Applied Nursing Research xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Original Article
Diabetes management unawareness: what do bedside nurses know? Mary Beth Modic, DNP, RN a,⁎, Anne Vanderbilt, MSN, RN a, Sandra L. Siedlecki, PhD, RN a, b, Rebecca Sauvey, BS, RN a, Nancy Kaser, MSN, RN c, Christina Yager, BS a a b c
Nursing Institute, Cleveland Clinic, Cleveland, OH, USA Walden University, Minneapolis, MN, USA Cleveland Clinic, Cleveland, OH, USA
a r t i c l e
i n f o
Article history: Received 4 July 2013 Revised 30 November 2013 Accepted 14 December 2013 Available online xxxx Keywords: Diabetes knowledge Bedside nurses Inpatient diabetes management
a b s t r a c t Background: Nurses are responsible for critical aspects of diabetes care. Purpose: The purpose of this study was to examine nurses' knowledge of inpatient diabetes management principles before and after a structured diabetes education program. Methods: In this descriptive, correlation study, 2250 registered nurses working in a quaternary health care center completed a 20 question assessment. The assessment was administered pre and post attendance at a 4 hour diabetes management course. Findings: Nurses' knowledge of inpatient diabetes management principles was low. There was no correlation between knowledge scores and age, education, employment status, years of experience or clinical specialty. Conclusions: In general, our findings suggest that nurses do not feel comfortable and are not adequately prepared to make patient care decisions or provide survival skill education for patients with diabetes in the hospital. © 2013 Elsevier Inc. All rights reserved.
Diabetes management principles for the hospitalized patient have changed rapidly over the past several years, specifically in the area of blood glucose (BG) targets and insulin regimens (NICE-SUGAR Study Investigators, 2009). The ability to stay abreast of all of these changes presents a challenge for most bedside nurses. Inadequate knowledge of recent trends in diabetes management can affect the quality and safety of the hospitalized patient with diabetes, resulting in longer lengths of stay and increased readmission rates (American Diabetes Association, 2013). The purpose of this study is to examine nurses' comfort, familiarity, and knowledge of inpatient diabetes management principles and to explore areas where knowledge gaps persisted even after completing a 4-hour educational intervention. 1. Review of literature Nurses and physicians confront daily challenges of safely managing BG levels in hospitalized patients (Cook et al., 2007). In one study, hyperglycemia was present in 38% of patients admitted to the hospital, 26% of whom had no history of diabetes (Umpierrez, Smiley, Zisman, & Prieto, 2007). The issue of tight glycemic control (BG levels maintained at b 110 mg/dl) in the hospitalized patient has received much attention since Van den Berghe first published her positive results of aggressive BG control in a surgical ICU in 2001 (Van den ⁎ Corresponding author at: Diabetes: Nursing Education and Professional Practice Development, Cleveland Clinic, 9500 Euclid Avenue, Mail Code P32, Cleveland, Ohio 44195. Tel.:+1 440 838 8463, +1 216 444 9005; fax: +1 216 445 0455. E-mail address: [email protected] (M.B. Modic).
Berghe et al., 2001). However, subsequent studies have reported conflicting and contrary findings suggesting that tight glycemic control results in an increased risk of hypoglycemia (Turchin et al., 2009; Umpierrez et al., 2007). In 2004, Clement, Braithwaite, Magee, Ahmann, Smith, Schafer and Hirsch published a technical review which evaluated the evidence for glucose control and made recommendations for treatment and monitoring as well as strategies for patient education (Clement et al., 2004). Several studies have been published related to inadequate diabetes management knowledge of nurses and physicians (Derr, Sivanandy, Bronich-Hall, & Rodriquez, 2007; Gerrard, Griffin, & Fitzpatrick, 2010; Modic et al., 2009; Rubin, Moshang, & Jabbour 2007). Knowledge deficits have been identified in relation to use of insulin (Umpierrez et al., 2007). Other studies identified knowledge deficits in the areas of insulin therapeutics, food and diabetic drug interactions, prevention of diabetes complications and current drug treatment for patients with diabetes (Gerrard et al., 2010; Griffis, Morrison, Beauvis, & Bellafountaine, 2007; Modic et al., 2009). 2. Methods The purpose of this descriptive study was to examine nurses' comfort, familiarity, and knowledge of diabetes management principles for the hospitalized patient and to explore areas where knowledge problems persisted after completing a 4-hour educational program. Designed by two inpatient certified diabetes educators (CDEs), the curriculum was based on a previously conducted needs assessment,
0897-1897/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnr.2013.12.003
Please cite this article as: Modic, M.B., et al., Diabetes management unawareness: what do bedside nurses know?, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2013.12.003
2
M.B. Modic et al. / Applied Nursing Research xxx (2014) xxx–xxx
adherence to a hypoglycemic rescue protocol and insulin error data. The four topics covered within the course were hyperglycemia, insulin therapeutics, hypoglycemia prevention and management, and diabetes survival skills. The teaching strategies used in the class included a pre-assessment test, lectures, strategic questioning, and case studies. Following presentation of course content, a posttest was administered, allowing attendees to identify areas for further improvement. 2.1. Specific aims The specific aims of this research were the following: • Specific aim 1: Is there a relationship between age and level of knowledge demonstrated on the Diabetes Management Knowledge Assessment Tool (DMKAT)? • Specific aim 2: Is there a difference in level of knowledge demonstrated on the DMKAT based on education or years of experience? • Specific aim 3: Is there a difference in the relationship between nurses' self-rated comfort and familiarity and level of knowledge demonstrated on the DMKAT? • Specific aim 4: Is there a gain in knowledge of inpatient diabetes management principles as demonstrated on the DMKAT after a diabetes course? 2.2. Procedure
Familiarity was defined as knowledge or mastery of a skill measured by summing the next six items in the DMKAT. Familiarity scores could range from 0 to 60 with higher scores indicating greater familiarity. Principle component analysis with varimax rotation confirmed a one-factor solution in support of construct validity. Reliability of this measure was .78. Comfort and familiarity were only assessed prior to the course. The knowledge portion of the DMKAT included 20 multiple choice questions and measured nurses' knowledge in four content areas of diabetes management presented in the class: hyperglycemia, insulin therapeutics, hypoglycemia prevention and management, and diabetes survival skill teaching. Five questions assessed major concepts presented in each content area. Each correctly answered questioned scored one point. Total scores ranged from 0 to 20 with a higher score indicating more knowledge. Content validity was assessed through consensus using a modified two-stage Delphi technique. Fifteen inpatient CDEs from local hospitals served as content experts. Content validity index for the final instrument was .95. The content experts agreed that an acceptable mean item score (for group) and whole test score (individual and group) of 80% or higher indicated acceptable knowledge of diabetes management skills for the hospitalized patient. This instrument was administered as both pretest and posttest assessment during the 4 hour class. 2.5. Data analysis
Level of knowledge related to diabetes was assessed via pretest immediately prior to a 4-hour diabetes management course and again at the completion of the course. The course included content on hyperglycemia, insulin therapeutics, hypoglycemia prevention and management, and diabetes survival skill. Participation in this study was voluntary. Tests were anonymous and the Institutional Review Board (IRB) approved this study. The completed pre and posttests were collected by the researchers, and data were entered into SPSS (version 19) in preparation for data analysis.
