Introduction

This paper proposes a teaching activity I could undertake to help patients in their self-management of type 2 diabetes. The teaching activity is designed to train two learners who will be referred to as Sam and Mary, which are not real names of the intended learners as required by the Nursing and Midwifery Council code of conduct and Data Protection (2015). The activity aims at improving the self-management of type 2 diabetes by training the skill of maintaining a persistent exercising schedule. As explained by Kolka (2013), exercising remains a common natural method of managing diabetes. The paper will look at the context of the activity and describe how the activity could be undertaken effectively. Aspects of behaviourist learning theory, as portrayed by Thorndike, will be employed to critically analyse how the training activity is designed and how effective it can be. The conclusion will be a reflection of how the knowledge gained from the training exercise can have a positive impact on the effective management of type 2 diabetes in the U.K.

Description

This paper is proposing a teaching activity that will enhance the self-management of type 2 diabetes by maintaining a persistent schedule of exercising. Type 2 diabetes is a prolonged condition where the blood sugar becomes too high. Type 2 diabetes affected more than 3.8 million people in the U.K. by 2018, and this number is estimated to rise to 5 million by 2025 (Diabetes U.K., 2019). An estimated 90% of diabetic people have type 2 diabetes, which makes it both costly and time-consuming to manage (NHS, 2017). Unlike type 1 diabetes, type 2 diabetes is not dependent on insulin (IDF, 2019). While there are drugs used in the management of type 2 diabetes such as metformin, such drugs have side effects such as weight gain or loss, diarrhoea, and swollen ankles. Considering the high cost of type 2 diabetes management and the side effects of drugs used, self-management using natural methods is significant. Maintaining a persistent exercising schedule is a natural way of keeping the blood sugar at moderate levels, and individuals can easily manage independently (Colberg et al., 2016).

The proposed teaching plan is designed for Sam and Mary. Both learners have recently been diagnosed with type 2 diabetes, and while they have started taking drugs to help manage the condition, they are sceptic about the use of drugs and have experienced side effects. Their diabetes nurses have recommended maintaining a healthy diet and regularly exercising for the next three months, after which their conditions will be re-evaluated for further recommendation. If their blood sugar improves substantially, they would not be required to take the drugs. By their own admission, both learners have a poor persistence when it comes to maintaining an exercising schedule. The training sessions will take place at the homes of each learner at scheduled times in consultation with both learners and their families.

Aim

The aim of the teaching activity is to enable Sam and Mary to self-manage their type 2 diabetes by maintaining a persistent exercising schedule.

Objectives

• Discussing the benefits of exercising
• Develop a sustainable exercising schedule
• Discuss ways of maintaining the exercising schedule persistently

The training sessions will begin with an introduction of the session where the aim and objectives will be discussed. The educator will assess the needs of the learner through a question and answer session. The educator and the learner will discuss the benefits of exercising and various ways of exercising, such as running or hitting the gym. The significance of family support will also be discussed with the family members and ways through which they can ensure that the learner adheres to the exercising schedule. The educator will then explain the process through which maintaining a persistent exercising schedule can lower blood sugar. A break will be provided for the learner and the family to focus on their schedule and decide the best way of exercising and support options. After the break, the learner will develop an exercising schedule with the guidance of the educator in consideration of the learners’ other schedules as well as input from the family members. It is expected that the family members will consider accompanying the learner during exercising sessions for support.

Analysis

As suggested by Honey and Mumford (1989), learning occurs when an individual knows something they did not previously know or when they can do something they could not previously do. Learning can then be defined as a process where people gain new skills or knowledge they previously did not have, which then changes the way they feel about their actions, behaviours or attitudes (Dunning, 2013). As Dewey (1986) suggests, learning occurs from experience, but not all experiences result in learning, and as reinforced by Aristotle, people learn things they need to learn by doing them. There are several learning theories that explain how individuals learn. A learning theory, as defined by Braungart and Braungart (2008), is a framework that describes and elaborates on how people learn.

