[The teacher] If he is indeed wise he does not bid you enter the house of his wisdom, but rather leads you to the threshold of your own mind.
Kahlil Gibran (1883–1931)
Introduction
The purpose of Chapter 5 is to encourage diabetes educators to reflect on and challenge their notions of ‘a good teacher/diabetes educator’ and suggest diabetes educators owe it to people with diabetes to strive to become exceptional educators. In order to become exceptional, educators must develop extended competencies and truly understand healing and holism. But, it is difficult to define ‘good’ and decide when good becomes exceptional.
When I use a word, Humpty Dumpty said in a rather scornful tone, it means just what I choose it to mean—neither more nor less.
The question is, said Alice whether you can make words mean different things.
Lewis Carroll (1993)
So, for the time being ‘good’ is what the reader chooses it to mean. However, good is a value judgment that implies a linear continuum from good to bad: but people, including diabetes educators and people with diabetes, are rarely one or the other, just as HbA1c is neither good nor bad: they are what they are—part of the whole picture.
Health professionals (HPs) need to consider the whole picture rather than focusing on the individual parts, because the whole reflects the sum of the parts (Bortoft 1986). One can only understand the whole by understanding the parts, that is, by taking a ‘holistic’ view. Holism is particularly relevant to diabetes education; for example, consider the number of parts that make up an education encounter such as the component parts of the educator and of the person with diabetes and aspects of the environment in which the encounter takes place. When the parts work together synergistically the capacity for learning is great, but if they do not, the outcomes may not suite either person, and compromise healing. Insightful educators recognise dysfunctional relationships and refer the individual to another educator.
Similarly, research that includes quantitative and qualitative aspects of the issue under study is more likely to reflect a composite or holistic view of the issues involved. For example, a randomised controlled trial of a new medicine is needed to determine effective medicine doses, dose range and dose intervals, and the safety profile. In-depth interviews using open questions will elicit participant’s experience taking the medicine and the type of information people might need to take the medicine appropriately to achieve maximum benefit.
Healing
I use ‘healing’ deliberately: most diabetes educators know curing/treating/managing diabetes does not necessarily lead to ‘good control’ or optimal health, particularly when a whole person approach is not used. ‘Health’ comes from Anglo Saxon ‘haelth’ or whole; and heal from ‘haelen’ to restore to wholeness. Restoring to wholeness does not mean curing. It refers to mind, body and spiritual balance, accepting the situation and finding ways to move forward (transformation).
Many experts suggest the body has the capacity to heal itself, sometimes described as ‘the doctor within’. The HP’s role is to optimise conditions to aid the healing process. Empowering the person with diabetes is a central tenet of modern diabetes education philosophy and is linked to effective diabetes self-management (Skinner and Cradock 2000). However, if we consider Gibran’s view that the teacher leads the learner to the threshold of their own mind, and the doctor within theory, ‘patient empowerment’ is not something educators can take sole credit for.
Educators can only create the conditions and trusting relationship within which a person with diabetes can empower themselves. Significantly, educators must be empowered themselves and competent teachers to create learning environments in which people can become whole and integrate diabetes into their lives, a process known as transformation.
Healing, in the broad context of making whole, is a social process that occurs within a therapeutic relationship (Mitchell and Cormack 1998, pp. 4–5). The healing process involves restoring the individual’s sense of connectedness and control and relieving suffering, that is, to achieve balance and empowerment through holistic care (Cassell 1991). Holism recognises:
- The person’s mind, body and spirit contribute to their individuality and capacity for self-empowerment and healing.
- The individual exists in a unique context: physical, social and cultural and has unique life- and diabetes-related experiences.
- The various aspects of treatment must complement each other (synergistic) to create a system where each part contributes to and enhances other parts. The educator enhances the person with diabetes’ healing and self-care capacity through ‘good’ teaching and their way of being.
- Caring is at the heart of healing: Caring is the art that complements science. Diabetes care and education need both art and science to be holistic. Diabetes education is a complex activity. As indicated in Chapter 6, learning ‘diabetes’ is also a complex, lifelong activity for people with diabetes and for HPs. Caring is a highly complex phenomenon demonstrated through exceptional communication, creative care strategies, up-to-date knowledge, competence and above all the capacity to show empathy and be with the person in the moment.