Data were analyzed using SPSS version 19.0. The sample was described by measures of central tendency (mean, median and standard deviation, frequency and percentage). Pearson's correlation was used to examine relationships for continuous level data (age) and Spearman's was used to assess nominal level data (education level and years of experience). Analysis of covariance (ANCOVA) controlling for age was used to examine baseline differences in knowledge related to education level and years of experience. Finally, a paired ttest was used to examine changes in knowledge. Because of the large sample to control for the likelihood of a type I error, the significance level was set at .01 rather than .05.
2.3. Settings and sample
3. Results
The study was conducted in a large 1200 bed health care center in the Midwest. Participants included registered nurses in all specialties except the operating room and neonatal intensive care unit. Nurses included in this study were clinically active in any role; staff nurse, nurse manager, clinical instructor, or clinical nurse specialist; regardless of work status: full time or part time were included. The course, offered 32 times over a 4-month period, resulted in a convenience sample of 2250 nurses.
3.1. Sample characteristics
2.4. Instruments The research team developed a tool that measured nurses' comfort, familiarity, and knowledge of diabetes management principles of the hospitalized patient, titled “The Diabetes Management Knowledge Assessment Tool” (DMKAT). Content for the DMKAT was developed through a review of the literature and information from guidelines and standards of care published by the American College of Endocrinology (AACE) and the American Diabetes Association (AACE Diabetes Mellitus Clinical Practice Guidelines Task Force, 2011; Standards of Medical Care in Diabetes 2010). Comfort was defined as a sense of confidence in performing a skill or using knowledge, and was measured by summing the score of eight items. Comfort scores could range from 0 to 80 with higher scores indicating greater levels of comfort. Construct validity was assessed using principle component analysis with varimax rotation, which confirmed a one-factor solution. Reliability of this scale was .87.
The final sample consisted of 2250 registered nurses (Table 1). Nurses in this study were most often female 86.4%, Caucasian 80.9%, and worked full time 71.1%. The mean age of nurses in this sample was 36.2 (SD = 10.9). Years of experience was nearly equally divided between those with more than 5 years' experience (48%) and those with five or fewer years of experience (52%). All nursing specialties were represented except neonatal intensive care nurses and operating room nurses. Critical care nurses were the greatest in attendance (n = 423; 18.8%), followed by cardiac nurses (n = 410; 18.2%) other specialties including subacute and ambulatory (n = 264; 11.3%) and medical nurses (n = 226; 10.0%) (Table 2). 3.2. Results Specific aim 1: Using Pearson's correlation, we found a negative correlation (r = − .182; p b .001) between age of the nurse and level of knowledge demonstrated on the DMKAT, with scores decreasing as age increased. Using Spearman's correlation, we found that age was correlated with education level (r = − 140; p b .001) and with years of nursing experience (r = .759; p b .001). Nurses with more education and those with the most experience were older than those with less education and less experience. Specific aim 2: Analysis of covariance (ANCOVA), controlling for age was used to determine if there were differences in level of
Please cite this article as: Modic, M.B., et al., Diabetes management unawareness: what do bedside nurses know?, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2013.12.003
M.B. Modic et al. / Applied Nursing Research xxx (2014) xxx–xxx Table 1 Demographics. Variable Gender Male Female Race Caucasian African, American Asian Hispanic Native, American Education AD Diploma BSN MSN Years of experience b 1 year 1–2 years 2–5 years 6–10 years 11–15 years 15–20 years N 20 years Work status Full time Part time
3
Table 3 DMKAT challenging questions. n
%
254 1945
11.3 86.4
1821 186 129 28 22
80.9 8.3 5.7 1.2 1.0
611 237 1252 64
27.2 10.5 55.6 2.8
548 233 376 285 214 199 369
24.4 10.4 16.7 12.7 9.5 8.8 16.4
1600 648
71.1 28.8
knowledge as demonstrated on the DMKAT based on education or years of experience. We found no differences in level of knowledge as demonstrated on the DMKAT based on education level [F(4, 2090) = 1.564; p = .181] or years of experience [F(6, 2086) = 1.549; p = .158]. Specific aim 3: Pearson's correlation was conducted to determine if there was a relationship between comfort level or familiarity and diabetes management knowledge. While we found no correlation between neither comfort (r = .002; p = .912) nor familiarity (r = −.013; p = .556) and diabetes management knowledge; we did find a correlation between comfort and familiarity (r = .706; p b .001). Specific aim 4: A paired t-test was used to examine differences in diabetes management knowledge before and after the Diabetes Management Educational Program. As expected we found a significant [t(2238) = 90.59; p b .001] increase in scores from pretest (x = 11) to posttest (x = 20). However, it is important to note that four questions continued to be problematic (Table 3). One question explored the causes of hyperglycemia in the hospitalized patient. Eight hundred and seventy nurses (38%) did not answer this question correctly on the posttest (Fig. 1). The three other questions focused on insulin regimens (Figs. 2 and 3). A question about an insulin order that required clarification from the prescriber was missed by 68% of the nurses (Fig. 4). It is unclear whether the questions were confusing.