The Behaviourist learning theory has been developed over many years, from operational conditioning to observational and vicarious reinforcement (Ashworth et al., 2004). It was first developed by Pavlov (1927), who argued that conditioning animals elicit a specific behaviour (Peel, 2005). Skinner (1938), as well as Watson (1913), applied these principles to human behaviour by incorporating additional reinforcement and found that operant responses that are related to everyday behaviour can be achieved (Kimble, 2001). Thorndike (as cited in Peel, 2005) expanded the Behaviourist theory and developed the systematic learning theory by incorporating the consequences of behaviour. Thorndike argued that the results of earlier behaviour could motivate prospective behaviour. This led to the development of the ‘Law of Effect,’ which holds that behaviours that elicit positive consequences are repeated (Jarvis, Holford and Griffin, 2003). The behaviouristic theory is based on external factors influencing motivation. The teaching activity more so the session has been designed around motivation. This is designed to help Sam and Mary get motivated to change their behaviour to maintain a persistent training schedule. Research and experimentation suggest that behaviours that elicit positive results motivate people to adopt them. (Aliakbari et al., 2015). The session is thus based on motivating the learners by informing them about the positive consequences of exercising in the management of type 2 diabetes and then helping them experience positive results to motivate their adherence to the exercising schedule.

Vicarious reinforcement suggests that learning can occur through hearing the consequence of a behaviour. For both Sam and Mary, the objective is for them to experience the positive aspect of adhering to a training schedule. Once the educator, as well as family members, talk about their experiences or experiences of other people pertaining to training schedules, the learners will be motivated to try the schedule. Once they initiate their schedule and their blood sugar improves for the better, the behaviour will be reinforced. As argued by Kemm (2014), the probability of promoting healthy behaviour increases as the perceived benefits are increased while the perceived barriers are reduced. Maintaining the exercising schedule while addressing any hindrances will thus motivate the learners to continue their schedule and in so doing, develop the skill of persistently maintaining the schedule with ease.

What will facilitate or hinder learning?

Considering the complexity of the learning process, there are factors that can facilitate or hinder learning. The teaching sessions are designed on the importance of superior knowledge. It is thus significant that the educator is competent and knowledgeable about the process of exercising and how it helps reduce blood sugar to promote positive learning. The educator should be able to answer any and all questions that the learners or their families ask pertaining to the topic. The educator should also create a learning environment built on faith and trust and to be able to impact the right skills to the learners (Peek et al., 2014). Lewis et al. (2015) found that patients with type 2 diabetes who were provided with learner-centred self-management skills portrayed an increase in their knowledge. People are diverse, and thus the self-management being instilled as well as the education session should be centred on the learner.

The learners on their part can also hinder or facilitate the learning process. In order to function optimally, the human brain requires glucose. Excess glucose in the body impairs self-control and cognitive skills. Again, low glucose affects cognitive functioning as well as concentration and attention (Lennox, Gibbs, and Gibbs, 1938). It is thus significant to ensure that the sessions are held when the glucose levels of the learners at optimal levels to ensure there are concentration and attention, and the brain is sharp. In addition, other factors such as economic condition, stress levels, and socio-cultural backgrounds can hinder learning. External actors can raise the level of stress in the learners, which then hinders cognitive functioning and memory (McEwen and Sapolsky, 1995). As found by Abdulrehman et al. (2016), cultural beliefs are significant in the self-management of diabetes in that some cultures do not accept the responsibility of self-management. It is thus paramount that the educator considers the cultural as well as other external factors that can hinder learning.

Evaluation and measures

In any teaching exercise, it is significant to conduct an evaluation to identify whether the targeted objective has been achieved and inform the enhancement of the learning experience (Briggs and Sommefeldt, 2002). The first evaluation will focus on identifying whether both learners have achieved the aim, which is to keep their blood sugar low. To identify whether the learners have understood the benefits of exercising, a simple question and answer exercise will be conducted. In addition, through observation, the educator will be able to identify whether the learners have identified the support and equipment needed and whether the exercise schedule developed is being followed. Furthermore, family members will also be influential in reporting the progress of the learners.

While evaluation will occur regularly during and after the teaching exercise, evaluation tools will be used to identify areas that need modification. A toolkit developed by the Department of Health (DoH), National Diabetes Support Team (NDST), and Diabetes U.K. (2006) will be used to self-review the educator (Appendix B) as well as the leaners (Appendix C). The objective is for the educator to reflect and evaluate any inconsistencies. The toolkit is intended to accomplish the NICE criteria for education programmes for diabetes (NICE, 2016).