Who is a teacher?
Excellent teaching is the most powerful influence on a learner’s achievements (Masters 2004) and probably on teacher satisfaction and self-efficacy. ‘Teach/teacher’ come from the Old English ‘Taecan’, to show the way, point out and give instruction. Of these, ‘to show the way’ is the closest approximation to leading the learner to the threshold of their own mind.
Other words for teacher include Lama (Tibet), Sensi (Japan), Guru (India) and Hari Guru (Malaysia). Gurus and Sensis are known for their wisdom and authority and are revered as guides who dispel ignorance and lead people into the light. First they must achieve enlightenment themselves. The attributes of a ‘good’ guru are:
- Being well versed in the Vedas
- Not envying others
- Knowing yoga
- Knowing the self (self-knowledge)
- Being humble
- Practising what they preach.
In other words, a good Guru must ‘have the goods’ and know how to ‘deliver the goods’ or’ market’ their message.
Attributes of a ‘good’ teacher
Not surprisingly, western literature indicates ‘good’ teachers have the same attributes as good gurus, although the language used to describe the attributes is different. A literature search of teacher attributes in 2011 yielded a great deal of information especially from school and university sources. My conversations with diabetes educator and teacher colleagues about the issue suggest diabetes educators’ collective opinion is consistent with the literature as well as with the leader attributes discussed in Chapter 13. However, only a few educators mentioned leadership in the context of teaching people with diabetes.
In addition, a thematic review of Internet blogs and publications in 2011 indicates good teachers are:
- Truthful
- Passionate
- Creative
- Flexible and adaptable
- Able to integrate and build on existing information
- Connected
- Able to recognise and teach at the teachable moment
- Good role models
- Able to promote excellence
- Able to earn and give respect
- Professional.
The book, My Favourite Teacher (Macklin 2011) and the associated web site www.myfavouriteteacher.com.au, is a collection of the stories and recollections of 96 prominent Australians about the teachers who shaped their futures. The ‘teachers’ the contributors described included family members and kindergarten and primary and secondary school teachers. Contributors were men and women writers, doctors, nurses, lawyers and politicians. Sixteen key themes emerged from a structured thematic analysis of the stories that suggest the contributors remembered teachers because they:
- Loved the students and teaching and their subject
- Lit a fire rather than filled an empty vessel
- Made space for future learning (created expectation, built on existing knowledge and linked the unknown to the known)
- Were kind and respectful
- Had ‘people skills’
- Used positive affirmation because it achieves more than giving negative feedback
- Were willing to go the extra mile
- Enabled students to expand their inner world
- Did something different
- Listened
- Encouraged learning partnerships and cooperation among students and between the teacher and students
- Encouraged students to consider their possibilities and options
- Understood students’ cultural context
- Did not suggest what to and how to think but encouraged students to think
- Created an environment where learning was valued and happened
- Were able to seize the teachable moment
- Understood the power of silence: She changed my life. And she did not say a word
One could criticise the Internet blogs, some of the literature, informal conversations and the book as ‘hearsay’ rather ‘true’ evidence. However, careful examination shows remarkable consistency among the sources and with diabetes educator competencies promulgated by diabetes professional associations in a number of countries, for example The Australian Diabetes Educators Association (ADEA), National Core Competencies for Credentialled Diabetes Educators (2008). The ADEA competencies encompass the skills, knowledge, attributes, values and abilities needed to perform in five areas: person-centred diabetes care, person-centred diabetes education, organising and managing a diabetes service, professional accountability and responsibility, and leadership and patient advocacy.
Likewise, the source information for the chapter is consistent with teaching and learning theories and models (Chapter 3). Holistic teaching, teacher–learner relationships, spirituality and caring are implied in all the sources but are not prominent.
Spirituality is largely neglected in Western health care or confused with religion. Spirituality is essential to holistic care/education, empowerment, personal growth and self-efficacy. For example, young people with diabetes who regarded spirituality as an important part of their lives had lower HbA1c and greater self-efficacy (Parsian and Dunning 2009). The finding is not surprising, given learning to live with diabetes is an ongoing transformational journey; transformation is at the heart of spirituality. Likewise, learning how to work with people with diabetes is part of the diabetes educator’s ongoing transformational journey.
