Nursing Clinical Education Article

 Introduction

Teaching is an essential feature of a nurse’s professional responsibility, for they are the key advocates in delivering quality patient education (Friberg, Granum & Bergh, 2012). In fact, the invaluable knowledge that we as nurses impart serves as basis for patients to achieve optimal health and independence in self-care. A noted mathematics educator, Lola May, believes that ‘there are three things to remember when teaching: know your stuff, know whom you are stuffing and then stuff them elegantly. However, what happens when nurses themselves don’t know their stuff necessary to deliver quality care for patients? This clinical education case study describes that some nursing staff in the ward aren’t familiar in caring for patients with type 1 diabetes. As a leader, the primary objectives of a nurse educator is to mentor staff and become teachers and clinical instructors to nursing students (Bastable, 2014). Ideally, the primary goal of teaching these ward nurses is for them to be able to deliver quality management and care for diabetic patients, effectively and independently without hesitation, by equipping them with the necessary knowledge and skills. This paper is going to argue and compare the works of various authors to develop an efficient educational session for the nurses in order to improve their knowledge and management of patients with type 1 diabetes mellitus. To achieve this, Craven and Hirnle (2009) reinstates that a thorough assessment of learner, effective teaching plan, implementation of the teaching process and clear evaluation (APIE) of the teaching plan and learners outcome is important. Nevertheless, a clear educational plan with precise behavioural objectives is key prior to teaching staff nurses as Mager (1997) asks, “If you don’t know where you’re going, how will you know which road to take to get there?” (p. 14). 

Objectives

In this case, to guide the behavioural objectives, the taxonomy of educational objectives developed by Bloom et al. (1956) and Krathwohl, Bloom and Masia (1964) is used. With the notion to provide a holistic learning experience, the objectives for this teaching session consist of a mix of the cognitive, affective and psychomotor domains. In the cognitive domain, after one hour lecture in the form of in-service education sessions over the course of one week, the nurses will be able to state accurately the pathophysiology, symptoms, diagnosis and treatment, complications and nursing management required for type 1 diabetes as Boyd, Gleit, Graham and Whitman (1998) believes that lecturing is an ideal method that serves as foundational background information and a base for group discussions. Moreover, after watching a 6- minute video of diabetes dietary requirements included in the lecture, nurses will be capable to provide at least five examples of food to be included in the diet. Furthermore, after reading handout materials supplemented during lecture, the nurses will be able to recognize the range of blood sugar levels for random, fasting and 2-hour post prandial plasma glucose tests

Besides that, following a 1 hour group discussion conducted over the course of 1 week after lecture sessions on the barriers and obstacles of nursing management in handling patients with diabetes, the affective domain is tapped as nurses will be able to share diabetes related knowledge with each other, gain peer support and reduce the obstacles in diabetes management. In addition, a massed practice after a demonstration of how to monitor blood glucose level and insulin injection administration, nurses will be able to return the demonstration in groups without mistakes, involving the psychomotor domain as well. As the ward nurses realize the need to acquire nursing management skills in managing diabetic patients, they possess the attention and attentive level required to learn as O’Sullivan (2007) believes that massed practice is useful for learners with good attention, concentration and endurance. 

After providing information on how to handle diabetic patients through lectures and group discussions, a written simulation is conducted so that nurses will be able to describe how they would handle a hypoglycaemic or hyperglycaemic patients as Beaubien and Baker (2004) believes that simulations allows participants to decide healthcare interventions in a safe environment and enables learners to evaluate the effectiveness of their actions.     

After a 5 minutes role play sessions enacting patients fear during insulin injection administration, nurses will be able to realize real-life situations and develop understanding of why people behave the way they do (Lowenstein, 2007). Relatively, after observing how nurse educators themselves interact, demonstrating vast knowledge and skills in managing diabetic patients through role modelling, nurses will be able to follow the interpersonal skills and develop critical thinking competencies as argued by Sorensen and Yankech (2008).  

Therefore, to accomplish these objectives, the learning needs of the nurses must first be critically assessed (Bastable, 2014) as in a research on nurses studying Bachelors of Nursing, Zareiyan Jahromi and Ahmadi (2005) found that the needs assessment by nursing instructors lies in the centre of learning. Hence, the nurses will be assessed based on three determinants of learning described by Haggard (1989), which is the assessment of their learning needs, readiness to learn and learning styles.

