this workshop as:
___Excellent
___Good
___Average
___Poor

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