Category
Question
Hyperglycemia
All of the following contribute to development of hyperglycemia in the hospitalized patient EXCEPT: A. vasopressors B. holding insulin for normal glucose C. tube feedings D. nutrition interruption Continuous IV insulin administration is the preferred method of treating DKA or HHS because an IV insulin infusion: A. brings down the glucose more quickly than the subcutaneous route B. sustains normal glucose once target glucose is achieved C. facilitates insulin stacking D. is safer Your patient takes insulin glargine (Lantus®) at bedtime and glulisine (Apidra®) insulin with meals. As you review the blood glucose levels the insulin dose that needs to be adjusted is:
Insulin
Tuesday Wednesday Thursday Friday
Breakfast
Lunch
Dinner
HS
mg/dl
mg/dl
mg/dl
mg/dl
86 126 111 420
58 62 66 63
97 89 92 172
78 74 80
A. Bedtime Lantus® B. Morning Apidra® C. Lunchtime Apidra® D. Dinner Apidra® All of the following medication insulin orders require clarification EXCEPT: A. Lantus® 10 units at 0800, Levemir®7 units at 0800 and 1730 B. Novolog® 5 units before meals Novolin® R 28 units at 0800 and 2200 C. Apidra® 10 units at 0800 and 1730 NPH 20 units at 0800 and NPH 10 units at 1730 D. Apidra® 8 units before meals Novolin® R Supplemental Scale at mealtime and bedtime
Two of the questions used the word “EXCEPT” in the stem and could have been perplexing as to the intent of the question or the nurses did not acquire the knowledge necessary to answer the question. The three insulin questions required that the nurses understand the pharmacokinetics and efficacy of different insulin regimens. 3.3. Limitations This study took place in a single facility that may not be like other facilities; however, the large sample and diverse age, education level, and years of experience for this sample suggest that findings may be
Table 2 Clinical specialty. Clinical specialty
n
Result
Behavioral health Cardiac Colorectal surgery Critical care ED Medicine Neurology Oncology Orthopedics Post anesthesia care unit Pediatrics Short stay/same day surgery Transplant Urology/GYN Vascular Other: (includes subacute and ambulatory)
36 410 84 423 63 226 111 100 38 71 104 38 41 38 15 264
1.7% 18.2% 3.7% 18.8% 2.8% 10.0% 4.9% 4.4% 1.7% 3.2% 4.6% 1.7% 1.8% 1.7% 0.7% 11.3%
All of the following contribute to hyperglycemia in the hospitalized patient EXCEPT: 1750 1500 1250 1000 750 500 250 0
1399 1048 623 426
490
357 89 68
Vasopressors Holding insulin Tube feedings for normal glucose Pre Test
Nutrition interruption
Post Test
Fig. 1. Sample question.
Please cite this article as: Modic, M.B., et al., Diabetes management unawareness: what do bedside nurses know?, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2013.12.003
4
M.B. Modic et al. / Applied Nursing Research xxx (2014) xxx–xxx
Continuous IV insulin administration is the preferred method of treating DKA on HHS because an IV insulin infusion is: 1600 1400
1444 1251
1200 1000 800 552
600
515 367
400 222
200
117 32
0 Brings down the glucose more quickly than subcutaneous insulin
Sustains normal glucose Facilitates insulin stacking once target glucose is achieved Pre Test
Is safer
Post Test
Fig. 2. Sample question.
generalizable to other facilities with a similar mix. While a type II error due to a small sample size was not a concern for this study, our very large sample size may have resulted in a type I error (finding a difference when one did not exist). To control for this possible effect, we used .01 rather than .05 for our significance level. Long term knowledge retention, although of interest, was not possible in this study. Finally, although the instrument and knowledge test underwent rigorous content evaluation by a team of content experts, psychometric analysis of the individual knowledge questions was not done. Thus, discriminant validity of individual questions is not known. 4. Nursing implications Overall level of knowledge of diabetes management by nurses for the hospitalized patient was lower than expected at baseline. Age had a negative correlation with knowledge. Years of experience and level of education were not related to knowledge, indicating that it is not only the novice nurse but also experienced nurses who are not current in inpatient diabetes management. This may be due to the rapid changes occurring in healthcare today. While this study demonstrates an improvement in knowledge related to attendance at this educational program, it is unclear whether these gains were sustained over time. Findings from this study suggest that nurses may not be aware of their knowledge deficits since they had high levels of comfort and familiarity despite low levels of knowledge. This may be due in part to the continual changes in diabetes management practices. Class
attendance and assessment of diabetes knowledge provides nurses with information about the level of their knowledge. In this study, we found that prior to the class nurses tended to overestimate their knowledge level. This is consistent with findings by researchers in Switzerland who found that nurses overestimated their knowledge (Trepp, Willie, Wieland, & Reinhart, 2010). Despite increased knowledge scores overall, posttest examination identified some perplexing knowledge gaps related to insulin. It may be important to allot more time for evaluating and discussing insulin regimens in future courses. In addition, the remaining knowledge gaps demonstrate a need for additional resources to help nurses manage the day to day clinical questions that may arise regarding inpatient diabetes management and specifically insulin therapy. 5. Conclusions This study, like other previous studies investigating nurses' knowledge, demonstrates that nurses' knowledge of diabetes management principles of the hospitalized patient was low, and this may be due in part to the inability to keep up with the rapidly changing technologies and drug regimens. The gains reflected in the posttest scores indicated that nurses' knowledge of factual content had increased. However, this may not necessarily be a true indication of an increase in knowledge since the nurses were familiar with the questions having completed the pretest at the beginning of the educational program.