Quality measures

The quality measure to be employed in this proposed teaching activity is effectiveness/outcomes, as suggested by O’Connor et al. (2011). When exercising, the muscles in the body need the energy to work and to provide this energy, the body burns sugar, which then lowers the glucose in the blood leading to lower HbA1c. However, the level of HbA1c can go up a few hours after meals, which is why it is imperative for the learners to maintain persistence in exercising. The learners will have their HbA1c levels checked regularly to identify if exercising is effective in reducing their blood sugar. The results will critically demonstrate the effectiveness of exercising and by extension, the effectiveness of the teaching sessions. If the activity is effective, the learners should be able to increase their functionality, avoid complications, speed up recovery, and manage their conditions.

Treatment of type 2 diabetes accounts for more than 9% of the NHS budget at an estimated £ 8.3 billion yearly. The high cost is due to complications such as blindness, amputations, stroke, and kidney failure, with 80% of the costs relating to these complications. There are other indirect costs, such as lost productivity due to complications, illnesses, and deaths. In the financial year 2010-2011, indirect costs were estimated to be £13 billion (Public Health England, n.d.). If type 2 diabetic patients were able to self-manage their condition effectively, the high costs would be reduced. This would reduce the financial pressure to the NHS and improve healthcare management. Furthermore, the indirect costs would be reduced through increased national productivity leading to economic growth.

Discussion

This paper has focused on behaviouristic learning theory to propose how Sam and Mary can adopt a new behaviour of regular exercise. I have learnt the significance of having superior knowledge in that such knowledge can be passed on to others through learning, and this is significant in any learning process. I have come to understand how the knowledge I acquire from different people on a daily basis end up affecting my learning experience and behaviour change. It is fascinating to learn that simply hearing about the positive consequences of behaviour can reinforce the same behaviour in me. While trying to learn new skills and behaviours, I always tend to focus on deliberate experience and observing other respected and trusted people.

Vicarious learning is very significant in the learning process. In the behavioural learning theory, I had not considered that hearing the consequence of behaviour can motivate the behaviour. I have always been a believer in learning by experience, which means reinforcing behaviours which a positive consequence has been experienced (Gibbs, 1988). This reflection has, however, changed my understanding of behaviour change by helping me recognise that hearing or seeing the consequences of other people can easily motivate behaviour in me. Thus, while this teaching session focuses on teaching the skill of persistent exercising, I would include success stories of other diabetic patients in other education programs. Listening to success stories of people who have effectively managed diabetes can motivate others to take the necessary steps of behaviour change. By including both success and failure stories, I can easily vicariously reinforce effective behaviour change to self-management of diabetes.

As a nurse, I meet different people, some of whom have little persistence and self-efficacy. In learning new skills or knowledge, believing in one’s own ability to achieve something is the first step. Without belief, there is no motivation, which makes it hard to reinforce the desired behaviour. Improving self-efficacy can improve many aspects of health, from healthy living to healthy behavioural change (Dehghan et al., 2017). Reinforcing self-efficacy by understanding the experiences of other people, is an effective method in healthcare. I have learnt and appreciated the power of self-efficacy in learning. As demonstrated by Zetou et al. (2012), self-efficacy improves the learning of new skills and performance. It is thus significant to ensure that learners reflect on themselves and identify their priorities and objectives before trying to learn new things. Believing in one’s ability to learn a skill is a determinant of success in the learning process.

Conclusion

By incorporating the behaviouristic learning theory, I have developed a proposed learning session for both Sam and Mary. Both have been diagnosed with type 2 diabetes and are seeking natural ways of self-management. I have proposed to teach them the skill of maintaining a persistent exercising schedule to maintain a low blood sugar with the support of their families. I have explored the concept of behaviour reinforcement through vicarious learning and motivation to enhance further learning and change of behaviour, and this has enabled me to put theory into practice (Peek et al., 2014). While they have failed in exercising persistently before, there is a higher chance of success this time with vicarious motivation. This analysis has furthered my understanding of behaviouristic learning and how individuals can be influenced by the experiences of other people into changing their own behaviours.

 

 

 

 

 

 

 

 

 

 

 

 

 

References

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Appendix A: Lesson plan to be used to teach Sam and Mary

Aim

The aim of the teaching activity is to enable Sam and Mary self-manage their type 2 diabetes by maintaining a persistent training schedule.