Although the attributes of ‘good’ diabetes educators are well documented and accepted globally, the attributes of exceptional diabetes educators are less clear. Some might regard credentialing/certification as evidence of exceptional practice; however, it is not clear that credentialed/certified diabetes educators actually perform differently from non-credentialled/certified diabetes educators, nor that core competencies reflect the competencies needed for exceptional practice.
Moving from good to exceptional
Once we accept our limits we go beyond them.
Albert Einstein (1879–1951)
The difference between good and exceptional diabetes educators may be recognising and going beyond individual limits. Exceptional educators are proficient in the core competences and have the required attributes. In addition they:
- Have a philosophy of diabetes care and education.
- Value and actively develop a therapeutic relationship with each individual they teache (people with diabetes and HPs).
- Know the self.
- Reflect in and on practice, individually or within communities of learning.
- Have the ability to be present with the individual in the moment.
- Take care of the self.
Philosophy of diabetes care and education
The following philosophy was generated from my personal upbringing, culture, learning, experience and other life influences. It evolved over time, and is likely to continue to evolve as I learn, and hopefully continue to grow. I have never discussed or shared my philosophy before; so I share it here with some trepidation.
- Diabetes education is not an isolated activity. It occurs within life and social contexts. It is a lifelong, continuous process of transformation for people with diabetes and diabetes educators.
- People with diabetes are diverse and have a range of experiences, self-knowledge and capabilities. They are entitled to individualised, holistic care and education that encompasses mind, body and spirit that maintains hope.
- Educators must know themselves, their capabilities and limitations, values, beliefs and attitudes in order to care for and teach others.
- In order to know themselves and improve practice, educators must be open-minded and reflect on each experience to achieve personal growth as part of continual professional development. They must look within and outside their profession for information and inspiration.
- Exceptional diabetes education is a creative blend of art and science. People with diabetes are entitled to best practice evidence-based care delivered using a range of creative strategies.
- Educators have an obligation to be effective, caring, holistic and professional, by practising within the limits of their knowledge and competence, role and scope of practice, legislation and regulatory frameworks, and codes of conduct and ethics and being aware of professional boundaries within consultations.
- Educators have an obligation to demonstrate leadership in teaching and practice by acting as role models, contributing to research, the profession and the community and the interdisciplinary team.
- Focusing on the positive and giving positive feedback are key empowering strategies.
- Sustaining hope is important to an individual’s self-care, self-concept and self-efficacy. Sustaining hope does not mean hope for a cure for diabetes.
- Educators must respect people’s learning styles, beliefs, attitudes, goals and explanatory models and do their best to accommodate them, be non-judgmental, use congruent teaching, optimal communication, openness and acceptance.
- Teaching and learning is an interrelated process where mutual learning occurs.
- Learning and self-growth can only occur within a trusting therapeutic relationship. In such a relationship people learn from each other.
- Effective communication is essential to establishing and maintaining therapeutic relationships. Effective communication includes verbal, written, body language, gestures, paralingual speech, active listening and silence.
- People’s stories are valuable. They provide essential information that enables educators to understand people’s life experiences, goals, attitudes and beliefs and the language they use. Stories help educators develop strategies to enhance people with diabetes’ self-concept and capabilities.
- Educators must create an environment where the individual feels safe to share their story recognising that they might disclose information that should remain confidential unless the individual agrees it can be disclosed (excluding mandatory reportable information).
- Educators can only create such an environment if they are present in the moment. In order to be present in the moment, educators must be connected and engaged on several levels: with the self, with the individual or group, the profession, the organisation and team the educator works in, and society/community.
- Educators must be skilled salespeople to market the product ‘diabetes’, a product most people would prefer not buy. Such marketing must be honest and accurate and disclose benefits, risks and costs. Diabetes educators can learn marketing skills from business models.
- It is important to evaluate outcomes and personal performance using appropriate valid tools/methods. Reflection in and on practice is part of personal evaluation.
- Exceptional diabetes educators, like exceptional leaders, are politically aware and advocate for and with people with diabetes.
- To sustain such a philosophy, diabetes educators must be committed, passionate and self-caring, that is, they have a responsibility to nurture the self.