Your patient takes insulin glargine (Lantus) at bedtime and glulisine (Apidra) insulin with meals. As you review the blood glucose levels the insulin dose that needs to be adjusted is: 1600 1400 1200 1000 800 600 400 200 0
1378 1136 584
612 330
Bedtime Lantus
Morning Apidra Pre Test
236
Lunchtime Apidra
172
52
Dinner Apidra
Post Test
Fig. 3. Sample question.
Please cite this article as: Modic, M.B., et al., Diabetes management unawareness: what do bedside nurses know?, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2013.12.003
M.B. Modic et al. / Applied Nursing Research xxx (2014) xxx–xxx
5
Fig. 4. Sample question.
This study can serve as an impetus for evaluating diabetes curriculum for relevance, accuracy, and current state of the science. A critical analysis should be conducted on the effectiveness of undergraduate programs and continuing diabetes education offerings. Although learner satisfaction and knowledge are important evaluation components, other outcome metrics should be considered. Measures used to assess impact of learning from a program such as this should include the percentage change in insulin errors and adherence to hypoglycemic rescue protocols, as well as the percentage of glucose values within target range. Future studies are needed to examine methods of fostering clinical application of inpatient diabetes management principles for the hospitalized patient, such as simulation or structured mentoring programs on the nursing unit. Inpatient diabetes management can be improved with innovative educational approaches and provision of accessible resources on the nursing unit that will provide nurses with “just in time” information to assist them with clinical reasoning, discernment, and judgment. References AACE Diabetes Mellitus Clinical Practice Guidelines Task Force (2011). AACE diabetes mellitus guidelines. Diabetes management in the hospital setting. Endocrine Practice, 17(S 2), 1–53, http://dx.doi.org/10.4158/EP.17.52.1. American Diabetes Association (2013). Economic costs of diabetes in the U.S. in 2012. Diabetes Care, 36(4), 1033–1046, http://dx.doi.org/10.2337/dc12-2625. Clement, S., Braithwaite, S., Magee, M., Ahmann, A., Smith, E., Schafer, R., et al. (2004). Management of diabetes and hyperglycemia in hospitals. Diabetes Care, 27(2), 553–591, http://dx.doi.org/10.2337/diacare.27.2.553. Cook, C., Castro, J. C., Schmidt, R., Gauthier, S., Whitaker, M., Roust, L., et al. (2007). Diabetes care in hospitalized noncritically ill patients: More evidence for clinical
inertia and negative therapeutic momentum. Journal of Hospital Medicine, 2(4), 203–211, http://dx.doi.org/10.1002/shm.188. Derr, R. L., Sivanandy, M. S., Bronich-Hall, L., & Rodriquez, A. (2007). Insulin-related knowledge among health care professionals in internal medicine. Diabetes Spectrum, 20(3), 177–185, http://dx.doi.org/10.2337/diaspect.20.3.177. Gerrard, S. O., Griffin, M. Q., & Fitzpatrick, J. (2010). Advancing quality diabetes education through evidence and innovation. Journal of Nursing Care Quality, 25(2), 160–167, http://dx.doi.org/10.1097/NCQob13e3181bff4fa. Griffis, S., Morrison, N., Beauvis, C., & Bellafountaine, M. (2007). Identifying the continuing diabetes education needs of acute care nurses in Northern Ontario. Canadian Journal of Diabetes, 31(4), 371–377, http://dx.doi.org/10.1016/514992671(07)14009-0. Modic, M. B., Albert, N. M., Nutter, B., Coughlin, R., Murray, T., & Brosovich, D. (2009). Diabetes teaching is not for the faint of heart. Journal of Cardiovascular Nursing, 24 (6), 439–446 (1097/JCN0b013e3181bld126). NICE-SUGAR Study Investigators (2009). Intensive versus conventional glucose control in critically ill patients. New England Journal of Medicine, 360(13), 1283–1297, http: //dx.doi.org/10.1056/NEJMoa810625. Rubin, D. J., Moshang, J., & Jabbour, S. A. (2007). Diabetes knowledge: Are resident physicians and nurses adequately prepared to manage diabetes? Endocrine Practice, 13(1), 17–21, http://dx.doi.org/10.1097/obo13e3181bld126. Standards of Medical Care in Diabetes (2010). Diabetes care, 3(S), 11–16, http://dx.doi. org/10.2337/dc10- S011. Trepp, R., Willie, T., Wieland, T., & Reinhart, W. (2010). Diabetes related knowledge among medical and nursing house staff. Swiss Medicine Weekly, 140(25–26), 370–375 (smw-12974). Turchin, A., Matheny, M., Shubina, M., Scanlon, J., Greenwood, B., & Pendergrass, M. (2009). Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care, 32(7), 1153–1157, http://dx. doi.org/10/2337/dco8-2127. Umpierrez, G. E., Smiley, D., Zisman, A., & Prieto, L. M. (2007). Randomized study of basal–bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 Trial). Diabetes Care, 30(9), 2181–2186 (2337/dl07-0295). Van den Berghe, G., Wouters, P., Weekers, F., Verwaest, C., Bruynincky, F., Schetz, M., et al. (2001). Intensive insulin therapy in critically ill patients. New England Journal of Medicine, 345, 1359–1367, http://dx.doi.org/10.1056/NEJMoa011300.