The Teaching Assesment, Planning, Implementation and Evaluation

Identifying the learner

Bastable (2014) explains that the first step to assess learning needs is by identifying the learner. How do we do that? One of the ways in assessing the learning needs of staff nurses is by asking nurses for ideas using formal and informal requests as addressed by Williams (1998) to conduct educational in-services that in turn reflect what they perceive as needs. This indicates what improvement is required among staff and whether these needs are congruent to the needs of other members. At the same time, Lewin (1935) proposed that once staff approaches to request an in-service programme pertaining to their learning need, nurse educators mustn’t delay in conducting the teaching as staff may lose interest in the topic over time, emphasizing the critical time factor in the approach- avoidance conflict. Hence, the ‘teachable moment’ when the learner is ready to accept and learn new information will be used to devise a relevant teaching plan (Leist & Kristofco, 1990) as the moment acts as a ‘natural’ motivator for adults to learn (Zemke & Zemke, 1995). This motivation will be tapped upon as Inott (2011) believes it’s the key factor in initiating education based on adult learning theory.  

Choosing the right setting

Prior to beginning the teaching session, a right atmosphere will be chosen for the teaching-learning process to take place effectively as  McDonald, Wiczorek and Walker (2004) suggest that distractions like noise during teaching greatly impacts the readiness to learn health information. Therefore, a conducive environment like the conference room in the hospital will be chosen as Carpenter and Bell (2002) describes that right settings with enough space, privacy, no noise or interference of staff work demands should be chosen to create a trusting environment among nurses for them to concentrate and carry out teaching-learning process. Relatively, 1 hour of lecture in the form of in-service will be conducted at the conference room in the hospital.

Although the importance of settings in the teaching-learning process is reinstated, Duffy (1998) found that tight budget allocations by organizations in staff educational programmes interferes with the implementation of innovative and time-saving teaching strategies. Consequently, the hospital needs to allocate experienced nurse educators, which are scarce in supply, to teach and mentor these staff and commit to financial costs of facility and salary payments (Thrall, 2007). Therefore, as Bastable (2014) suggests, an annual report to the administration on the money and time disbursed through the staff educational programme specifying the cost savings, benefits and recovery of these programmes to the institution will be provided.

 

Collecting information from the learner 

Moreover, Bastable (2014) also explains the importance to collect information about learners before teaching. Subsequently, a literature search about staff education in diabetes management will be done using databases like CINAHL, and EBSCO, to identify the type of teaching method, and content suitable to teach nurses as how Rutten, Arora, Bakos, Aziz and Rowland (2005) researched cancer patients to know the learning needs of that population. 

Collecting information from the nurses

Similarly, information will also be collected from the nurses themselves as Benner (1982) clarifies that in a group of nurses, there may be a mix of newly graduated nurses who are novices requiring more practice and veterans who are loaded with experiences. These new nurses experience anxiety due to transition shock in their professional adjustment (Duchscher, 2009). Consequently, this high level of anxiety interferes with readiness to learn as Ley (1979) believes that moderate anxiety level is optimal for individual to grasp what is being taught. Accordingly, humour will be used during lectures to allay their anxiety as it encourages freedom to explore alternatives in learning situations (Bastable, 2014). Nurses will also be asked what they want to learn through formal and informal requests described earlier as this step allays their fears making it easier to proceed to other topics (McNeill, 2012). 

Besides that, to recognize the new nurses learning needs, a staff self-assessment of needs by sharing reflections of their actions as well as peer review in the assessment process, as Grant (2002) suggests, will be used in group discussions consisting of 5 to 10 nurses to encourage nurses to speak up and relate to each other. Self-assessment methods like the strength, weakness, opportunities and threats (SWOT) analysis recommended by Sherwin and Stevenson (2011) will also be used to motivate professional self-reflection.  Subsequently, the information gathered through group discussion will be used to realize nurses’ readiness to learn based on their frame of mind enabling nurse educators to prioritize nurses’ learning needs as Maslow (1987) relates to the humanistic learning theory and believes that basic needs should be met before an individual can achieve self-actualization. In other words, the humanistic learning theory will be used as Rogers (1994) believes that instead of acting as an authoritative figure, nurse educators should be facilitators where listening rather than talking is the skill required. These ward nurses need to be perceived as competent and recognised for their skills before they can achieve self-actualization. 