Factors that influence philosophy
Each diabetes educator will have their own unique philosophy, even if it is not clearly articulated or documented. Many diabetes educators will recognise some elements in my philosophy they can relate to because we share similar training and clinical experiences, no matter where we worked or trained.
Elements of my philosophy originated within my family and at school. My father taught me to love books, my mother to care and contribute to the community. Two general practitioners (GPs), Drs Cookson and Holmes, who worked in the country town where I grew up, went to school, and trained as a nurse, lived and role modelled a philosophy I embraced. There were no house officers, consultant specialists or medical students in the town. Thus, the GPs had a very close working relationship with the nurses and relied on their expertise. GPs and nurses were closely connected to and were part of community in which they delivered care. There were five others in my training group. Drs Cookson and Holmes loved teaching.
About 3 months after I commenced my training, Dr Cookson said:
I see you have a day off tomorrow. I will pick you up at nine. Be on time.
I was about to protest when he said:
I am doing my home visits. I only need about an hour of your time. If you don’t know where these patients come from, their home situations, their relationships and pets, how will you plan their discharge and know they will be able to manage when they go home? How will you understand their stories?
Shortly after that he ‘invited’ me to a post-mortem: ‘You need to know how bodies go together to understand people’s diseases so you can provide good nursing care like preventing pressure sores’.
Both doctors insisted trainee nurses accompanied them on ward rounds—usually the prerogative of the ‘Sister’. They discussed people’s diseases, social situations, mental health and medical and nursing care. We learned in ‘real time’ and could apply the information immediately, which reinforced learning. They were masters at teaching at the teachable moment.
There was a standard curriculum and competencies that trainee nurses had to complete, but Drs Cookson and Holmes believed we learned more in the ‘teachable moment’ than ‘slavishly following the book’. We did complete all that was required and it did not seem to matter that the learning did not proceed in the sequence set out in the curriculum. We learned to assess, observe, listen, use all five senses, ask questions and reflect so we could make connections and recognise patterns that enable us to apply the knowledge in other situations.
The doctors insisted good medicine and good nursing were a blend of art and science and practitioner behaviours. They set ‘homework’ after teaching rounds from the prescribed textbooks and other relevant research they found, and, very exiting for me (but not all my fellow trainees), novels and poetry. Later, they asked us about the characters in the books: what motivated them, what shaped their characters and what could be applied to nursing care.
Three weeks before the final exams, the Drs asked Matron to arrange a meeting with the five finalists, where they announced:
The five of you sitting finals will be working morning shifts for the next three weeks. At six o’clock you will come to my house or Charlie’s [Dr Holmes]. Our wives will make dinner and we will revise, debate, question and clarify so you are all as well prepared for the finals as you can possibly be.
These two doctors embodied Gray’s observation that:
The physician, if he is properly educated to his profession must be familiar with many parts of his nature, philosophy, with natural history, botany, chemistry as well as with those branches of learning which more immediately connect themselves with the science of life and the knowledge of disease.
Gray (Undated)
The same could be said of any HP, especially exceptional HPs.
Later, many colleagues were role models for diabetes education, clinical care and research. People with diabetes and their relatives taught and continue to teach me about life with diabetes, which enriches my philosophy.
Therapeutic relationship
A respectful therapeutic relationship is essential to achieving optimal outcomes (Heine 1981; Hamburg and Inoff 1982; Bennett-Levy 2006). Significantly, the strength of the therapeutic relationship is a strong predictor of outcomes. Effective communication is the key to developing therapeutic relationships.
Bordin’s (1979) definition of therapeutic relationship or alliance is still used. Bordin defined three interrelated components:
- HP and individual agreement about treatment goals
- HP and individual agreement about how to achieve the goals
- A personal bond between the HP and the individual
The way an educator establishes a relationship with an individual is critical to the outcome of the relationship. The educator must be willing to share power and earn the individual’s trust before good communication and learning can take place. Diabetes educators must actively develop skills that will enable them to develop relationships. These skills include:
- Caring, which is an interpersonal process that generates a caring moment that enhances the likelihood of positive outcomes for both people in the relationship
- Accepting without judgment or blame
- Demonstrating respect
- Showing empathy, which requires active listening and understanding
- Listening, attending and actively involving the individual in the conversation
- Being truly present in the consultation by paying close attention (attending)
- Asking open questions to encourage dialogue
- Clarifying responses and reflecting people’s responses
- Using silence
- Being connected
- Providing support
- Effectively and appropriately using language including body language and respecting personal space and verbal, spatial and behavioural boundaries
- Promoting equality
- Being professional (Mitchell and Cormack 1998; Dziopa and Ahern 2009).
