Patient Education and Counseling 35 (1998) 139–147

Learning difficulties of diabetic patients: a survey of educators

*´Caroline Bonnet, Remi Gagnayre, Jean-Francois d’Ivernois

´Health Sciences Education Department, A WHO Collaborative Centre for Health Care Personnel, UFR-SMBH Leonard de Vinci,74 Rue Marcel Cachin, 93017 Bobigny Cedex, France

Received 12 May 1997; received in revised form 9 February 1998; accepted 16 February 1998

Abstract

This study was designed to shed light on the learning difficulties of diabetic patients. An open-ended questionnaire wassent to 85 health care professionals working in the field of diabetes and nutrition who had been trained in patient educationtechniques. They were asked to describe the skills that were the easiest to teach patients and those that patients mastered thebest, as well as the skills they found hardest to teach patients, those that patients mastered the least and those that gave rise toerrors persisting after the patients education was completed. On the whole, the results showed that the educators found iteasy to teach techniques: patients mastered procedures well and made few mistakes. In contrast, diabetic patients seem tohave problems learning skills, such as insulin dose adjustment, that require complex problem-solving (involving multiplevariables). Based on these findings, the authors discuss the notions of learning complexity and the time needed for successfulpatient education. 1998 Elsevier Science Ireland Ltd. All rights reserved.

Keywords: Learning difficulties; Diabetic patients; Educators

from team to team [4]. We showed in an earlier study1. Introductionthat diabetes educators employ a wide range ofteaching approaches, although a few programmePatient education has been an integral part ofmodels tend to predominate [5].diabetes treatment for over 30 years. In all countries,

Consequently, the real problem today is not toit is agreed that educating diabetic patients is effec-demonstrate the effectiveness of diabetic patienttive, particularly in reducing the number of hospitali-education, but to determine which pedagogical ap-zations, improving glycemic balance and reducing orproaches are more effective [6].delaying complications [1–3]. In France, nearly all

A recent survey by Albano [7] of the ‘‘Medline’’diabetes departments have instituted patient educa-literature published over the last 10 years (1986–96)tion programmes, but they are not uniform and varyfound that, of 57 401 references on diabetes, 9111mentioned patient education, 946 focused on the

*Corresponding author. education of diabetic patients and just 38 presented

0738-3991/98/$19.00 1998 Elsevier Science Ireland Ltd. All rights reserved.PI I : S0738-3991( 98 )00051-2

140 C. Bonnet et al. / Patient Education and Counseling 35 (1998) 139 –147

random experimental studies. In those 38 experi- seven physicians; (ii) six dieticians and (iii) 72ments, the general objectives were defined in 57% of nurses.the cases, and the specific objectives, in 43%. The For inclusion in the sample of health care profes-teaching methods were interactive in 60% of the sionals, a caregiver had to: (1) work in the field ofcases, and multi-disciplinary teams provided the diabetes and nutrition; (2) be actively involved ininstruction in 51%. patient education and (3) have undergone formal

Another question of interest to educators concerns training in diabetic patient education.the amount of time required to educate IDDM and Personally-addressed questionnaires were sent toNIDDM patients, both initially and in continuing 212 diabetes / internal medicine and diabetes depart-education. A recent survey [6] of 400 caregivers ments in 143 French cities. The sample was drawnindicated that 8 to 10 h were needed for the initial from a total of 400 caregivers who had completededucation of IDDM patients, and 12 to 14 h for their the training organized by the Institut de Perfectionne-

´follow-up training. The initial education of NIDDM ment en Communication et Education Medicalepatients normally required 5 to 6 h and their continu- (IPCEM, Institute for Advanced Medical Communi-ing education, 8 to 10 h. cation and Education) within the last four years. The

