Lessons Learned as a Diabetes Educator

Martha M. Funnell, MS, RN, CDE

Editor's note: This article is adapted from the address Ms. Funnell delivered as the recipient of the American Diabetes Association Outstanding Educator in Diabetes award for 1999. She delivered the address in June 1999 at the Association's 59th Annual Meeting and Scientifc Sessions in San Diego.

As educators, we generally view ourselves as teachers rather than learners. However, as I reflect on my years as a nurse and what is means to be a diabetes educator, I realize that I have learned a great deal, probably far more than I have ever taught.

While I have had many opportunities for learning during the past 16 years, I have not always taken time to reflect on what they meant or what they were teaching me. In the busy day-to-day world of taking care of and teaching our patients, we do not often take the time to think about what we do and what we are learning. So I decided to take advantage of this opportunity to put some of what I have learned into words and to share with you some of the things that are in my heart.

Now, I am very well aware that those who are reading this article are experts in this field and have learned many of these same lessons. But I hope that after you read this you will also take the opportunity to reflect on what you have learned from your patients, from your families and colleagues, and from being part of an organization such as the American Diabetes Association.

Lessons Learned From Patients
I am writing from my heart because one of the lessons I have learned is that diabetes care and education happen in the heart. Most of our efforts as educators are aimed for the head. I used to think that by filling up my patients' heads, I could help them to change their hearts and their minds about how they cared for themselves. I have learned, however, that the best curriculum is one that is based on the patient and that I am most effective when I can help patients to learn about diabetes within the context of their stories and their experiences.

A patient once said to me, "I never met a stranger until I got diabetes." That statement gave me all I needed to know to be a good teacher for him. And because it came from his heart, I could not only teach him, but also partner with him to help his experiences reflect what he hoped to achieve as he cared for himself each day.

Diabetes education is a journey. The journey begins in the hearts of the patient and the educator. It is a journey we take together, and one that the patient must lead. When we start our journey, we do not really know where it will end—with a cure, a complication, a life wasted on anger, or a life well-lived. Recognizing that education is a journey that begins in the heart helps both my patients and me to understand their hopes and fears that are part of the reality of living with diabetes.

The course and the results of the journey that we take are related to both clarity and choices. A patient once said to me, "Other people can act like their feelings are hurt because I don't eat what they do or drink what they do, but I have learned that what's best for me is best for the world." This was someone who had a lot of clarity, and it marked the path for our journey. I have learned that I need to help patients to reflect on what is in their hearts and what they want to accomplish, so that they can attain clarity. Without this understanding, it is easy to become side-tracked and lose direction.

I have also learned that I need clarity. I need clarity in my vision about patients and our respective roles in diabetes care. I can understand various theories and strategies in my head, but true clarity comes from my heart. The main thing I have to offer patients is not my knowledge, but myself. I cannot hide my vision and what is in my heart from them no matter how many theories I have in my head or how much I know about diabetes. And so, like our patients, we need clarity in our vision of diabetes education.

Patients have choices to make about their attitudes towards diabetes and the behaviors they choose to adopt. I have those same choices. What attitude do I bring to my interactions with patients? There is certainly evidence to support the value and influence of the attitude of the educator on outcomes. So I need to ask myself, do I show respect to patients and convey a positive attitude about their goals and their ability to care for themselves? Do I listen actively and nonjudgmentally to what is in their hearts? Do I create a collaborative relationship with my patients by recognizing that they bring to our relationship expertise on their lives, just as I bring expertise on diabetes? Do I convey that their expertise is just as valuable as mine to creating a diabetes plan that will be effective?

I also need to think about how I behave. Do I provide education so that patients can make informed choices? Do I teach content in a way that is useful and matches my patients' experiences with diabetes? Do I acknowledge patients as the primary decision-makers, or do I label them and create distance by becoming judgmental? Do I reinforce that patients are in control, not only of their diabetes care but also of their education, by meeting their agendas rather than my own? And, how do I help patients to learn from their choices and decisions?

Probably the most important lesson that I have learned is that by traditional measures of an effective diabetes educator, I am a complete failure. I have learned that I cannot get patients to change their behavior or become compliant or adherent. Nor can I motivate anyone to change. My patients have taught me that no matter what new technique I use, they remain in control of their own care. I have learned that I can inspire, I can give patients information and tools to make changes and wise choices, I can offer support, and I can help patients to reflect on what is in their hearts, but the only person I can truly change is myself.

I recently heard that the definition of insanity is "doing the same thing over and over and expecting a different outcome." So, rather than continuing to do the same thing over and over and feeling like a failure, I have learned from my patients to make changes in how I do things and how I define outcomes and success. They have taught me that there truly is no such thing as failure, only feedback. I have learned that by not trying to get patients to change, eliminating the concepts of adherence and compliance from my thinking, and meeting patients where they are, we are able to create a relationship that allows us to rewrite their story of living with diabetes. I consider the opportunity to take part in my patients' journey as an educator to be the highest privilege.

I have found that the more that I listen rather than talk, the more that I ask rather than tell, the more that I help patients to explore solutions to their own problems rather than advise, and the more I resist labeling and categorizing patients, the better able I am to facilitate their learning. I have learned to judge success by the relationships we are able to create in our hearts, the partnerships we are able to build, and the journey we are able to take together. It is through this journey that true education and change occurs, both for my patients and for me.

Lessons Learned From Others
I have been fortunate to have a lot of cheerleaders in my life, and I have learned a great deal from them. From my family, I have learned the importance of setting goals and working to reach them. I have also learned the necessity of support.

I have learned a lot from my colleagues, many of whom were first my heroes and now are friends. Some of them include Sharon Brown, who taught us all that diabetes education and diabetes educators do make a difference; Richard Rubin, who showed me the value of caring; and Russ Glasgow, who once paid me the ultimate compliment by introducing me as the heart of empowerment. I have also been given the time and support to take advantage of many opportunities by my colleagues at the Michigan Diabetes Research & Training Center, and I have learned from them, especially Bob Anderson, who challenged me to articulate my vision, inspired me to remain true to it, and taught me that the journey to empowerment begins in the heart.

Lessons Learned from the American Diabetes Association
I have also learned a great deal from my work with the American Diabetes Association. In 1983, after 1 week as a diabetes educator, I went to the Association's Annual Meeting and Scientific Sessions in San Antonio. Back then, there was no health professional leadership. There was only about a half day of sessions of interest for educators, and most of that was focused on trying to get patients to adhere. While I enjoyed getting to know other diabetes educators, I also remember thinking that we had a long way to go to both recognize the role of educators and the need for a different approach to patients.

I recently had the experience of interacting with health professionals who work with patients who have another chronic illness. In the middle of a discussion with them about patient education, I thought to myself, this group is years behind. One of the reasons, I suspect, is that they do not have an organization such as this one to help them to learn and grow. So one lesson I have learned is that organizations can change and can influence the way that we practice. The American Diabetes Association has helped to shift the thinking about our roles as health professionals and reminds us that the people with diabetes not only need to be the center of our care and education, but also are the heart of this organization and our reason for being here. We have come a long way. Through this Association, we are able to touch the lives and hearts of people with diabetes, and we make a difference.

Finally, please accept my heartfelt gratitude for this incredible honor that I will spend the rest of my life trying to deserve, for all of your care and support, and for all that you have taught me.

Acknowledgment
This work is supported in part by the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 5P60 20572.

Martha M. Funnell, MS, RN, CDE, is director of administration at the Diabetes Research and Training Center at the University of Michigan in Ann Arbor.

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