Objectives

• Discussing the benefits of exercising
• Develop a sustainable exercising schedule
• Discuss ways of maintaining the exercising schedule persistently

Content	Learning Activities	Resources	Approx. Time (mins)	Learning Style
Introduction to the session, discuss aims and objectives	Educator to talk to the learners through the session aims and objectives. Ask if Sam/Mary or their families have any questions	Verbal	10
Discuss and show the equipment needed	Ask learners what equipment’s and support they think they need; discuss each equipment and uses of them as well different form of support from family	Equipment	15
Break			10	To have regular breaks to keep the learners attention, and allow them to internalise what they have observed.
Develop exercising schedule	Develop a training schedule for learner and consider other life elements as well as the schedule of the family supporters	Scheduler software	20	Vicarious reinforcement is another concept of Behaviouristic learning which suggesting reward or punishment can reinforce the desired behaviour.
Evaluation of the session	Educator to discuss objectives, and to give Sam/Mary an evaluation form	Evaluation tool 4: Patient Course Evaluation (DoH, NDST and Diabetes UK, 2006).	5

 

 

 

 

 

 

 

Appendix B:

An evaluation tool I will use to evaluate my own contribution to the teaching session (Department of Health, National Diabetes Support Team and Diabetes UK, 2006).

TOOL 1: Self Review

Part 1: The foundations of the course

	Good	Satisfied	not- satisfied	Evidence
1.  To what extent is the course well-founded (that is, based on good practice, known to be effective)?
2.  Is the course written down?
3.  To what extent are relevant characteristics of the patients known?
4.  Other (specify)
5.   To what extent have the aims and objectives of the course been clearly identified?
6.   To what extent has the knowledge (facts, understandings) that the patients should acquire been identified?
7.   To what extent have the skills (know-how) the patients should acquire been identified?
8.   To what extent is the course broken down into a manageable, sessions?
9.   To what extent has the order of presentation been identified?
10. To what extent have suitable examples to make meaning clear been identified?
11. Is it clear who will deliver the various parts of the course?
12. Is it clear when and where the course will be held?
13. To what extent is the environment where the course will be held conducive to learning?
14. To what extent are the teaching resources available and appropriate (e.g. media, materials, and handouts)?
15. To what extent has provision been made for the health and safety of the patients while they are on the course?
23. To what extent is the pacing of the presentations appropriate for the patients?
29. To what extent was the programme delivered as specified?
30. To what extent did the patients acquire the expected knowledge and skills and have relevant attitudes supported?
31. Is there a procedure for those who do not acquire the knowledge and skills or who do not complete the course?
32. Based on follow-up of the patients’ progress, to what extent do the patients manage their condition effectively?
33. Based on follow-up of the patients’ progress: to what extent does the patients’ quality of life improve?
34. Would the patients recommend the course to others?
35. Other (specify)

Appendix C:

An evaluation tool I will use to give to the learner to evaluate the teaching session (Department of Health, National Diabetes Support Team and Diabetes UK, 2006).

TOOL 4: Patient Course Evaluation

(The numbers in brackets at the end of the lines indicate the items in TOOLS 1 and 3 that the responses are likely to relate to.)

1. To what extent did you understand what the course might do for you?	(22)
2.  To what extent were the dates of the course convenient for you?	(12)
3.  To what extent was the place where the course was held comfortable?	(12)
4.  To what extent could you see and hear well enough?	(13)
5.  What about health and safety? Were you happy about that?	(15)
6.  How did you find the sessions? Was there too much in them? Was the order right for you? Was the information presented too quickly, too slowly or just about right for you?	(8, 9, 23, 24)
7.  To what extent did you understand what you had to do?	(10, 19, 20-27)
8.   Did you find the activities helpful?	(20, 21)
9.   Did you get enough practice?	(21)
10. Did you find that the educator could answer your questions for you?	(25)
11. Do you feel confident enough to give your new skills a try?	(30)
12. Do you think it might make a difference in the quality of your life?	(33)
13. Did you enjoy the course overall?	(34)
14. Would you recommend the course to others?	(34)
15. Any other comments e.g. suggestions for improving the course?