Our approach to the problem of the right education response rate was 40% (n 5 85). The questionnairefor diabetic patients (IDDM and NIDDM) is some- contained five open-ended questions (Table 1) and awhat different. Independent of programme type or space for additional comments. It was made cleartraining duration, we wondered which skills were the that the word ‘‘skills’’ included not only cognitiveeasiest to teach patients, which were the hardest to skills (knowledge, reasoning ability), but also techni-teach them and which ones diabetics were still the cal skills (abilities) and attitudes.weakest in after their education was completed. The The responses obtained were analyzed using thepurpose of this study was to determine the relative content analysis method; they were broken down intodifficulty of achieving the various objectives of 26 response sub-categories and then those responsesdiabetic patient education, so that health profession- were grouped into nine categories (Table 2). Inals can rethink their teaching methods and better analyzing questions 1 to 5, the responses were talliedestimate the time needed for it. Thus, we surveyed a by category with allowance made for synonyms andsample of 85 French caregivers, all involved in the equivalent responses. The different groupings ex-education of diabetic patients. plain why in some cases the number of responses

exceeded the number of respondents.Additional comments were not classified into

2. Methods groups. The correlation between the number ofresponses to the questions was determined using the

The group surveyed consisted of 85 respondents. Spearman rank correlation test, and the usual level ofTheir professional breakdown was as follows: (i) p 5 0.05 or better was considered significant.

Table 1Questionnaire sent to the caregivers

National survey on the education of diabetic patients

Question 1 As an educator, what skills do you consider to be the most difficult to teach diabetic patients (IDDM and NIDDM)?]]]]]]

Question 2 As an educator, what skills do you consider to be the easiest to teach diabetic patients (IDDM and NIDDM)?]]]]]

Question 3 During your various evaluations, which skills do you find patients have mastered the least well?]]]]]]]

Question 4 During your various evaluations, which skills do you find patients have mastered the best?]]]]]

Question 5 In your experience, which errors do patients persist in making, even after continuing education?]]

Your comments on any aspect of patient learning difficulties

C. Bonnet et al. / Patient Education and Counseling 35 (1998) 139 –147 141

Table 2Response categories (9) and sub-categories (26), defined after analyzing caregiver responses using the content analysis method

Illness (diabetes) Self-monitoring Disease management

General knowledge Urinary monitoring technique Adjustment of dosesKnowledge of complications Blood glucose level monitoring technique Adjustment of physical activity

Notebook record Adjustment to new situationsPrevention /consultation / follow-up

Intrepretation of results RestrictionsReasoning logicCompliance with treatment (NIDDM)

Hypoglycaemic episodes Hyperglycaemic episodes Insulin

Recognition, prevention What to do Preparation / injection techniqueWhat to do Rotation of injection sites

Diet, nutrition Hygiene /Aespsis Behaviuor /attitude

Nutritional balance /monitoring Foot care AcceptanceGlucide equivalencies Motivation /confidenceLipid checks Personal support system

Adjustment and change in habits

3. Results mastered the least well (15 /220) and in which theycontinued to make errors after education (16/171).

The analysis of responses produced several inter- This seems especially true of foot care instruction.esting findings (Table 3). On the whole, management Other patient education objectives seemed easierof their illness seems to be the hardest thing to teach to achieve, and patients mastered those areas better.diabetes patients (cited 96 times). Patients showed Examples include self-monitoring, the easiest tothe poorest mastery of management skills (cited 85 teach (mentioned 92/210) and the best mastered skilltimes), which gave rise to a large number of persist- (94 /199). In particular, patient monitoring of blooding errors (cited 60 times) after training was com- glucose levels ranked as the easiest skill to teachpleted. (52 /92; best mastered 58/94; with no errors persist-