Age Differences

Building a rapport with the staff also helps in identifying different age groups of nurses as well. Relatively, Leiter, Jackson and Shaughnessy (2009) believe that nursing consists of the Millennial, generation Xers, baby boomers and the veterans. Each generation have their own sets of teaching and learning approaches as explained by Strauss and Howe (1991). Although the silent generations or veterans are very knowledgeable and experienced, they may have difficulty in technological related learning compared to the millennial who are the ‘net generation’ as described by Johnson and Romanello (2005). This creates a situation where instead of the younger generations turning to older generation for advice, older nurses rely on younger co-workers in using the computer for everything (McNeill, 2012). 

Therefore, this teaching session will incorporate a variety of teaching methods as Bill Gates says, ‘technology is just a tool. In terms of getting the kids working together and motivating them, the teacher is the most important’. Aligned with technology, audio-visual aids will be used alternatively to teach as Kessels (2003) believes this stimulates both hearing and seeing leading to more permanent memory storage. Hence, a 6-minute online video on current diabetes dietary requirements (Singapore General Hospital, 2013) produced by the hospital itself will be included as Sherer and Shea (2011) found that involving technology in lectures energizes discussion and able to meet learning goals. Permission will be asked from the hospital prior to use. A group discussion will be organized after the video and after each lecture to encourage nurses to describe at least five types of food suitable for diabetics, share their opinions and elicit feedback of the teaching session as Quinton and Smallbone (2010) found that stimulating feedback from the learner and educator creates room for improvement by being able to compare their own performance to what others expect of them.    . 

Reverse Mentoring

Another way to bridge technological knowledge gap is by reverse mentoring as explained by Reinbeck and Fitzsimons (2014) whereby an older staff is teamed up with a younger staff to share the younger employee’s expertise. Relatively new, this method seems promising because instead of solely depending on the nurse educator’s initiative, nurses could depend on each other as Donner, Levonian and Slutsky, (2005) believes that the vital factor to the success of nursing profession is for nurses to teach other nurses. Therefore, each group formed for all group discussions will consist of a skill mix of nurses, of both young and older staff. Through this interdependence and teamwork, the internet will be used to develop electronic discussion group (Bastable, 2014) to create a platform to share diabetes related information among nurses and also as a form of feedback for the teaching session. Team collaboration at this level subsequently promotes greater job satisfaction (Kalisch & Begeny, 2005) and satisfaction once achieved, promotes level of aspiration leading to better work performance (Bastable, 2014).   

Lecture

Bastable (2014) found that to provide foundational background information as a base for group discussions, lecture is an effective way. Thus, lecture sessions will be conducted over 1 week, from the 11th to 15th July 2016. Topics about type 1 diabetes mellitus where pathophysiology will be on Day 1, symptoms on Day 2, diagnosis and treatment on Day 3, its complications on Day 4 and nursing management on Day 5 will be covered as described in Appendix A. This scheduling of lectures is essential as Bain (2004) believes a well- organized lecture can be a beneficial method of teaching. Microsoft PowerPoint will be used to prepare lecture content that includes graphics and pictorial guidelines of diabetes management, for instance, step by step instructions on insulin injection administration and blood glucose monitoring will be used as Feldman (2004) believes that successful use of drawings and description enhances the understanding of the learner. The lecture will begin by stating the objectives and its relevance in the form of questions that will be answered in the body of the lecture to engage nurses’ attention. This use of set pulls the learners attention, focusing the group to the educator and setting the stage for learners to be prepared to listen (Kowalski, 2004). It is vital to realise the relevance of educational programmes to these nurses as active management and relevance are essential for learning (OECD, 2007). Moreover, Bass (2005) relates to adult learning theory reinstating that adults are relevancy orientated where they must know the reason why something is taught. Therefore, nurses will be explained that it’s their legal responsibility to adhere to the nurses’ code of ethics and be competent to deliver quality care to patients (Lachman, 2009a, 2009b). Stressing on the ethical principle of beneficence and non-maleficence, they’ll be made to realise that healthcare is committed to provide safe quality care without harming anyone (Engebretson, Mahoney, & Carlson, 2008). The reasons of why is it important to know how to manage a diabetic patient will be explained during the introduction into the lecture sessions, with the use of anecdotes and examples such as stories of past diabetic nursing management gone wrong and case scenario of correct diabetic nursing management will be included to help nurses better relate to the issue and their past experiences (Sullivan & McIntosh, 1996).