Please cite this article as: Modic, M.B., et al., Diabetes management unawareness: what do bedside nurses know?, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2013.12.003
Contents lists available at ScienceDirect
Applied Nursing Research journal homepage: www.elsevier.com/locate/apnr
Original Article
Diabetes management unawareness: what do bedside nurses know? Mary Beth Modic, DNP, RN a,⁎, Anne Vanderbilt, MSN, RN a, Sandra L. Siedlecki, PhD, RN a, b, Rebecca Sauvey, BS, RN a, Nancy Kaser, MSN, RN c, Christina Yager, BS a a b c
Nursing Institute, Cleveland Clinic, Cleveland, OH, USA Walden University, Minneapolis, MN, USA Cleveland Clinic, Cleveland, OH, USA
a r t i c l e
i n f o
Article history: Received 4 July 2013 Revised 30 November 2013 Accepted 14 December 2013 Available online xxxx Keywords: Diabetes knowledge Bedside nurses Inpatient diabetes management
a b s t r a c t Background: Nurses are responsible for critical aspects of diabetes care. Purpose: The purpose of this study was to examine nurses' knowledge of inpatient diabetes management principles before and after a structured diabetes education program. Methods: In this descriptive, correlation study, 2250 registered nurses working in a quaternary health care center completed a 20 question assessment. The assessment was administered pre and post attendance at a 4 hour diabetes management course. Findings: Nurses' knowledge of inpatient diabetes management principles was low. There was no correlation between knowledge scores and age, education, employment status, years of experience or clinical specialty. Conclusions: In general, our findings suggest that nurses do not feel comfortable and are not adequately prepared to make patient care decisions or provide survival skill education for patients with diabetes in the hospital. © 2013 Elsevier Inc. All rights reserved.
Diabetes management principles for the hospitalized patient have changed rapidly over the past several years, specifically in the area of blood glucose (BG) targets and insulin regimens (NICE-SUGAR Study Investigators, 2009). The ability to stay abreast of all of these changes presents a challenge for most bedside nurses. Inadequate knowledge of recent trends in diabetes management can affect the quality and safety of the hospitalized patient with diabetes, resulting in longer lengths of stay and increased readmission rates (American Diabetes Association, 2013). The purpose of this study is to examine nurses' comfort, familiarity, and knowledge of inpatient diabetes management principles and to explore areas where knowledge gaps persisted even after completing a 4-hour educational intervention. 1. Review of literature Nurses and physicians confront daily challenges of safely managing BG levels in hospitalized patients (Cook et al., 2007). In one study, hyperglycemia was present in 38% of patients admitted to the hospital, 26% of whom had no history of diabetes (Umpierrez, Smiley, Zisman, & Prieto, 2007). The issue of tight glycemic control (BG levels maintained at b 110 mg/dl) in the hospitalized patient has received much attention since Van den Berghe first published her positive results of aggressive BG control in a surgical ICU in 2001 (Van den ⁎ Corresponding author at: Diabetes: Nursing Education and Professional Practice Development, Cleveland Clinic, 9500 Euclid Avenue, Mail Code P32, Cleveland, Ohio 44195. Tel.:+1 440 838 8463, +1 216 444 9005; fax: +1 216 445 0455. E-mail address: [email protected] (M.B. Modic).
Berghe et al., 2001). However, subsequent studies have reported conflicting and contrary findings suggesting that tight glycemic control results in an increased risk of hypoglycemia (Turchin et al., 2009; Umpierrez et al., 2007). In 2004, Clement, Braithwaite, Magee, Ahmann, Smith, Schafer and Hirsch published a technical review which evaluated the evidence for glucose control and made recommendations for treatment and monitoring as well as strategies for patient education (Clement et al., 2004). Several studies have been published related to inadequate diabetes management knowledge of nurses and physicians (Derr, Sivanandy, Bronich-Hall, & Rodriquez, 2007; Gerrard, Griffin, & Fitzpatrick, 2010; Modic et al., 2009; Rubin, Moshang, & Jabbour 2007). Knowledge deficits have been identified in relation to use of insulin (Umpierrez et al., 2007). Other studies identified knowledge deficits in the areas of insulin therapeutics, food and diabetic drug interactions, prevention of diabetes complications and current drug treatment for patients with diabetes (Gerrard et al., 2010; Griffis, Morrison, Beauvis, & Bellafountaine, 2007; Modic et al., 2009). 2. Methods The purpose of this descriptive study was to examine nurses' comfort, familiarity, and knowledge of diabetes management principles for the hospitalized patient and to explore areas where knowledge problems persisted after completing a 4-hour educational program. Designed by two inpatient certified diabetes educators (CDEs), the curriculum was based on a previously conducted needs assessment,
0897-1897/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.apnr.2013.12.003
Please cite this article as: Modic, M.B., et al., Diabetes management unawareness: what do bedside nurses know?, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2013.12.003
2
M.B. Modic et al. / Applied Nursing Research xxx (2014) xxx–xxx
adherence to a hypoglycemic rescue protocol and insulin error data. The four topics covered within the course were hyperglycemia, insulin therapeutics, hypoglycemia prevention and management, and diabetes survival skills. The teaching strategies used in the class included a pre-assessment test, lectures, strategic questioning, and case studies. Following presentation of course content, a posttest was administered, allowing attendees to identify areas for further improvement. 2.1. Specific aims The specific aims of this research were the following: • Specific aim 1: Is there a relationship between age and level of knowledge demonstrated on the Diabetes Management Knowledge Assessment Tool (DMKAT)? • Specific aim 2: Is there a difference in level of knowledge demonstrated on the DMKAT based on education or years of experience? • Specific aim 3: Is there a difference in the relationship between nurses' self-rated comfort and familiarity and level of knowledge demonstrated on the DMKAT? • Specific aim 4: Is there a gain in knowledge of inpatient diabetes management principles as demonstrated on the DMKAT after a diabetes course? 2.2. Procedure
Familiarity was defined as knowledge or mastery of a skill measured by summing the next six items in the DMKAT. Familiarity scores could range from 0 to 60 with higher scores indicating greater familiarity. Principle component analysis with varimax rotation confirmed a one-factor solution in support of construct validity. Reliability of this measure was .78. Comfort and familiarity were only assessed prior to the course. The knowledge portion of the DMKAT included 20 multiple choice questions and measured nurses' knowledge in four content areas of diabetes management presented in the class: hyperglycemia, insulin therapeutics, hypoglycemia prevention and management, and diabetes survival skill teaching. Five questions assessed major concepts presented in each content area. Each correctly answered questioned scored one point. Total scores ranged from 0 to 20 with a higher score indicating more knowledge. Content validity was assessed through consensus using a modified two-stage Delphi technique. Fifteen inpatient CDEs from local hospitals served as content experts. Content validity index for the final instrument was .95. The content experts agreed that an acceptable mean item score (for group) and whole test score (individual and group) of 80% or higher indicated acceptable knowledge of diabetes management skills for the hospitalized patient. This instrument was administered as both pretest and posttest assessment during the 4 hour class. 2.5. Data analysis
Level of knowledge related to diabetes was assessed via pretest immediately prior to a 4-hour diabetes management course and again at the completion of the course. The course included content on hyperglycemia, insulin therapeutics, hypoglycemia prevention and management, and diabetes survival skill. Participation in this study was voluntary. Tests were anonymous and the Institutional Review Board (IRB) approved this study. The completed pre and posttests were collected by the researchers, and data were entered into SPSS (version 19) in preparation for data analysis.
