One of the most far-reaching changes in health care is hospitalizations of shorter duration and the resultant increasing acuity during the time of hospitalizaron. A majority of hospitalized children are hospitalized for the diagnosis of chronic conditions or the acute exacerbation of those conditions. The shortened duration of hospital stays and the increased acuity during those hospitalizations challenges nurses to optimize teaching opportunities and to maximize the effectiveness and efficiency of their teaching.
Approximately 120,000 school-age children in the United States have insulindependent diabetes mellitus (IDDM or Type I diabetes), with 14 to 16 new cásea per 100,000 children ages O to 14 diagnosed each year (American Diabetes Association, 1993). One of the hallmarks of diabetes is that, after the time of diagnosis, this chronic condition is largely managed by the family. This is especially significant when one considers that the need for modifications of insulin dose based on glucose levels and physical symptoms make the managemeat of IDDM one of the more complex among chronic conditions. The magnitude of the short-term and long-term side effects of mismanagement make the situation potentially even more precarious (Orchard, 1994).
Many characteristics of the children and of the families, both independently and interdependently, affect adherence to the diabètes-management regimen (Brands & Magyary, 1993). Furthermore, a child who has diabetes that has been well controlled may become less well controlled as that child gets older, especially in adolescence.
At the time of diagnosis, virtually all children who are diagnosed at 3 diabetes center and at least one family member are given an intensive program about diabetes and its management. Ongoing education is less common and less rigorous. Many of the acute and chronic complications of IDDM result from mismanagement or non adherence. Formal education programs have been shown to increase shortterm and long-term knowledge about diabetes in children and parents (Brands & Magyary, 1993) and have been demonstrated to be effective in many other ways such as social support about the condition (Glasgow & Osteen, 1992). Families often are required to use their knowledge not only to manage the child's condition hut also to teach others involved in the child's daily life such as teachers, coaches, and babysitters about diabetes, Uarrett, Hillam, Bartech, & Lindsay, 1993). Regardless, the availability of and reimbursement for ongoing formal education about diabetes outside the context of acute exacerbations are limited.
While the effectiveness of diabetes education is mediated by social and environmental factors (Glasgow & Osteen, 1992), the conveyance of precise and appropriate information remains the cornerstone of diabetes education. The goal of diabetes education is that the children remain as healthy as possible, as evidenced by an appropriate glycosylated hemoglobin level, lack of symptoms of hyperglycemia or hypoglycémie, and the ability to participate in all normal, developmentally appropriate activities. These factors demonstrate ideal long-term and short-term management. Comprehensive diabetes education by RNs is essential. Several studies have evaluated RNs' knowledge of diabetes and found this knowledge to be insufficient (Drash, 1986; Gossain, Bowman, & Rover, 1993; Jayne & Rankin, 1993; Leggett-Frazier, Turner, & Vincent, 1994; Ruby, Blarney, Haas, Patrick, & Patrick, 1993; Scheiderich, Freibaum, & Peterson, 1983).
The purpose of this study was two-fold:
* To assess the preparedness of nursing students and RNs in the early stages of practice to care for children with IDDM and to teach about IDDM.
* Evaluate the adequacy of diabetes education in nursing school by evaluating nursing students.
Sample. The sample included 155 subjects who volunteered to participate. Registered nurses !Group I, p = 55) were from two hospitals specializing in the care of children. They practiced on a variety of subspecialty unite. Basic preparation of RNe included baccalaureate, 22 (40%); associate degree, 20 (36.4%); and diploma, 13 (23.6%). Length of practice ranged from 2 weeks to 1 year (mean = 7.8 months ± 1.7). The ages of the nurses ranged from 20 to 36 (mean = 25.8 ± 4.6). The student nurses (Group II, p = 45) were juniors and seniors in baccalaureate nursing programs. They already had received course content on diabetes end its management. The non-nursing students (Group ??, ? = 55) were university undergraduates from two universities. They had a variety of majors including economics, psychology, physics, business, and biology.
A 20-item Diabetes Knowledge Questionnaire (DKQ) was developed to assess the knowledge of nurses and nursing students about a variety of specific topics pertinent to the care and self-care of children with diabetes. The DKQ assessed knowledge in the following six categories:
* Etiology of diabetes.
* Classification of diabetes.
* Insulin action.
The categories and questions were based on the guidelines front the American Diabetes Association (1995). Content validity was established by a panel of experts comprised of two endocrine clinical nurse specialists, five diabetes nurse educators, and two pediatric endocrinologiste. The DKQ is a 20-item tool, and each item is worth five points. To calculate interrater reliability, all DKQs were scored by both investigators. Interrater reliability was 96%.