Establishing relationships can be challenging, even when the educator is experienced and skilled, especially within the time constraints and other barriers:
- Characteristics of the individuals involved
- Competing priorities of both individuals
- Waiting times
- Consultation environment, e.g. privacy can be compromised in shared hospital rooms
- Time pressures
- Interruptions during consultations
- Organisational imperatives and expectations
- Nature of the information disclosed and shared.
Likewise, there are many missed opportunities to establish relationship, for example the exchange in Chapter 6 under the subheading ‘voices’ is an opportunity to ‘seize the day’. Currently, many HPs caring for people with diabetes focus on diabetes, rather than the person with diabetes. The biomedical focus could be partly due to current guidelines and care algorithms that outline care pathways, medicines and medical care, but rarely include the art of care, and often collect closed information by ‘ticking boxes’ (Chapter 13).
Listening
Listening is essential to developing therapeutic relationships and is a particular skill. People with diabetes spend most of the time in medical and education encounters listening. Ideally, the situation should be reversed because people only remember a fraction of what they are told.
A great deal of effort and concentration is needed to actively listen. Active listening involves the listener:
- Receiving aural input
- Interpreting the message in light of their background, existing knowledge and experience
- Understanding the language the speaker uses.
Information is initially processed as it is being received. People are still processing the information they just heard, when the next piece arrives. In addition, listeners (educators and people with diabetes) have to adapt to the speaker’s language and delivery mode (Chapter 6). People with low literacy levels, those who speak different languages and people with hearing deficits find listening challenging and often stop listening.
Different sorts of information require different listening skills; for example ‘How are you?’ is less demanding on the listener then a long speech that contains multiple pieces of information that might be new or not relevant to the listener, or out of context.
Becoming an exceptional diabetes educator is part of the educator’s transformational journey. Transformation occurs through self-knowledge and reflection.
Know yourself
An HP’s duty of care includes knowing the limits of their knowledge and competence. Self-knowledge, like education, is a journey towards ways of seeing and being in the world.
Understanding the self requires self-honesty, reflection and willingness to change. Teaching, like other human activities, emerges from within the educator. If a teacher is willing to critically review their performance, they have a chance of increasing self-knowledge.
Knowing myself is as crucial to good teaching as knowing my students and my subject. In fact, knowing students depends on self-knowledge. If I do not know my students I cannot teach well.
Palmer (1998, p. 2)
Many educators engage in ‘self-talk’ after a teaching encounter, usually when things do not go well. That is not genuine self-reflection and rarely improves practice, essentially because knowledge of self does not change, therefore, nothing else changes. When things do not work, the educator needs to change what they are doing. Deep self-questioning can be confronting and can be undertaken alone. Alternatively, objective peer-review that focuses on the behaviour not the person, constructive patient evaluation and mentoring relationships can aid self-knowledge.
Some personal attributes educators could consider are:
Emotional intelligence: A set of essential individual human capacities that shape the individual’s ability to manage their emotions and develop positive relationships (Goleman 1995).
Social intelligence: Human brains are hard-wired to connect with other people. That is, humans are innately social beings. Relationships shape people’s experiences and biology: nourishing relationships have a beneficial effect on health; toxic or demoralising relationships affect physical, mental and spiritual health (Goleman 2007, p. 5).
Multiple intelligence: The Theory of Multiple Intelligences (Gardner 1983) is widely used but is sometimes criticised as being rhetoric rather than evidence. Gardner believed people have different capacities for performing different activities and described eight categories of intelligence:
- Linguistic—using and understanding language
- Logical mathematical—mathematical ability and ability to see patterns and be analytical and scientific
- Musical—appreciation of musical, hearing tones and rhythms
- Bodily—kinaesthetic-body awareness, know how bodies work
- Spatial—knowledge of distance and space and spatial relationships
- Interpersonal—understanding other people including non-verbal language and own capabilities and limitations
- Naturalist—recognise and categorise things
- Existential or spiritual—self-knowledge and personal growth.