Data were analyzed using SPSS version 19.0. The sample was described by measures of central tendency (mean, median and standard deviation, frequency and percentage). Pearson's correlation was used to examine relationships for continuous level data (age) and Spearman's was used to assess nominal level data (education level and years of experience). Analysis of covariance (ANCOVA) controlling for age was used to examine baseline differences in knowledge related to education level and years of experience. Finally, a paired ttest was used to examine changes in knowledge. Because of the large sample to control for the likelihood of a type I error, the significance level was set at .01 rather than .05.
2.3. Settings and sample
3. Results
The study was conducted in a large 1200 bed health care center in the Midwest. Participants included registered nurses in all specialties except the operating room and neonatal intensive care unit. Nurses included in this study were clinically active in any role; staff nurse, nurse manager, clinical instructor, or clinical nurse specialist; regardless of work status: full time or part time were included. The course, offered 32 times over a 4-month period, resulted in a convenience sample of 2250 nurses.
3.1. Sample characteristics
2.4. Instruments The research team developed a tool that measured nurses' comfort, familiarity, and knowledge of diabetes management principles of the hospitalized patient, titled “The Diabetes Management Knowledge Assessment Tool” (DMKAT). Content for the DMKAT was developed through a review of the literature and information from guidelines and standards of care published by the American College of Endocrinology (AACE) and the American Diabetes Association (AACE Diabetes Mellitus Clinical Practice Guidelines Task Force, 2011; Standards of Medical Care in Diabetes 2010). Comfort was defined as a sense of confidence in performing a skill or using knowledge, and was measured by summing the score of eight items. Comfort scores could range from 0 to 80 with higher scores indicating greater levels of comfort. Construct validity was assessed using principle component analysis with varimax rotation, which confirmed a one-factor solution. Reliability of this scale was .87.
The final sample consisted of 2250 registered nurses (Table 1). Nurses in this study were most often female 86.4%, Caucasian 80.9%, and worked full time 71.1%. The mean age of nurses in this sample was 36.2 (SD = 10.9). Years of experience was nearly equally divided between those with more than 5 years' experience (48%) and those with five or fewer years of experience (52%). All nursing specialties were represented except neonatal intensive care nurses and operating room nurses. Critical care nurses were the greatest in attendance (n = 423; 18.8%), followed by cardiac nurses (n = 410; 18.2%) other specialties including subacute and ambulatory (n = 264; 11.3%) and medical nurses (n = 226; 10.0%) (Table 2). 3.2. Results Specific aim 1: Using Pearson's correlation, we found a negative correlation (r = − .182; p b .001) between age of the nurse and level of knowledge demonstrated on the DMKAT, with scores decreasing as age increased. Using Spearman's correlation, we found that age was correlated with education level (r = − 140; p b .001) and with years of nursing experience (r = .759; p b .001). Nurses with more education and those with the most experience were older than those with less education and less experience. Specific aim 2: Analysis of covariance (ANCOVA), controlling for age was used to determine if there were differences in level of
Please cite this article as: Modic, M.B., et al., Diabetes management unawareness: what do bedside nurses know?, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2013.12.003
M.B. Modic et al. / Applied Nursing Research xxx (2014) xxx–xxx Table 1 Demographics. Variable Gender Male Female Race Caucasian African, American Asian Hispanic Native, American Education AD Diploma BSN MSN Years of experience b 1 year 1–2 years 2–5 years 6–10 years 11–15 years 15–20 years N 20 years Work status Full time Part time
3
Table 3 DMKAT challenging questions. n
%
254 1945
11.3 86.4
1821 186 129 28 22
80.9 8.3 5.7 1.2 1.0
611 237 1252 64
27.2 10.5 55.6 2.8
548 233 376 285 214 199 369
24.4 10.4 16.7 12.7 9.5 8.8 16.4
1600 648
71.1 28.8
knowledge as demonstrated on the DMKAT based on education or years of experience. We found no differences in level of knowledge as demonstrated on the DMKAT based on education level [F(4, 2090) = 1.564; p = .181] or years of experience [F(6, 2086) = 1.549; p = .158]. Specific aim 3: Pearson's correlation was conducted to determine if there was a relationship between comfort level or familiarity and diabetes management knowledge. While we found no correlation between neither comfort (r = .002; p = .912) nor familiarity (r = −.013; p = .556) and diabetes management knowledge; we did find a correlation between comfort and familiarity (r = .706; p b .001). Specific aim 4: A paired t-test was used to examine differences in diabetes management knowledge before and after the Diabetes Management Educational Program. As expected we found a significant [t(2238) = 90.59; p b .001] increase in scores from pretest (x = 11) to posttest (x = 20). However, it is important to note that four questions continued to be problematic (Table 3). One question explored the causes of hyperglycemia in the hospitalized patient. Eight hundred and seventy nurses (38%) did not answer this question correctly on the posttest (Fig. 1). The three other questions focused on insulin regimens (Figs. 2 and 3). A question about an insulin order that required clarification from the prescriber was missed by 68% of the nurses (Fig. 4). It is unclear whether the questions were confusing.
