62 AJN t July 2010 t Vol. 110, No. 7 ajnonline.com
atients with newly diagnosed or poorly
controlled diabetes will typically leave the
hospital with a diabetes education packet
that the nurse hopes will be read. These packets
are rarely individualized to the patient’s education
level, age, financial situation, comorbidities, or
other specific characteristics. While in the hospital,
many patients won’t ask for help with their self-
care. Some will rely on euphemisms like “touch
of sugar” or “borderline diabetes” to downplay
the importance of good control. If a nurse doesn’t
offer them information, patients may think there’s
nothing to know. If the nurse does teach them self-
management skills, they’re often grateful to have
help with this complex and chronic condition.
The 5 M’s. The goal when teaching diabetes self-
management in the hospital is to give the patient
what the American Diabetes Association has called
The American Association of
Diabetes Educators has identified seven core diabe-
tes self-management skills2
that we’ve condensed,
as shown below, into five clear, simple categories
starting with the letter “m”:
• Meter: monitoring blood glucose
• Meds: taking medication
• Meals: healthful eating
• Move: being active
• More: problem solving, such as sick-day man-
agement or responding to hypo- or hyperglyce-
mia; healthy coping, such as stress management;
and reducing risks, such as foot care, blood
pressure and lipid monitoring, eye examina-
tions, and quitting smoking
Even during a busy shift there are many “teacha
ble moments” when an informed and well-prepared
nurse can make use of this simple self-care termi-
nology to introduce inpatients to the skills they’ll
need upon discharge.
Knowledge deficit. A 2002 study by Uding and
colleagues revealed that increasing nurses’ knowl-
edge of diabetes is the first step toward effective
However, the study also re-
vealed that 53% of nurses failed to attend an in-
service program on the subject of diabetes in the
previous two years, while 26% said they’d never
attended a diabetes in-service program. Many
nurses feel uneasy recommending lifestyle changes
to patients and believe that they lack adequate
skills in lifestyle counseling. For example, they
may be uncomfortable talking to a patient about
topics like weight.4
Time crunch. The current health care environ-
ment, with its short staffing, shorter patient stays,
and cost containment, lends itself to nurses feeling
time constraints for delivering patient care. One
aspect of today’s nursing practice is that patient
education can easily fall by the wayside, even
though nurses know education is important to
patients and families.5
The expectations of today’s
staff nurses include caring for, educating, medicat-
ing, and planning the discharge of their patients
in a very short span of time. And shorter hospital
stays decrease the quality time nurses can spend
at the bedside with a patient, leaving many nurses
feeling conflicted about the quality of care they
can deliver. Competent, knowledgeable nurses are
needed to achieve quality, cost-effective care and
positive patient outcomes.3
Meter, Meds, Meals, Move, and More
A simple bedside approach to teaching diabetes self-management.
By Peggy A. Ulrich, MSN, RN, CDE,
and Nancy Abner, RN, CDE
firstname.lastname@example.org AJN t July 2010 t Vol. 110, No. 7 63
The Five M’s1, 2, 6
What to Ask How to Individualize It
Meter When check-
Do you have a glucose meter at
What meter do you use at home?
How often do you check your blood
glucose level at home?
Do you use a logbook? Do you
need a new logbook?
What have your blood glucose val-
ues been at home?
Do you know what the numbers on
the meter mean and what numbers
should be your goals?
How do you obtain your test strips?
Demonstrate use of the glucose meter, including
how to obtain a fingerstick sample from the side of
Encourage the patient to practice using the glucose
Explain the use of the logbook; leave the log at
the bedside and encourage the patient to record
glucose values; show the patient how to check the
glucose meter’s record for past readings.
Inform the patient of the American Diabetes
Association (ADA) target glucose ranges: fasting,
70–130 mg/dL; two hours after a meal, under
180 mg/dL (this value should be individualized
for each patient); hypoglycemia, under 80 mg/dL;
hyperglycemia, 200 mg/dL or higher.
Explain the “rule of 15” for treating hypoglycemia:
consume 15 g carbohydrates, wait 15 minutes,
check glucose level, repeat steps if necessary.
Explain when to seek help: for low (under
70 mg/dL) or high (over 300 mg/dL) glucose values
that are persistent and unresponsive to treatment.
Meds When giving
What medications do you take at
home for your diabetes?
Do you understand your medications
and how they work?
Is it difficult to afford your medica-
Do you ever forget your medica-
What do you do if you forget to
take your medications?
Ask patients to describe the name, action, dosage,
timing, and any relevant adverse effects of their
medications (provide handouts as needed).
Teach patients about insulin preparation, injection,
site selection, site rotation, proper storage, and
drug action (peak, duration, when to look out for
lows or highs).
Teach how to handle skipped or forgotten medica-
tions (never double the next dose; call provider
with questions, if necessary).
Suggest resources for obtaining free or reduced-
price medications (such as pharmaceutical compa-
nies or social workers).
64 AJN t July 2010 t Vol. 110, No. 7 ajnonline.com
What to Ask How to Individualize It
Meals When provid-
ing or inquir-
Do you count carbohydrates at
Do you measure your food?
Do you read labels?