The Theory of Multiple Intelligences has been used to describe learning styles to help teachers plan teaching strategies to match the learning style (see Chapters 3 and 13). People may have one preferred ‘intelligence style’, but they can develop several styles to suit different learning situations: educators who develop a spectrum of ‘intelligences’ may be more competent at engaging with and forming relationships with people with diabetes, than educators who do not.
Wounded healer
Some educators may not be familiar with ‘wounded healer’ theories. The concept is relevant to all educators but may be particularly applicable to diabetes educators who have diabetes. Basically, when an individual experiences a ‘wound’, which might be trauma, diagnosis of a disease such as diabetes, a mental disorder or loss, they pass through stages of healing/recovery: wounded, walking wounded and wounded healer and when they are healed they transcend the wound (Conti-O’Hare 2002).
Wounded healers develop significant self-knowledge and can use their experience constructively to help other people. People who have not commenced the healing process and the walking wounded may suffer emotional distress when they encounter other people with the same condition, or develop enmeshed and/or non-productive relationships that result in miscarried helping (Anderson and Coyne 1991).
In the end, only the wounded physician heals and even he, in the last analysis, cannot heal beyond the extent to which he has healed himself (van der Post 1975).
Reflection
Reflection is essential to continued professional development and exceptional diabetes education. Schon (1983) presented a model for reflective practice that is still relevant. He observed that when effective practitioners were faced with a problem, they instinctively drew on previous experience, recognised patterns and considered various solutions, which he called reflection-in-action (reflection during the event). He suggested that learning could be enhanced by reflection-on-action (reflection after the event). Further, Schon believed the ability to reflect both in and on action distinguishes ‘effective from less effective practitioners’.
Reflection-on-action can occur individually or in groups such as case studies and when evaluating critical incidents. Group reflection enables educators to examine the link between abstract knowledge, information learned but not used in practice and actual practice. Schon’s work highlights the importance of practical experience to the learning process.
Practical experience also teaches us to learn from mistakes and that simple strategies are often the most effective, as the Sorcerer’s apprentice found out when he tried out his magic skills on the brooms when the sorcerer was away. The brooms became uncontrollable, very disobedient and created havoc in the house: Desist broom the apprentice repeatedly cried to no avail. The sorcerer returned, stared at the mess and said stop! And the broom did.
Reflection in and on practice can help diabetes educators:
- Record and explore experiences and learn from them.
- Enhance their problem-solving skills.
- Explore personal beliefs, attitudes and explanatory models.
- Evaluate performance.
- Acquire self-knowledge and enhance professional practice.
- Enhance continuing professional development activities (Moon 1999). In fact, reflection will be mandatory when the revised ADEA continuing professional development process is implemented later in 2012.
Educators could help people with diabetes use reflection in and on their diabetes self-care behaviours and outcomes during consultations, since reflection is essentially a problem-solving technique. Likewise, reflection could be a useful strategy to actively involve people in the consultation.
Being present in the moment
Effective education is more likely when the educator is fully engaged, actively listening and connected (present). The phenomenon is sometimes referred to as authentic presence (Newman 2008). Being present is also a form of accompaniment or witnessing that can help people come to terms with their diagnosis, even when they do not understand the disease or its treatment (Weingarten 2004). Significantly, being fully present is essential to establishing effective relationships.
The educator can demonstrate authentic presence by being attentive, open and focused on the individual. People are more likely to share their stories and explanatory models and disclose key information if the educator is fully present, because presence nurtures hope.
Self-care
Diabetes education is emotionally and physically demanding. Exceptional practice is only possible if the educator manages stress, lives a healthy lifestyle, that is, lives what they preach and heal their own wounds.
Summary
‘Good’ worked very hard in this chapter and
That’s a great deal to make one word mean said Alice in a thoughtful tone.
When I make a word do a lot of work like that said Humpty Dumpty I always pay it extra.
Lewis Carroll (1993)
People with diabetes are likely to benefit when diabetes educators move from being good to being exceptional teachers. Learning to be an exceptional educator is a transformational journey. The more educators learn about themselves and the more they reflect on and develop their knowledge and skills, the more effective they will be.
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