The complexity of learning to adjust insulin doses ing after education). Patient urine self-checks cameis what make diabetes management so difficult to in second (easiest skill, 25 /92; best mastered, 26/94;instil. Insulin adjustment was the skill that was with no persisting errors).hardest to teach (mentioned 51 times out of 96) and Insulin injection techniques also seem fairly easymastered most poorly (54/85), with persisting errors to teach (cited 57/210 as the easiest skill to teach,(35 /60). The difficulties with management also stem mentioned 54/199 as the best mastered and with nofrom the complexity of diabetic diets (48/239 as the persisting errors after education). On the other hand,hardest; 33 /220 as the least well mastered; and caregiver opinions concerning teaching injection-site38/171 as causing persisting errors), notably because rotation were less conclusive.of the need to maintain and follow a specific Comparisons were made of the educators’ opin-nutritional balance (hardest skill, 30 /48; lowest skill ions of the difficulty of teaching patients what to domastery, 20 /33; persisting errors, 33 /38). in the event of hypoglycaemia and hyperglycaemia.

It also appears difficult to change patients’ at- Nineteen respondents considered handling hypo-titudes toward their illness, mainly because of the glycaemia an easy skill to teach, one that patientsdifficulty in changing habits. Respondents rated mastered well, although some errors persisted afterhygiene and asepsis as difficult habits to instil (16 / education (cited 11/62). Hyperglycaemia is a differ-239). Both ranked among the abilities patients ent story. The skills needed to deal with excess blood

142 C. Bonnet et al. / Patient Education and Counseling 35 (1998) 139 –147

Table 3Caregiver responses, by categories (9) and sub-categories (26)

Categories and Quest 1 Quest 2 Quest 3 Quest 4 Quest 5 Frequencysub-categories Hardest Easiest Lowest level Highest level Persisting

skills skills of mastery of mastery errors

Knowledge of the disease 19 11 12 10 3 55General knowledge 13 10 8 10 3Knowledge of complications 6 1 4 0 0

a aSelf-monitoring 10 92 9 94 3 208Urinary technique 1 25 1 26 0Blood glucose level technique 5 52 2 58 0Notebook record 4 9 6 7 3Interpretation of results 3 0 10 0 1

a a a bDisease management 96 11 85 12 60 278Adjustment of insulin doses 51 1 54 2 35Adjustment of physical activity 8 2 1 0 6Adjustment to new situations 5 0 9 0 2Prevention /consultation / follow-up 17 5 13 6 10Restrictions 5 0 3 3 5Reasoning/ logic 4 0 1 0 0Compliance with treatment (NIDDM) 3 3 0 1 0

aHypoglycaemic episodes 5 19 8 19 11 62Recognition /prevention 0 2 2 5 3What to do 5 17 6 12 8

a a aHyperglycaemic episodes 11 3 27 1 14 56What to do 10 0 23 0 14

Insulin 4 60 10 56 6 136Technique: preparation / injection 1 57 3 54 0Rotation of injection sites 3 3 7 2 6

Diet /nutrition 48 8 33 5 38 132Nutritional balance /monitoring 30 3 20 4 33Glucide equivalencies 18 3 13 0 3Lipid checks 0 2 0 1 2

Hygiene /asepsis 16 5 15 1 16 53Foot care 9 3 11 1 9Other 7 2 4 0 7

aBehaviour /attitude 27 1 11 1 19 59Acceptance 8 0 3 0 2Motivation /confidence 3 0 1 1 4Personal support system 3 0 4 0 2Adjustment /change in habits 13 1 3 0 10

Total 239 210 220 199 171a Indicates a higher total for the category than for the sub-categories that make it up, because of responses matching the category designationalone. Example: Self-monitoring, question 2: category 5 92, sub-categories 5 86. Six of the responses consisted of ‘‘self-monitoring.’’b The citation frequency of the interpretation of results sub-category was added to the citation frequency of the category.

