PATIENT TEACHING

Patient education is an internationally accepted basis for diabetes management and patient empowerment. Diabetes education enables patients to help identify their own needs, requirements for lifestyle adjustment, and means to prevent or delay complications. This concept is known as needs-based learning and is an important adult learning model that cultivates greater adherence to best practices (Makiling & Smart, 2020).

While certain clinicians hold specialized qualifications in diabetes education, every healthcare provider must also be knowledgeable in basic diabetes education, especially when it comes to care of the diabetic foot. For instance, several studies have shown the important role nurses play in diabetes education and providing psychological support to patients with diabetes (Nikitara et al., 2019).

The goal of diabetes self-management education is to provide the patient with the necessary knowledge and skills to incorporate practices into their daily life that will allow them to remain healthy and prevent complications. If the patient’s foot care is being performed by someone else, such as a family member, that individual, with the patient’s permission, is also included in the teaching sessions.

Teaching Newly Diagnosed Diabetes Patients

When a patient is first diagnosed with diabetes, teaching focuses on what is immediately necessary to keep the patient safe, such as learning how to check blood sugars, administer insulin, and make dietary changes. To clinicians, these actions may all seem straightforward and easy to accomplish. However, to a patient who has never held a needle or syringe or who is accustomed to eating only “junk food,” dealing with even the essentials of diabetes care can be unnerving. Clinicians must therefore see education as an ongoing process and not limited to a few sessions with a diabetes educator or a dietitian.

A frequent complaint from many patients with diabetes, particularly after they have been newly diagnosed with diabetes, is that “there is too much to remember.” Clinicians have to be mindful of this and summarize teaching into two or three major points, such as:

1. A healthier diet
2. More physical activity
3. Smoking cessation

Patients are reminded that even small advancements in these three areas will improve their general health and decrease the likelihood of developing foot problems.

Individualizing the Teaching

Although the steps in preventive diabetic foot care are basically the same for all patients, teaching is individualized to meet the particular needs of each patient. Various factors are taken into consideration when devising a teaching program, such as:

• Age of the patient. Cognitive impairment can be a significant problem for older adults. Unfortunately, it often goes undetected. One study found that doctors were not aware of cognitive deficits in >40% of their cognitively compromised patients (NIA, 2021).
• Language. Does the patient speak English, is it their first language, and is it their preferred language for health education? Will the clinician need an interpreter present for teaching?
• Literacy. One in 5 persons in the United States read at or below the fifth-grade reading level (NCES, 2019).

Clinicians must also ensure that the teaching materials are appropriate for the patient. Handing a male in his late 20s a pamphlet on daily foot inspections with pictures of an elderly male will not convey the correct message; the young patient’s unspoken response may be, “I can wait to check my feet until I’m old.” It may also be ineffective to give a middle-aged African American woman living in a rural area educational materials that portray a young White female living in an urban area. Patients must be able to identify with the examples and the instructions in the educational materials in order for meaningful learning to take place.

Clinicians must be aware of the cultural influences and health beliefs of the patient. It is important to explore with the patient what they already know about diabetes, diabetic foot care, and how diabetes is perceived in their culture. For instance, some cultures have a negative view of insulin; they believe that taking insulin will only worsen their condition or that the use of insulin could be an obstacle to their religious practices. It is important for the clinician to respect the patient’s beliefs and provide them with facts (Cervoni, 2021). If there is a concern about the effects of diabetes care on religious practices, it may be prudent to refer the patient to a religious scholar or someone in their faith community who can provide them with accurate knowledge and insights.

The role of socioeconomic factors is also part of formulating education for patients. The clinician must consider whether any of the recommended interventions will be financially burdensome on the patient. It can be easy to label a patient as “noncompliant” when the real reason they are not participating in their care is their inability to purchase the long-handle mirror, insoles, or shoes recommended by the clinician. What alternatives and suggestions can the clinician offer to help offset these costs?

Listening and Speaking Effectively

Effective listening and speaking are vital to establishing the partnership needed between the clinician, patient, and other caregivers to achieve the common goal of preventing foot ulceration.

In her highly popular book Kitchen Table Wisdom (1996, p.143), Dr. Rachel Naomi Remen writes, “I suspect that the most basic and powerful way to connect to another person is to listen, just listen. . . . When people are talking, there is no need to do anything but receive them.” When clinicians practice empathetic listening with a patient in an environment in which the patient feels “safe” to talk, they usually hear the real reasons why self-care is not being done, either directly or indirectly (e.g., “I can’t stand my wife fussing over me to check my feet; it makes me feel like an invalid”).

The clinician’s language when teaching is very important. Staying away from medical terminology and jargon as much as possible is vital for successful communication. Sometimes patients can be too stressed and too weary to request a clarification of information they may not understand. For this reason, it is helpful if a family member or other caregiver is part of the education process, with the patient’s permission.

Clinicians can probably speak volumes about the terms risk and benefit, but to many patients these terms are vague and not easily conceptualized. When teaching preventive care to a patient with diabetes, benefits and risks must be clearly explained in concrete terms.

Consistency in terminology is imperative. If during the first encounter with the patient, the clinician talks about a diabetic “foot ulcer” but at a subsequent visit refers to a diabetic “wound,” this may convey different meanings to the patient. Many people see a wound as something that is cleaned up and heals quickly, whereas an ulcer will be there for a long time.