Learning Styles

Parallel to past experiences, as most students enter into nursing at an older age, majority of them are adults (Bastable, 2014). These adults bring along diverse life experiences into their learning process (Knowles, 1984).  In this case, these experiences will be incorporated into the teaching plan by establishing a learning contract as described in Appendix A. As Atherton (2005) believes that learners are active partners rather than passive in the teaching-learning process, a written learning contract will be mutually agreed upon specifying the what, where and how of the teaching plan. Furthermore, as Beagley (2011) describes adult learners to be autonomous and self-directed, the use of learning contracts further encourages active participation of the nurses promoting professional development. This emphasizes learners to learn on their own, gives them opportunity to choose appropriate learning styles and self-evaluate (Waddell, 1998). Ethically, by providing them the authority to choose their learning style, autonomy is given to these ward nurses to decide independently. In a study by Holstrom and Roing (2010), the authors emphasize that caregivers must surrender their need to control to the patient to empower patients. Although this paper refers to patients, the concept of empowerment is relatable to educator-staff relationship as well, where the nurse educator must be the one to strike a power balance with the nurses in order to empower them from within.      

However, although it is important to identify learning styles as Sternberg (1996) reinstates in his paper, Tennant (2006) believes that striving to match learning styles is not always necessary as adults may in fact benefit from different approaches to learning because it promotes creativity and tolerance for differences. Besides that, it also difficult and time-consuming to assess learning styles of each nurses in the lecture group. Therefore, as adults learn best with combined teaching strategies (Russell, 2006), the lecture session will include visual, auditory and kinaesthetic approaches through videos, group discussions, demonstrations and return demonstrations and simulations as Bastable (2014) believes there is no one perfect teaching method for all learners in any settings.

Literacy

In terms of difference in learning styles,  the ward nurses are from diverse cultural background where difference may exists in their birthplace, citizenship, language, religion, race, ethnicity and more (Jeffreys, 2006). Therefore, the first and foremost assessment to be done is whether these nurses can speak and understand English as Andrus and Roth (2002) defines literacy as the ability to read, write and speak in English. Although most foreign nurses have to surpass a mandatory English language proficiency exam before commencing work, they may be slow to understand and speak English (Davis & Nichols, 2002). Hence, based on the gestalt principle of cognitive learning theory (Koffka, 1935), a simple and clear information delivery is what’s actually required for learners to completely comprehend what is taught. Relatively, instructions of the handout materials after lecture session on Day 1 will be made based on up-to date information, avoiding unnecessary details and abiding by the keeping it simple and smart (KISS) rule as suggested by Brownson (1998) and Doak, Doak and Root (1996) to enhance better understanding of the range of blood sugar levels for random, fasting and 2-hour post prandial plasma glucose tests in managing diabetic patients. 

  

Cultural Differences 

At the same time, it’s also imperative for nurses to be knowledgeable about each other’s distinctiveness to promote harmony and better quality care to patients (Baegley, 2011). They must first understand the core values that each culture have on which all other values are based as the starting point in understanding different cultures (McFarland, 2006).  Hence, during group discussion on Day 2, diversity self-awareness will be taught through diversity assessment whereby cultural sharing among health professionals is encouraged by developing a multicultural workplace competence using the acronym COMPETENCE- Caring, Ongoing, Multidimensional, Proactive, Ethics, Trust, Education, Networking, Confidence and Evaluation (Jeffreys, 2007). Through this diversity group discussion using the acronym COMPETENCE as described in Appendix B, nurses will be able to share their obstacles and barriers they face in everyday nurse-client experiences and develop ways to overcome these obstacles together as a team.  

However, prior to teaching about cultural diversity, the nurse educators themselves should be knowledgeable about various cultures and sensitivity in order to be a role model to the nurses (Armstrong, 2008). Relatively, Toofany (2007) believes that nurse leaders should be educated and trained first before upholding their posts referring to transformational leadership. Consequently, nurse educators will be role models to the ward nurses by showing them how to communicate with diabetic clients of different background as Albert Einstein says, ‘example isn't another way to teach, it is the only way to teach’. This relates to the social learning theory where Bandura (2001) believes that people learn by observing other people’s behaviour. When these nurses observe how nurse educators interact with different patients, they will realise that an effective communication style with patients from different cultural backgrounds not only leads to better diabetes management among patients, but also increases self-esteem and recognition from colleagues as they are perceived competent in their jobs. Thus, achieving self-esteem is vital to attain self-actualization as explained but Maslow (1987) in his hierarchy of needs, where nurses will realise their true potential and are motivated to continue performing their best for patients. However, rather than depending on nurse-client interaction alone to perform their best in providing quality diabetic care for patients, nurses must first understand how patients feels, be in their shoes and know why clients behave the way they do. How is it possible to achieve this?

