NUR 3380 Module 2 Diabetes Paper: Self-Management Education and Closing the Loop With Teach-Back Example

Closing the Loop in Spanish: Diabetes Self-Management Education for a Farmworker in Bridgeton

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-3380: Applying the Nursing Process to Alteration in Health

Mentor Name

Month Day, Year

Closing the Loop in Spanish: Diabetes Self-Management Education for a Farmworker in Bridgeton

The Patient

The patient and the health center are invented. Mr. Hernández, 49, works seasonally on farms in Cumberland County and lives with his wife and three children. His A1c at a free screening was 9.4 percent. He speaks Spanish, completed four years of school in Mexico and says he does not read much. He is worried because his mother lost a foot to diabetes. He works long hours in the fields, eats tortillas and rice at most meals and drinks sweetened sodas during the day. The nurse practitioner started metformin and referred him to the student for education.

Assessment

The student, working with a bilingual medical assistant, assessed Mr. Hernández's understanding, beliefs and resources. He believed diabetes came from a fright years ago and that insulin causes blindness. He has a cell phone but no computer. His work hours vary, and meals are irregular during harvest. His wife cooks for the family and is eager to help. He uses a single-item screener and says he often needs help reading medical forms, which suggests limited health literacy.

What Education Achieves

Norris et al. (2002) pooled randomized trials that taught adults with type 2 diabetes to manage the disease themselves. Education lowered glycated hemoglobin by about 0.76 percentage points at the first follow-up compared with control, but the effect declined over time, to about 0.26 points after four months or more. The amount of contact time between educators and patients predicted the size of the effect. The authors concluded that education works but must be reinforced.

Checking Understanding

Schillinger et al. (2003) audio-recorded clinic visits in which physicians saw diabetes patients who had trouble with health information. Physicians rarely asked patients to explain back what they had been told, which the authors called closing the loop. When physicians did assess patients' recall or understanding, their patients were much more likely to have better glycemic control. The study suggests that teaching is incomplete until the patient shows they understood.

When Education Is Needed

Powers et al. (2015), writing jointly for diabetes educators, the American Diabetes Association and dietitians, named four points when education and support are most needed: when diabetes is first diagnosed, once a year after that, whenever a new complication or problem appears and whenever the person's care setting changes. They described education as an ongoing process tailored to the person's culture, literacy and resources, and noted that it is underused.

Nursing Diagnoses

His beliefs about the cause of diabetes and about insulin pointed to deficient knowledge. Long days with skipped meals and sugary drinks created a risk for unstable blood glucose. His fear of losing a foot, like his mother, and his family's eagerness to help signaled readiness for enhanced self-care.

Planning

Goals were written for Mr. Hernández to demonstrate in Spanish. By the end of the first session, he will explain in his own words what diabetes is and why metformin helps. Within two weeks, he will check his blood sugar correctly with a meter and know what to do if it is low. Within one month, he will replace sweetened sodas with water or unsweetened drinks at work. In three months, his A1c will be lower.

Implementation

Teaching took place over three sessions, each about thirty minutes, with the medical assistant interpreting and his wife present. The student used pictures, a plate model showing half vegetables, a quarter protein and a quarter tortillas or rice, and the meter itself rather than written instructions. After each topic, she asked him to explain back. When he said metformin should be taken when he felt sick, she taught it again and asked him to show which meals he would take it with; on the second try he explained correctly. She addressed his belief about insulin respectfully, explaining that high blood sugar, not insulin, damages the eyes and that his mother's foot was lost to diabetes that was not controlled.

Planning for Harvest

Because his meals change in harvest season, the student and Mr. Hernández planned for long days: water bottles instead of sodas, a packed lunch his wife would prepare and what to do if he felt shaky. She gave him a picture card with low blood sugar symptoms and steps.

Medication and Low Blood Sugar

Low blood sugar is unusual with metformin alone, but the student still taught the signs, because Mr. Hernández works long hours in heat and sometimes skips meals. She explained that metformin can upset the stomach at first and is best taken with food, which mattered because he had planned to take it on an empty stomach in the morning. She also checked with the nurse practitioner about his kidney function, since metformin dosing depends on it, and confirmed that his results were normal. Finally, she gave him a pill organizer marked with pictures of the sun and moon for his two doses.

Using His Phone

Mr. Hernández uses his phone for messages with family. With his permission, the health center enrolled him in a text reminder service in Spanish that sends a short reminder to check his sugar and a weekly health tip. He agreed to send a photo of his meter reading each week, for the first month, to the bilingual medical assistant.

Evaluation

At two weeks, Mr. Hernández checked his blood sugar correctly and explained what to do if it was low. He had replaced most sodas with water. At three months, his A1c was 7.8 percent. Following Powers and colleagues' guidance, the student recommended education again at the start of the next harvest season, a transition in his routine.

Limits

The meta-analysis found that effects fade, so three-month results may not last. Teach-back was studied with physicians, and its effect in nurse-led teaching is assumed rather than tested here. Interpreting through a medical assistant can lose meaning, and a trained interpreter is preferable when available.

Conclusion

Mr. Hernández needed education that fit his language, literacy, work and beliefs. Evidence showed that education lowers A1c but must be reinforced, that checking understanding matters and that support is needed at critical times. Short sessions with pictures, teach-back and his wife's involvement helped him manage his diabetes and set a plan for continued support.

References

Norris, S. L., Lau, J., Smith, S. J., Schmid, C. H., & Engelgau, M. M. (2002). Self-management education for adults with type 2 diabetes: A meta-analysis of the effect on glycemic control. Diabetes Care, 25(7), 1159-1171. https://doi.org/10.2337/diacare.25.7.1159

Powers, M. A., Bardsley, J., Cypress, M., Duker, P., Funnell, M. M., Hess Fischl, A., Maryniuk, M. D., Siminerio, L., & Vivian, E. (2015). Diabetes self-management education and support in type 2 diabetes: A joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Care, 38(7), 1372-1382. https://doi.org/10.2337/dc15-0730

Schillinger, D., Piette, J., Grumbach, K., Wang, F., Wilson, C., Daher, C., Leong-Grotz, K., Castro, C., & Bindman, A. B. (2003). Closing the loop: Physician communication with diabetic patients who have low health literacy. Archives of Internal Medicine, 163(1), 83-90. https://doi.org/10.1001/archinte.163.1.83