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Table 4Frequency distribution of caregiver responses, ranked in decreasing order on the 26 sub-categories

Hardest skills (n 5 239) Easiest skills (n 5 210) Skills with the lowest Skills with the highest Persisting errorslevel of mastery (n 5 220) level of mastery (n 5 199) (n 5 171)

1. Adjustment of insulin 1. Insulin injection technique; 57 1. Adjustment of insulin 1. Technique for patient monitoring 1. Adjustment of insulindoses; 51 doses; 54 of blood glucose level; 58 doses; 35

2. Nutritional balance; 30 2. Technique for patient monitoring 2. What to do in case of 2. Injection technique; 54 2. Nutritional balance; 33of blood glucose level; 52 hyperglycaemia; 27

3. Glucide equivalencies; 18 3. Technique for patient monitoring 3. Nutritional balance; 20 3. Technique for patient monitoring 3. What to do in case ofof urine; 25 of urine; 26 hyperglycaemia; 14

4. Prevention / follow-up 4. What to do in case of 4. Glucide equivalencies prevention 4. What to do in case of 4. Prevention / follow-up//consultations; 16 hypoglycaemia; 17 /consultations / follow-up; 13 hypoglycaemia; 12 consultations,

Changes in habits; 10

5. Changes in habit and 5. General knowledge; 10 5. Foot care; 11 5. General knowledge; 10 5. What to do in case ofgeneral knowledge; 13 hypoglycaemia, Foot care; 11

144 C. Bonnet et al. / Patient Education and Counseling 35 (1998) 139 –147

glucose were rated harder to teach (cited as a harder tionnaires) [8,9]. The method was chosen in order toskill 11 /56; as less well mastered, 27/56; and give caregivers time to think and prepare consideredsubject to persisting errors, 14 /56). written responses to the questions. Given the high

For patient knowledge of diabetes, general knowl- workload of medical teams during the day, theedge about the disease (physiopathology, knowledge authors felt that any other survey method (telephoneof the role of insulin, knowledge of food categories) interviews for example) would be more difficult towas separated from knowledge of the complications carry out and, most important, would not giveof the illness in the response sub-categories. The respondents the time they needed to think about theresponses indicated that patients do not invariably questions.find this kind of knowledge easy to acquire. Care- Another limitation was that caregivers weregiver opinions were mixed. Nineteen of them consid- questioned about the difficulties of educating bothered such knowledge difficult to teach and that IDDM and NIDDM patients. Theoretically, the twopatients failed to master it (12 /55). On the other types of diabetes call for distinct objectives andhand, 11 caregivers found general knowledge and educational programmes, except for the NIDDMknowledge of complications easy to teach, and patients (usually insulin-dependent) taught andbelieved that their patients had mastered them well treated in hospitals. In France, it is primarily patients(10/55). in this NIDDM category that take part in the same

Table 4 lists the five most frequently cited sub- teaching programme as IDDM patients. The othercategories, in descending order, for each question. NIDDM patients are usually treated and taught, ifThis summary illustrates the hierarchy of complexity they receive instruction at all, by general practition-of the skills to be taught, the degree of their mastery ers outside a hospital setting.by patients and the rate of errors persisting after Moreover, the study obviously could not bring outcompletion of patient education (Table 4). On the the kind of treatment the patients were receiving, awhole, caregiver responses were consistent. When it factor that might have influenced the caregivers’comes to response categories, there was a positive responses. However, the fact is that the surveyoverall correlation between the number of times the focused on the difficulties in teaching diabetic pa-categories ‘‘Disease management’’, ‘‘Diet /nutri- tients from the standpoint of those doing the teach-tion’’, ‘‘Behaviour /attitudes’’, ‘‘Hygiene /asepsis’’ ing. The questions posed were broad and openand ‘‘Hyperglycaemic episodes’’ were cited as the enough to bring out nuances or concepts particular tomost difficult skills and the number of times they patient type in responses involving treatment strate-were rated as the most poorly mastered by patients gies. Moreover, educational programmes in France(r 5 0.94; p 5 0.02). The skills considered the most differ considerably from one clinical department todifficult to teach were also the ones with the highest another [5]. However, the most common patientrate of persisting errors (r 5 0.95; p 5 0.04). The education programme in diabetes departments is theskills considered easiest-self-monitoring, insulin, week-long course, that is, a five-day hospital stayhypoglycaemia-were mastered the best by patients during which patients are studied and taught.(r 5 0.98; p , 0.01), although some errors persisted Judging from the responses given to the open-(for instance, concerning what to do about hypo- ended questions, the respondents cited the sameglycaemia). topics and goals (knowledge of the illness, adjust-