Role-playing

In a study, Redman (2007) clarifies that role playing is an effective simulation to develop understanding of other people by placing nurses in a real-life situation. Therefore, following one hour lecture on Day 4, a fifteen minutes group discussion will be allowed to discuss the lecture content, which is nursing management and then be separated into two groups to. The first group plan the script of case scenario on patient’s fear during insulin injection administration and the second group on blood glucose monitoring. After discussion, the nurses conduct a 5 minutes role play to re-enact how patients from different cultural backgrounds behave during insulin administration and how nurses manage them. In this way, nurses will be able to comprehend the fear patients feel and explain important cultural characteristics that are inappropriate (Shearer & Davidhizar, 2003). Through this, problem-solving skills are also tapered for nurses to relate and use these skills in their real-life experiences. Following the role-play activity, a short 10 minutes sharing session will be organized to discuss how each nurses felt as Comer (2005) believes that it’s essential to gain insight of what participants understand of their role expectations and interpersonal relationships after role-playing. 

 

Demonstration

Simultaneously, to administer insulin injections and monitor blood glucose level, nurses must first know the correct techniques of both skills. Hence, on Day 3, after thorough explanations on diagnosis and treatment of diabetes in the lecture, a demonstration on insulin injection administration will be done. A supervised massed practice will be conducted after both skills demonstration where nurses first will draw up saline in real syringes, practice injecting sponges 8 times in sets of three and then will progress to a mannequin which will be borrowed from the hospital learning labs before actually injecting patients. Using sponges and reusable syringes saves direct costs of materials. Only one mannequin will be borrowed to reduce cost because when one group is learning injection administration, the other will be learning glucose monitoring and vice versa. For blood glucose monitoring, nurses will practice once on each other using disposable sterile lancets and test strips as well as a glucometer which will be borrowed from the hospital. In the process of demonstration, explanation of why each step needs to be carried out will be verbalized as Brookfield (2006) believes it prevents bad habits from being integrated in the procedure and enhances remembrance of information in long term.  Although a study by Donovan and Radosevich, (1999) proved that distributed practice showed significantly better performance by learners compared to massed practice, Shumway-Cook and Woollacott (2007) found that the decreased in performance with massed practice doesn’t impact retention negatively. Hence, by using these inanimate objects, Aldridge (2009) found that this hands-on technique capitalizes learners learning styles and promotes retention of information. 

Return demonstrations 

After practicing, nurses will return the demonstration of skills learned. For each step performed correctly, they’ll be praised along the way as Skinner (1974) believes that positive reinforcement through verbal encouragement reinforces the behaviour and promotes confidence to accomplish tasks successfully. This not only increases the motivation of nurses to perform at their level best, but also increases their self-efficacy to provide diabetic nursing care. In a paper by Syx (2008), the self-efficacy model is explained as the individual’s believe on their ability to make and sustain changes and positive outcomes in their lives. Therefore, motivating nurses to believe in their true potential and making them realise the positive implications of a good nursing management, promotes excellence in patient care delivery. At the same time, nurses may feel anxious as they may view return demonstrations as a form of test where they’re expected to perform perfectly (Bastable, 2014). Hence, initially humour will be used appropriately to coach and build rapport with these nurses to allow each other’s personality to shine through and allay their anxiety to ask questions throughout the teaching session. In a study by Kaplan and Pascoe (1977), the authors found that the use of humour in teaching significantly improved the retention and comprehension of the teaching contents. Constructive extrinsic feedback will also be given continuously in the early stages of teaching to promote motor learning (Biodeau, 1966).

However, the next time the nurses demonstrates these skills, coaching will only be given when needed as Lorig (2003) believes it interrupts the thought process and mental imprint of the procedure while performing the task. Besides that, the least amount of concurrent feedback for the shortest time possible will be used to encourage nurses to self-detect errors in order to promote long term information retention (Gentile, 2000).     