The purpose of this study was to assess diabetes knowledge acquired through basic nursing education and through the early stages of practice (less than 1 year) as an RN. Because diabetes is a familiar topic to many because of personal experience and coverage in the lay press, the DKQ was administered to a comparison group of students who were not studying to be nurses.
Procedure. The DKQs were distributed to nurses at two pediatrie hospitals, and to students at two universities. The same tool was given to each group. An oral explanation was provided, and the questionnaire was distributed. A written explanation accompanied the DKQ. Completion of the instrument and demographic data were taken as consent to participate in the study. No names were used; therefore, participante were clear that participation in the study was not related to grading, performance evaluation, or other institutional feedback mechanisms.
Frequencies were used to describe the samples. Test scores were a percentage from O to 100; each question was worth 5 points. Unpaired t tests were calculated to determine differences in scores among the groups.
Diabetes knowledge was found te be lacking in all groups (Group I, RNs; Group II, baccalaureate nursing students; and Group III, non-nursing undergraduates). The mean scores were as follows: Group I = 65.3% (± 14.4%); Group II = 57.4% (± 17.3%); Group UI = 13.1% (± 11.0%). The scores for practicing RNs ranged from 20% to 95% (mean = 64.3% ± 14.4%). The four nursea who scored 85% or above all had personal experience with diabetes through friends or family members. There was no relationship between the type of educational preparation (baccalaureate or diploma) and test scores. The test scores for both RNs and nursing students were low. However, the scores of RNs (Group I) were significantly higher than those of nursing students (Group II) (p < .05, i = 2.14). Scores far Group IT ranged from 30% to 100% (mean = 57.3% ± 17.3%). The one student who scored 100% had IDDM.
The DKQ assessed subjects' knowledge in six areas. Scores for practicing nurses and student nurses were:
* Etiology (70% versus 76%).
* Classification (64% versus 71%).
* Insulin action (52% versus 61%).
* Diet (73% versus 59%).
* Hypoglycemia: signs/symptoms/treatment (60% versus 49%).
* Hyperglycemia: signs/symptoms/treatment 35% versus 36%).
Item analysis showed that RNs' knowledge was poorest in the area of insulin action (52% correct) and in signs, symptoms, and treatment of hyperglycémie (35% correct). Nurses frequently confused the signs, symptoms, and treatment of hyperglycemic with keteacidosis.
Item analysis showed that student nurses scored highest in areas of diabetes etiology and classification and lowest in signs, symptoms, and treatment of hyperglycémie. Of note, 100% of the student nurses correctly responded to the item asking which insulin should be drawn first when drawing two types of insulin. However, only 18% correctly responded when asked about the time of the peak action of NPH insulin (isophane suspension insulin). Similar to the practicing nurses, only 18% of the nursing students provided the correct answer te the item about the signs, symptoms, and treatment of hyperglycemia.
The student nurses actually scored higher than the RNs in three categories: etiology, classification, and insulin action. The student nurses confused the symptoms of hyperglycemia with hypoglycemia, while the practicing nurses confused hyperglycemia with ketoacidosia. The student nurses scored significantly higher than the control group of non-nursing students (p < .0001, i = 15.4). The knowledge of the non-nursing students was not unexpectedly poor in all areas.
The findings of this study are consistent with several others that found inadequate knowledge of RNs about diabetes (Drass, Muir-Nash, Boykin, Turek, & Baker, 1989; Gossain et al., 1993; LeggettFrazier et al., 1994; Ruby et al., 1993; Scheiderich et al., 1983) and of nursing students (Fueatal, 1976). This study is unique because it compared the knowledge of nursing students to practicing nurses. The inadequate knowledge of nursing students as well as nurses practicing less than 1 year points to a deficit either of diabetes education in nursing school or in the retention of what has been taught. The lack of knowledge was demonstrated more than 20 years ago (Fueatal, 1976) and is currently still evident.
The significance of these findings ia pertinent for nuieiag schools and for health care institutions employing new nursing graduates. The higher scores that students attained in the three categories of etiology, classification, and Insulin action indicates greater theoretical knowledge. However, the students were less able to solve practice situations. This indicates a need for a much greater emphasis on student recognition and treatment of diabetes management situations, especially of emergencies.
