Teaching self-administration of insulin to newly diagnosed diabetic patients

Clinical Learning Outcomes

Interaction of Variables.

Evaluating clinical learning outcomes

Describe the skill and the learner you intend to teach and evaluate

Because of cutbacks in the number of days new patients are allotted to spend in the hospital, patients and their families are increasingly responsible for more of the patient's care, even immediately following a diagnosis of a serious illness such as type I, or juvenile, insulin-dependent diabetes. Teaching patients to correctly monitor their blood sugar and self-administer insulin is essential, but it requires a high level of patient compliance and willingness to learn. It is essential that young patients and their parents have a thorough understanding of the process.

Briefly describe how you would design the learning experience

Learning is a step-by-step process. It is important not to bombard patients with knowledge right away, when they are still frightened and confused. Also, although there are real risks with insulin injection, these risks should not be presented to the patient before he or she even attempts the injection.

First ask the patient what he or she knows about diabetes, so the nurse-educator can build upon that knowledge. The patient might say: "I know I have a problem because my body doesn't make insulin." Then, explain how injected insulin can remedy that problem by controlling blood glucose levels. "Better to start with what patients see as the most frightening aspect of self-administration -- the injection itself. After your patient has mastered this, learning will be easier" (Hahn 1990: 70). Before the learning process even begins, the patient should have received administered insulin injections by a health practitioner and have been encouraged to 'watch' how this was done, to enable him or her to learn visually. In addition to the visual reinforcement, the patient can feel the injection, which will reduce the fear of intense pain that many patients (especially young patients) have regarding injections.

To make the self-administration process seem less 'scary,' the nurse should show the basic syringe or insulin pen that will be used for the injections. Next, the patient should have the opportunity to 'practice' on an orange or on something that will allow him or her to understand the mechanics of the operation in a safe fashion. Parents may be asked to experiment with injections. If they are confident with using the implements, the child is more likely to be willing to role-model the behavior. Only after these initial, non-intimidating steps are undertaken should the patient then be allowed to engage in self-administration of the insulin injection. The nurse should take the patient step-by-step through the process, slowing down whenever necessary for questioning.

Checking blood glucose levels and balancing insulin injections with the consumption of food takes time, and will vary with every patient. Monitoring diabetes is often more of an art than a science. Although the patient must be aware of the need for treatment refinement and the potential risks, the nurse should address concerns such as balancing insulin levels with food and needle sterility afterward. Emphasizing the mechanics first and then addressing other concerns reduces the intimidation factor of the first injections.

How your evaluation plan demonstrates sound educational practices for clinical learning

Learning ideally builds upon existing knowledge. Patients feel more confident and are more receptive to learning when they feel that they have some pre-existing basis of knowledge of the skills they are learning. Being able to 'practice' or over-learn a process makes the mechanics seem more natural. Role-modeling the action of others provides visual as well as emotional reinforcement. The final test, however, is when the patient can perform the injections independently, or with parental supervision alone at home, and is able to remain medically stable regarding his or her illness in a reasonable and independent fashion. This, like all diabetes-related skills, is a lifelong process, and there is no 'final exam' that can determine a person deserves an 'A' in insulin monitoring. However, patients should be able to report back to the treatment team that their confidence regarding injections has grown, that they no longer feel fear or anxiety about the process. Their lab reports and measurable symptoms should support this positive self-report as well.