Written Simulation

Besides eliciting questions from the nurses, questions on how they would respond to different case scenarios will also be asked using written simulations on Day 5. During lectures, staff nurses may be asked in descriptive pattern like “What are the signs and symptoms of diabetes?”, clarifying questions that prompts nurses to convey thoughts and feelings like “When do you feel most anxious?”, and higher-order questions that tests cause-effect relationships like “Why does low-fat diet help to control blood sugar level?” as identified by Babcock and Miller (1994). The information will be repeated if necessary or when nurses don’t fully understand as it reinforces learning by guiding the retention of information (Willingham, 2004). When it comes to written simulation, nurses will be asked how they would handle a scenario of hyperglycaemic or hypoglycaemic patient in the ward. The choice of their decision, consequences and alternatives to their responses as well as their verbal feedback of the simulation will be discussed in a follow-up debriefing session. Subsequently, by facilitating their analysis of experience, it enables anticipatory learning to take place (Jeffries, 2005), which nurses can implement in their daily diabetic nursing management. 

Conclusion

Thus, being advocates in patient education and the backbone in nurses’ professional development, nurses must continually seek ways to improve their skills and knowledge. As William Osler says, ‘the trained nurse has become one of the greatest blessings of humanity, taking a place beside the physician and the priest. However, as time goes by, the nursing management is faced with myriad of challenges to keep pace with the rapid technological development, to manage resources with staff shortages and meet the ever demanding working environment. The tight budget allocations and lack of reimbursements by institutions in educational programmes only heightens the event of the problem. In other words, it’s a war out there and nurses need to be prepared for the battle. Despite being mentally, physically and emotionally strong themselves, nurses aren’t the only one who holds responsibility for this challenging nursing framework. Additionally, the collaboration of the healthcare system as a whole, be it the institution, higher management authorities or government are necessary to prepare nurses to deliver the best quality patient care possible. As Helen Keller once said, ‘alone we can do so little; together we can do so much’.  

By Jessica John Posko

       

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Appendix A

Learning Contract

Learner: Staff Nurses from ward

Educator: Clinical Nurse Educator Jessica John

Time Frame of Contract: 11th July-15th July 2016

Terms of Contract: Staff nurses will gain more knowledge and master the skills of managing type 1 diabetic patients following 1 week teaching session.

Days	Learning Objectives	Learning Resources and Strategies	Specific Measurable Criteria to be Evaluated	Who will Judge Evidence	Target Date of Completion
Day 1	-To explain the pathophysiology of type 1 diabetes - To recognize the normal and abnormal range of blood glucose levels	-Lecture - Reading handout materials -Group  Discussions -Electronic group discussions	-Describe clearly how insulin in the body is produced. -Identify the range of blood sugar levels for random, fasting and 2-hour post prandial plasma glucose tests	-Nurse educator -Ward nurses	11th July 2016 (Monday)
Day 2	-To identify the symptoms of diabetes type 1 -To identify the right dietary requirements for diabetic patients. -To share the obstacles and barriers faced in nursing management of type 1 diabetics	-Lecture -6-minute video -Group discussions -Electronic group discussion	-List at least 2 symptoms, complications, and nursing management of type 1 diabetes -List at least 5 foods suitable for type 1 diabetics. - To be less anxious and share at least 1 obstacles faced by nurses	-Nurse educator -Ward Nurses	12th July 2016  (Tuesday)
Day 3	-To state how to diagnosis and treat type 1 diabetes -To apply right methods of insulin injection administration and blood glucose monitoring	-Lecture -Demonstrations -Massed practice -Return demonstrations	-To explain why insulin injections are necessary  - To demonstrates the correct techniques of insulin injection administration and blood glucose monitoring	-Nurse Educator -Ward Nurses	13th July 2016 (Wednesday)
Day 4	-To recognize how patients feel during diabetic treatments - To recall the appropriate nurse-client interaction	- Role Playing - Group discussion -Questionnaires - Role-modelling	-To compare real-life situations on patient’s fear of insulin injection administration and blood glucose monitoring. -To identify the suitable interpersonal skills of two-way communication  with clients	-Nurse educator -Ward nurses	14th July 2016 (Thursday)
Day 5	- To predict the right nursing management for diabetic complications	-Written simulations -Group discussion	-To describe the correct nursing management of hyperglycaemia and hypoglycaemia.	-Nurse educator -Ward nurses	15th July 2016 (Friday)

Signature of Learner:

Signature of Educator: 

Appendix B

The acronym COMPETENCE used to guide the cultural diversity teaching among nurses in group discussion on Day 2. 

By Jeffreys, M. (2007). Dynamics of diversity: becoming better nurses through diversity awareness. Imprint, 55(5), 36-41. Retrieved from: http://www.nsna.org/Portals/0/Skins/NSNA/pdf/Imprint_NovDec08_Feat_Jeffreys.pdf