ment of insulin doses, hypoglycaemia, etc.) apparent-ly regardless of programme type. This suggests that

4. Discussion the pedagogical differences among patient educationprogrammes for diabetics have more to do with the

While this study had certain limitations, chief educational techniques, order in which topics areamong them being the fairly small number of taught, emphasis on specific objectives, programmerespondents, the percentage of returned ques- length and composition of the instructional team.tionnaires is acceptable for the type of survey The basic objectives of diabetic patient educationmethod employed (i.e., mailed, open-ended ques- appear to be identical for all the respondents, sug-

C. Bonnet et al. / Patient Education and Counseling 35 (1998) 139 –147 145

gesting that the difficulties they mentioned are amount of food they ate using measurements thatcommon. were more real to them and convenient to use in their

The most important finding of this study is that the daily lives, such as units, teaspoons or plates [12].greatest difficulty is found with cognitive skills The educators surveyed felt that patients also hadinvolving interpretation of information and problem a problem learning and applying strategies for deal-solving. At work is a process described by cognitive ing with hyperglycaemia and hypoglycaemia. Apsychology researchers [10] as: a shift from lower- major stumbling block in teaching patients how tolevel cognitive skills (memorization or simple re- manage hyperglycaemia is the complexity in teach-tention of information from authoritative sources) to ing them the concept of acetonuria (often associatedhigher intellectual skills (analysis, assessment and in educator responses). Thus, persisting errors afteracceptance of personal responsibility for ones education usually seem to stem from a poor integra-choices). tion of information on the part of patients. In

Insulin dose adjustment ranks at the top of skills contrast, information on how to deal with episodes ofeducators believe patients have mastered the least hypoglycaemia appears easy to teach and patientswell (and which generate a high number of persisting master it well. Nonetheless, the educators notederrors after education). The difficulty seems to stem persisting errors after education, raising questionsfrom the complexity of the task. about the patients’ ability to apply their knowledge

Indeed, patients must make a decision (to adjust in a crisis. It is reasonable to conclude that improv-insulin doses) based on earlier information (previous ing knowledge about hypoglycaemia does not neces-doses of insulin injected), current information (re- sarily lead to a change in behaviour towards hypo-sults of blood glucose level checks) and anticipated glycaemia. An earlier study by Beeney and Dunnfactors, such as physical exertion and food intake. [13] suggested as much when it confirmed that betterConsequently, they must incorporate different vari- knowledge of the causes of hypoglycaemic episodesables in three time frames (past, present and future) was not a predictor of changes in their frequency.in their reasoning, and patients might view this as an The study concluded that education needed to focusadditional obstacle for someone forced to live ‘‘day on the observable behaviours and attitudes of pa-to day’’. tients.