Are you able to read labels?
Would you like to see the dietitian?
Would you like a copy of a meal
Do you eat out often?
Who does the cooking in your home?
Teach carbohydrate counting and portion control;
help patients obtain individualized meal plans from
a dietitian (the person who prepares food at home
should be present for the dietitian consult, if pos-
sible); give handouts on meal planning.
Reinforce the principles of good nutrition; stress the
importance of not skipping meals and avoiding
excess snacking between meals.
Explain the benefits of weight loss, if appropriate.
Move When help-
ing a patient
ring to a
chair or walk-
What kind of exercise or movement
do you get at home? How regular
What barriers make it difficult for
you to exercise?
Do you have safety concerns about
exercise or physical activity?
What is your favorite physical activ-
Would your family exercise with
Do you know that walking is a great
Collaborate with patients to explore exercise
options at home.
Focus on realistic activity goals for each patient.
Demonstrate chair exercises when necessary.
Work closely with patient’s physician and other
health care providers (physical therapist, diabetes
Emphasize the benefits of exercise: decreased
insulin resistance; weight loss; greater well-being,
mental focus, energy.
Teaching tips. A nurse can save time and im-
prove patient learning by seizing teachable mo-
ments. These moments occur naturally in a nurse’s
daily routine. Preparation and organization are
crucial. One strategy is to keep handouts, videos,
forms, and other information sources readily avail-
able. All materials should be in plain language that
can be understood even by those with little educa-
It’s also important to vary your approach. If
you deliver the same talk over and over, you and
your patient may both end up bored and disen-
gaged. As often as possible move beyond merely
having patients read pamphlets or listen to you
describe strategies; it’s well established that learn-
ing happens best when the learner must explain
her or his understanding of a topic or actually per-
form certain tasks while talking about them.
Often nurses are too busy delivering care to
stop and listen to patients. A nurse may be teach-
ing healthful eating to a patient who’s worried
about affording the next meal after leaving the
email@example.com AJN t July 2010 t Vol. 110, No. 7 65
hospital. Patients may feel overwhelmed by new
medical terminology. Relying on the simple lan-
guage of the five M’s will not only give the nurse
a clear focus but will also help the patient better
understand. This method includes asking pertinent
questions and individualizing teaching for specific
Peggy A. Ulrich is an assistant professor of nursing at Brevard
Community College in Titusville, FL. She formerly worked at
Parrish Medical Center as an inpatient diabetes educator and
developed and implemented the 5M strategy she describes in
this article. Nancy Abner is a certified diabetes educator at
MIMA (Melbourne Internal Medicine Associates) in Melbourne,
FL. Contact author: Peggy A. Ulrich, firstname.lastname@example.org.
Diabetes Under Control is coordinated by Jane Jeffrie Seley,
MPH, MSN, GNP, BC-ADN, CDE: email@example.com.
1. American Diabetes Association. Standards of medical care
in diabetes—2009. Diabetes Care 2009;32 Suppl 1:S13-
2. American Association of Diabetes Educators. Professional
resources. AADE7 self-care behaviors. n.d. http://www.
3. Uding J, et al. Efficacy of a teaching intervention on nurses’
knowledge regarding diabetes. J Nurses Staff Dev 2002;
4. Jallinoja P, et al. The dilemma of patient responsibility
for lifestyle change: perceptions among primary care physi-
cians and nurses. Scand J Prim Health Care 2007;25(4):
5. London F. No time to teach? A nurse’s guide to patient and
family education. Philadelphia: Lippincott; 1999.
6. Funnell MM, et al. National standards for diabetes self-
management education. Diabetes Care 2010;33 Suppl 1:
What to Ask How to Individualize It
More When talking
to a patient
time you are
speaking to a
Do you understand the signs and
symptoms of hypoglycemia?
Do you know how to treat a hypo-
Do you get your feet checked regu-
larly when you see the physician?
Do you have regular checkups?
Do you have family or social sup-
Do you understand complications
that can happen if you do not con-
trol your blood sugar?
Do you know what to do if you get
Have you been to outpatient diabe-
tes education classes?
Would you like me to make you an
appointment for outpatient diabetes
Will you need transportation to a
diabetes education follow-up?
Teach recognition of the signs and symptoms and
treatment of hypo- and hyperglycemia; what to do
about missed medications and sick days; when to
call for help.
Explain that stress can raise blood glucose levels
and that depression is common among those with
diabetes; help the patient obtain a mental health
consult if appropriate.
Explain the importance of frequent foot inspec-
tions; yearly eye examinations; flu vaccination;
monitoring blood pressure and cholesterol levels;
measuring the hemoglobin A1c level every three
months until it’s less than 7% or within individual-
ized target range, then every six months thereafter;
Provide resources, including connecting patients
to outpatient diabetes programs (classes or indi-
vidual appointments with a certified diabetes
educator); helping patients find transportation to
follow-up care and education; letting them know
about other community resources such as clin-
ics and smoking cessation programs; informing
them about online resources such as the ADA
(www.diabetes.org) and (for patients and fami-
lies of those with type 1 diabetes) the Juvenile
Diabetes Research Foundation International