Category
Question
Hyperglycemia
All of the following contribute to development of hyperglycemia in the hospitalized patient EXCEPT: A. vasopressors B. holding insulin for normal glucose C. tube feedings D. nutrition interruption Continuous IV insulin administration is the preferred method of treating DKA or HHS because an IV insulin infusion: A. brings down the glucose more quickly than the subcutaneous route B. sustains normal glucose once target glucose is achieved C. facilitates insulin stacking D. is safer Your patient takes insulin glargine (Lantus®) at bedtime and glulisine (Apidra®) insulin with meals. As you review the blood glucose levels the insulin dose that needs to be adjusted is:
Insulin
Tuesday Wednesday Thursday Friday
Breakfast
Lunch
Dinner
HS
mg/dl
mg/dl
mg/dl
mg/dl
86 126 111 420
58 62 66 63
97 89 92 172
78 74 80
A. Bedtime Lantus® B. Morning Apidra® C. Lunchtime Apidra® D. Dinner Apidra® All of the following medication insulin orders require clarification EXCEPT: A. Lantus® 10 units at 0800, Levemir®7 units at 0800 and 1730 B. Novolog® 5 units before meals Novolin® R 28 units at 0800 and 2200 C. Apidra® 10 units at 0800 and 1730 NPH 20 units at 0800 and NPH 10 units at 1730 D. Apidra® 8 units before meals Novolin® R Supplemental Scale at mealtime and bedtime
Two of the questions used the word “EXCEPT” in the stem and could have been perplexing as to the intent of the question or the nurses did not acquire the knowledge necessary to answer the question. The three insulin questions required that the nurses understand the pharmacokinetics and efficacy of different insulin regimens. 3.3. Limitations This study took place in a single facility that may not be like other facilities; however, the large sample and diverse age, education level, and years of experience for this sample suggest that findings may be
Table 2 Clinical specialty. Clinical specialty
n
Result
Behavioral health Cardiac Colorectal surgery Critical care ED Medicine Neurology Oncology Orthopedics Post anesthesia care unit Pediatrics Short stay/same day surgery Transplant Urology/GYN Vascular Other: (includes subacute and ambulatory)
36 410 84 423 63 226 111 100 38 71 104 38 41 38 15 264
1.7% 18.2% 3.7% 18.8% 2.8% 10.0% 4.9% 4.4% 1.7% 3.2% 4.6% 1.7% 1.8% 1.7% 0.7% 11.3%
All of the following contribute to hyperglycemia in the hospitalized patient EXCEPT: 1750 1500 1250 1000 750 500 250 0
1399 1048 623 426
490
357 89 68
Vasopressors Holding insulin Tube feedings for normal glucose Pre Test
Nutrition interruption
Post Test
Fig. 1. Sample question.
Please cite this article as: Modic, M.B., et al., Diabetes management unawareness: what do bedside nurses know?, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2013.12.003
4
M.B. Modic et al. / Applied Nursing Research xxx (2014) xxx–xxx
Continuous IV insulin administration is the preferred method of treating DKA on HHS because an IV insulin infusion is: 1600 1400
1444 1251
1200 1000 800 552
600
515 367
400 222
200
117 32
0 Brings down the glucose more quickly than subcutaneous insulin
Sustains normal glucose Facilitates insulin stacking once target glucose is achieved Pre Test
Is safer
Post Test
Fig. 2. Sample question.
generalizable to other facilities with a similar mix. While a type II error due to a small sample size was not a concern for this study, our very large sample size may have resulted in a type I error (finding a difference when one did not exist). To control for this possible effect, we used .01 rather than .05 for our significance level. Long term knowledge retention, although of interest, was not possible in this study. Finally, although the instrument and knowledge test underwent rigorous content evaluation by a team of content experts, psychometric analysis of the individual knowledge questions was not done. Thus, discriminant validity of individual questions is not known. 4. Nursing implications Overall level of knowledge of diabetes management by nurses for the hospitalized patient was lower than expected at baseline. Age had a negative correlation with knowledge. Years of experience and level of education were not related to knowledge, indicating that it is not only the novice nurse but also experienced nurses who are not current in inpatient diabetes management. This may be due to the rapid changes occurring in healthcare today. While this study demonstrates an improvement in knowledge related to attendance at this educational program, it is unclear whether these gains were sustained over time. Findings from this study suggest that nurses may not be aware of their knowledge deficits since they had high levels of comfort and familiarity despite low levels of knowledge. This may be due in part to the continual changes in diabetes management practices. Class
attendance and assessment of diabetes knowledge provides nurses with information about the level of their knowledge. In this study, we found that prior to the class nurses tended to overestimate their knowledge level. This is consistent with findings by researchers in Switzerland who found that nurses overestimated their knowledge (Trepp, Willie, Wieland, & Reinhart, 2010). Despite increased knowledge scores overall, posttest examination identified some perplexing knowledge gaps related to insulin. It may be important to allot more time for evaluating and discussing insulin regimens in future courses. In addition, the remaining knowledge gaps demonstrate a need for additional resources to help nurses manage the day to day clinical questions that may arise regarding inpatient diabetes management and specifically insulin therapy. 5. Conclusions This study, like other previous studies investigating nurses' knowledge, demonstrates that nurses' knowledge of diabetes management principles of the hospitalized patient was low, and this may be due in part to the inability to keep up with the rapidly changing technologies and drug regimens. The gains reflected in the posttest scores indicated that nurses' knowledge of factual content had increased. However, this may not necessarily be a true indication of an increase in knowledge since the nurses were familiar with the questions having completed the pretest at the beginning of the educational program.