Second, special dietary requirements also demand One obstacle cited by caregivers to changingreasoning and decision-making based on multiple patient attitudes about their illness is motivation.variables. According to the responses given by the Behaviours that demand discipline on a daily basis,educators, patients seem to have more trouble learn- such as foot care, also seem difficult to instil ining procedures than they do theoretical or factual patients. In the opinion of the educators, this appearsinformation. Once again, we run up against a prob- to have nothing to do with the content of instruction,lem that has long been recognized: diabetics’ poor but rather stems from the difficulty of motivatingcompliance with their prescribed diets. In dietetics, patients sufficiently to overcome their resistance tocontrolling glucide equivalencies is an especially the burden of regular monitoring and care (as withacute problem. The prospective study by Mulloch et foot care). However, we believe that such an analysisal. [11] showed that new educational methods (such obscures other aspects of the problem of teachingas hands-on experience at meal-times or videocasset- foot care to patients. It has been noted, for example,te instruction) are more effective than conventional that patients often do not understand the meaning ofdietary instruction sheets. The authors demonstrated terms used during podology consultations [14].that these hands-on and visual methods have a strong Technical terms can be memorized without neces-influence on knowledge, compliance and metabolic sarily being understood. When the perceived messagecontrol in diabetic patients. A survey of glucide is not correct, the ensuing behaviour is likely to beequivalence instruction given to IDDM and NIDDM incorrect as well. This has also been shown in thepatients has also shown that, on their return home, case of patients’ understanding of certain medicalthey had trouble weighing their food as they had terms used in connection with diabetic retinopathybeen taught. Patients preferred to estimate the [15]. In both these studies, the authors were surprised

146 C. Bonnet et al. / Patient Education and Counseling 35 (1998) 139 –147

that socio-cultural variables had no effect on pa- educators surveyed, the three hardest skills to teachtients’ understanding of medical terms. It seems diabetic patients are those involving relatively com-therefore essential that caregivers verify that their plex tasks that demand real reasoning ability, such aspatients have in fact understood, whatever their adjusting insulin doses.background. Patients show the lowest levels of mastery and the

In general, this study shows that the content of highest rates of persisting errors for skills thatdiabetic patient education is far from uniform both in require them to solve problems involving multipleterms of the number of concepts taught and the variables. In contrast, teaching practical techniquescomplexity of the cognitive structures of which those seems much easier; patients learn hands-on skillsconcepts are a part. There is a pedagogical lesson to well and make fewer errors. This is consistent withbe learned here: the hardest skills to teach patients what has long been known in the field of education,require a greater investment of time along with namely that mastering a reasoning or decision-mak-specific teaching methods to facilitate learning (case ing process requires more effort than learning factualstudies, problem solving, etc.). Moreover, the time information or technical procedures. Consequently,scheduled for patient education must be based on the the amount of time devoted to teaching reasoning ordifficulty of the skills to be taught and not be set a decision-making to diabetic patients should not bepriori. Other studies are required to determine the set a priori by caregivers, but established in accord-average amount of time patients need to master each ance with how complex patients find these skills toof the basic objectives in their training. When figures learn.are given for the number of hours required for Since this study surveyed a small number ofdiabetic patient education, it is possible that, once educator /caregivers, further studies on a larger sam-again, teaching time is confused with learning time ple of professionals (physicians, nurses, dieticians)[6]. are needed. In addition, the survey solicited the

Such confusion is common in nearly all areas of opinions of educators only, and not patients. That iseducation. Programme directors and instructors de- why we have initiated another nation-wide study,cide the amount of time needed to learn a discipline this time with diabetic patients, to ascertain the careor subject based on criteria that may be more and management topics they find easy or difficult to‘‘teacher-centred’’ than ‘‘student-centred’’. Admit- grasp.tedly, curricula cannot be extended indefinitely. Butin the case of patient education, educators whomonitor their patients’ health over the course of Acknowledgementsmany years have the opportunity to see them regular-ly. Consequently, they have more time to ensure that The authors would like to thank Dr. Jean-Lucespecially difficult skills are mastered [16,17]. ´Bosson of the Service d’Information Medicale at the

Centre Hospitalier Universitaire de Grenoble(France) and the Institut de Perfectionnement en

5. Conclusion ´Communication et Education Medicales (IPCEM),`13 Rue Jean Jaures 92807 Puteaux (France), for their

Several authors [17,18] have pointed out how help.difficult it is to educate patients, given their diversebackgrounds, varying degrees of motivation anddiffering learning abilities. This study focused solely

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