There seems no reason to believe that this deficit ia unique to knowledge about diabetes. Rather, one could assume that similar deficits exist in other areas within pediatrie nursing. However, it seems of no benefit that an outcome should be a great deal of research exploring nurses' knowledge of, for example, spina bifida, infectious diseases, or gastric motility disorders. Rather, such assessment, based on the likelihood of a knowledge deficit, should occur as nurses begin practicing with new populations such as patients with diabetes in whom the care provided by nurses is pivotal.
It is commonly stated in nursing schools that the symptoms of hypoglycemia and hyperglycémie are easily confused. In reality, there is little similarity in the symptoms. (The only exception is the person who is unconscious, who could theoretically have hypoglycémie or hyperglyeemia. However, the person with diabetes who is unconscious is much more likely to have hypoglycémie, particularly if the patient is a child.) For the most part, for most clinical situations, there is no such ambiguity. It ia possible that nursing students in this study frequently confused the symptoms of hypoglycémie and hyperglycémie as a result of this misinformation.
Respondents were asked how they would determine, in a specific clinical situation, if a child were hypoglycémie or hyperglycémie. Only 54% responded that they could resolve the diagnosie with bedside glucose monitoring. Students also had extremely poor knowledge of what glucagon is end when it should be used.
Rather than focusing merely on the theoretical concepts of diabetes, these results indicate a need to provide nursing students with multiple case studies of diabetes management issues. This would help students become prepared to address actual clinical situations. Additionally, there would be greater practicality in their teaching children and families. Although these authors believe it is critical that nursing students have specific content and case studies pertaining to children, it does not appear the students scored poorly on the DKQ because of their inadequate knowledge about diabetes in children but rather because of a pervasive inadequacy of knowledge about diabetes.
This study also has implications for those employing new graduate nurses who will be educating and caring for individuals with diabetes. The practicing RNs did score significantly higher on the DKQ than nursing studente (p < .05). Their greater diabetes knowledge may be because of preparation for the nursing h censure examination and hospital orientation. However, their knowledge of diabetes still is not adequate (mean = 64%). These nurses should not be expected to educate patients with diabetes, or even to care for those patients, without intensive education and careful precepting.
Patients with newly diagnosed diabetes are extremely vulnerable. Misinformation at the time of diagnosis can take a long time to correct. Only 52% of the practicing nurses could correctly identify the times regular and NPH insulins peak- a concept which must be taught to all patients and families with diabetes and understood by all nurses caring for those patients.
Practicing RNs frequently confused hyperglycémie and ketoacidosis. Unfortunately, the use of pediatrie nursing textbooks to prepare for nursing licensure and for practice is a likely cause for such misinformation. Textbooks frequently contain a table listing symptoms of hypoglycémie and hyperglycemia. The symptoms listed under hyperglycémie sometimes include abdominal pain, acetone breath, and rapid, deep respiration (e.g., Pillitteii, 1995-, Wong & Wilson, 1995). These are symptoms of ketoacidoeis not hyperglycemia. If such inaccuracies occur in textbooks, it is not surprising that nurses evidence the same confusion of the disorders.
Many institutions are now employing diabetes educators, nurse practitioners, or clinical specialists to educate patients with diabetes. This actually may compound the problem. Scheiderich et al. (1983) found that diabetes knowledge of staff nurses was poorer at a hospital in which there was a diabetes clinical specialist-presumably because all the diabetes questions were fielded by the diabetes educator. Perhaps as a result, the staff nurses were even less motivated or perceived less of a need to learn about diabetes. Certainly diabetes educators are not always present. It is essential that staff nurses are able to answer questions for patients and families. In addition, it is staff nurses who provide bedside care for patients with diabetes, and they must be knowledgeable to provide safe care. The roles of clinical nurse specialists, diabetes educators, or other advanced practice nurses all include education. It is the responsibility of these nurses to include staff education along with patient and family education. It is the responsibility of staff nurses to acquire and maintain the knowledge and skills necessary to provide comprehensive care.
Nurses' knowledge of diabetes is significant both for the direct provision of care to children with diabetes and because of the role of nurses as educators about diabetes. When it has been demonstrated that nurses' knowledge is lacking, recommendations have included providing a "solid foundation" in basic nursing programs (Leggett-Frazier et al., 1994, p. 309), These results underscore the importance of appropriate education at the undergraduate level but, of at least as great importance, is the need for ongoing diabetes education. These authors support the use of diabetes educators or advanced practice nurses. However, it is crucial that they work in collaboration with staff nurses. The improvement of staff nurses' knowledge of diabetes must be one of their goals. The nature of diabetes is such that pediatrie nurses in every sub specialty area are likely to be required to care for children with diabetes. Improved knowledge of diabetes is needed for nurses to provide safe and effective care for that special population.
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