Your patient takes insulin glargine (Lantus) at bedtime and glulisine (Apidra) insulin with meals. As you review the blood glucose levels the insulin dose that needs to be adjusted is: 1600 1400 1200 1000 800 600 400 200 0
1378 1136 584
612 330
Bedtime Lantus
Morning Apidra Pre Test
236
Lunchtime Apidra
172
52
Dinner Apidra
Post Test
Fig. 3. Sample question.
Please cite this article as: Modic, M.B., et al., Diabetes management unawareness: what do bedside nurses know?, Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2013.12.003
M.B. Modic et al. / Applied Nursing Research xxx (2014) xxx–xxx
5
Fig. 4. Sample question.
This study can serve as an impetus for evaluating diabetes curriculum for relevance, accuracy, and current state of the science. A critical analysis should be conducted on the effectiveness of undergraduate programs and continuing diabetes education offerings. Although learner satisfaction and knowledge are important evaluation components, other outcome metrics should be considered. Measures used to assess impact of learning from a program such as this should include the percentage change in insulin errors and adherence to hypoglycemic rescue protocols, as well as the percentage of glucose values within target range. Future studies are needed to examine methods of fostering clinical application of inpatient diabetes management principles for the hospitalized patient, such as simulation or structured mentoring programs on the nursing unit. Inpatient diabetes management can be improved with innovative educational approaches and provision of accessible resources on the nursing unit that will provide nurses with “just in time” information to assist them with clinical reasoning, discernment, and judgment. References AACE Diabetes Mellitus Clinical Practice Guidelines Task Force (2011). AACE diabetes mellitus guidelines. Diabetes management in the hospital setting. Endocrine Practice, 17(S 2), 1–53, http://dx.doi.org/10.4158/EP.17.52.1. American Diabetes Association (2013). Economic costs of diabetes in the U.S. in 2012. Diabetes Care, 36(4), 1033–1046, http://dx.doi.org/10.2337/dc12-2625. Clement, S., Braithwaite, S., Magee, M., Ahmann, A., Smith, E., Schafer, R., et al. (2004). Management of diabetes and hyperglycemia in hospitals. Diabetes Care, 27(2), 553–591, http://dx.doi.org/10.2337/diacare.27.2.553. Cook, C., Castro, J. C., Schmidt, R., Gauthier, S., Whitaker, M., Roust, L., et al. (2007). Diabetes care in hospitalized noncritically ill patients: More evidence for clinical
inertia and negative therapeutic momentum. Journal of Hospital Medicine, 2(4), 203–211, http://dx.doi.org/10.1002/shm.188. Derr, R. L., Sivanandy, M. S., Bronich-Hall, L., & Rodriquez, A. (2007). Insulin-related knowledge among health care professionals in internal medicine. Diabetes Spectrum, 20(3), 177–185, http://dx.doi.org/10.2337/diaspect.20.3.177. Gerrard, S. O., Griffin, M. Q., & Fitzpatrick, J. (2010). Advancing quality diabetes education through evidence and innovation. Journal of Nursing Care Quality, 25(2), 160–167, http://dx.doi.org/10.1097/NCQob13e3181bff4fa. Griffis, S., Morrison, N., Beauvis, C., & Bellafountaine, M. (2007). Identifying the continuing diabetes education needs of acute care nurses in Northern Ontario. Canadian Journal of Diabetes, 31(4), 371–377, http://dx.doi.org/10.1016/514992671(07)14009-0. Modic, M. B., Albert, N. M., Nutter, B., Coughlin, R., Murray, T., & Brosovich, D. (2009). Diabetes teaching is not for the faint of heart. Journal of Cardiovascular Nursing, 24 (6), 439–446 (1097/JCN0b013e3181bld126). NICE-SUGAR Study Investigators (2009). Intensive versus conventional glucose control in critically ill patients. New England Journal of Medicine, 360(13), 1283–1297, http: //dx.doi.org/10.1056/NEJMoa810625. Rubin, D. J., Moshang, J., & Jabbour, S. A. (2007). Diabetes knowledge: Are resident physicians and nurses adequately prepared to manage diabetes? Endocrine Practice, 13(1), 17–21, http://dx.doi.org/10.1097/obo13e3181bld126. Standards of Medical Care in Diabetes (2010). Diabetes care, 3(S), 11–16, http://dx.doi. org/10.2337/dc10- S011. Trepp, R., Willie, T., Wieland, T., & Reinhart, W. (2010). Diabetes related knowledge among medical and nursing house staff. Swiss Medicine Weekly, 140(25–26), 370–375 (smw-12974). Turchin, A., Matheny, M., Shubina, M., Scanlon, J., Greenwood, B., & Pendergrass, M. (2009). Hypoglycemia and clinical outcomes in patients with diabetes hospitalized in the general ward. Diabetes Care, 32(7), 1153–1157, http://dx. doi.org/10/2337/dco8-2127. Umpierrez, G. E., Smiley, D., Zisman, A., & Prieto, L. M. (2007). Randomized study of basal–bolus insulin therapy in the inpatient management of patients with type 2 diabetes (RABBIT 2 Trial). Diabetes Care, 30(9), 2181–2186 (2337/dl07-0295). Van den Berghe, G., Wouters, P., Weekers, F., Verwaest, C., Bruynincky, F., Schetz, M., et al. (2001). Intensive insulin therapy in critically ill patients. New England Journal of Medicine, 345, 1359–1367, http://dx.doi.org/10.1056/NEJMoa011300.
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