Knowledge of diabetes mellitus amongst nursing students Effect of an intervention

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1 Knowledge of diabetes mellitus amongst nursing students Effect of an intervention Sukhpal Kaur, Indarjit Walia Abstract : Nurses are the key providers of diabetes care. However the information provided by them will depend upon their knowledge regarding the subject. Becton Dickinson India Private Limited in collaboration with student council organized three days workshop for B.Sc. Nursing interns on 'Better Diabetes Care' in the month of January 2006 at National Institute of Nursing Education, Post Graduate Institute of Medical Education and Research, Chandigarh. A total of 48 interns attended the workshop. Using a multiple-choice questionnaire their knowledge was assessed three times i.e. before starting the workshop, at the end of the workshop (post test I), and after three months of the workshop (post test II). There was a statistically significant difference in the mean knowledge score between the pre test and post test I, between pre test and post test II and also between post test I and post test II (t= 25.07, p<0.001, t=15.94, p<0.001, t=10.30, p<0.001) respectively. More than 50% scored between 91 %-1 00% marks in post test I. About one third scored between 81 %-90% in post test II. It was concluded that to provide quality diabetes care and education to the patients, the nursing staff should receive continuing education. Key words : Knowledge, diabetes mellitus, nursing students. Correspondence at : Sukhpal Kaur Lecturer, National Institute of Nursing Education, PGIMER, Chandigarh. Introduction Diabetes mellitus is a chronic disorder characterized by abnormalities in the metabolism of carbohydrate, protein and fat. In the last two decades there has been a marked increase in the prevalence of diabetes among urban Indians. According to a recent WHO report, India today leads the world with over 32 million diabetic patients and this number is projected to be 79.4 million by the year Diabetic patients are 25 times 30

2 more likely to develop blindness, 17 times more likely to develop kidney diseases, times more likely to undergo major amputation and twice more likely to develop coronary ar tery diseases and suffer from stroke than the individuals without diabetes 2 Being a chronic illness effective self management is crucial to the success of treatment. Most diabetes care is actually selfcare that requires patients to actively participate in decision making, goal setting and the process of daily management. Multiple behavioral changes are often required for patients to manage diabetes effectively and to achieve their desired level of glycemic control. Making and sustaining the behavioral changes needed for diabetes self management requires collaboration between the patient and the care providers to develop a relevant and useful plan. As has been mentioned in literature 3 that a multidisciplinary team consisting of a nurse, dietitian, pharmacist, physician, and behaviorist is required for effective diabetes management. The National Standards for Diabetes Self Management Education 4 best practice standards suggest that the team should consists of at least a registered nurse and a dietitian who communicate with other disciplines as needed. However nurses, in the role of case managers for patients with type- 2 diabetes have demonstrated positive results and generally are involved in the formal diabetes education programmes. 5 The management of diabetes demands a broad range of professional skills which includes communication, counseling, leadership and teaching etc. Nurses have been major contributor to the improvement in the quality of care provided to the people with diabetes. The role of nurse in diabetes is to facilitate patient empowerment and self care in the management of their disease through education and support. However the nurses need to be knowledgeable enough, must possess basic communication skills to be comfortable and to be effective in their teachings. New findings related to diabetes are constantly emerging and the nurses need to be aware and keep themselves up to date. 6 Experience and knowledge in diabetes and its management are crucial for teaching patients with diabetes effectively. The best educator is someone who has teaching skills and can assist and support the patients with initiating and maintaining behavior associated with optimal diabetes control. Studies indicate that instructors without specialized training in diabetes, behavioral interventions, teaching, learning and counseling skills may not focus on patient's behavior change and therefore clinical outcomes may not improve. 7,8 Thus to provide quality diabetes care and education professional staff should have an continuing education in diabetes educational strategies and behavioral intervention beyond their basic preparation. 9 Becton Dickinson India Private Limited in collaboration with student council organized a three days workshop on Better Diabetes Care in the month of January 2006 at National Institute of Nursing Education, PGIMER Chandigarh. 31

3 National Institute of Nursing Education is one of the premier institutes offering three programmes - B.Sc. Nursing (4 years), B.Sc. Nursing (Post Basic) and M.Sc. Nursing. The workshop was organized for B.Sc. Nursing interns who are posted in various units of hospital round the clock and are expected to provide total patient care. The task of organizing the workshop was undertaken by Becton Dickinson India Private Limited with an objective to update the knowledge of nursing interns regarding diabetes so that they can make use of that while working with the diabetic patients in clinical settings. Materials and Methods Total 48 B.Sc. Nursing interns attended the workshop. A detailed multiple-choice questionnaire of 40 marks was administered to assess their knowledge regarding the disease diabetes. Each correct answer was graded as 1 and incorrect answer as o. The test was administered three times i.e. before star ting the workshop, at the end of the workshop, and after three months of the workshop. The various topics discussed during the workshop were-histor y of diabetes, understanding, classification and diagnosis of diabetes, management which included detailed information regarding diet, drugs, exercise, monitoring and education and in the end complications and their management. The participants were also given demonstration on subcutaneous insulin injection. Results The mean age of the participants was 21.7 years ±0.92 with the range of years. All were female with the basic qualification of 10+2 (with medical subjects). Mean knowledge score of the participants The mean knowledge score of the participants before starting the workshop was 21.9±3.37 with the range between and it improved to 35.5±3.78 with the range of marks at the end of the workshop. After three months i.e. in post test II, the mean knowledge score was 31.2±3.47 with the range between There was a statistically significant difference between the pre test and post test I, between pre and post test II and also between post test I and post test II. (t= 25.07, p<0.001, t=15.94, p<0.001, t=10.30, p<0.001 respectively). (Table 1) Table 1. Mean knowledge score of the participants Maximum Score = 40 't' valve Mean ± S.D Range Pre test Vs Pre test Vs Post test I Vs post test I post test II post test II Pre test 21.9± Post test I 35.5± , 15.94, Post test II 31.2± p<0.001 p<0.001 P<

4 Percentage marks during pre test and post tests About one third of the participants had their score less than 50% and approximately half scored between 51-70% and just 4.2% could score between 71-80% in the pre test. However after attending the workshop more than 50% of the participants scored between % in post test I. In post test II, 45.8% participants could score between 71-80%. (Table 2) Table 2. Percentage marks during pre test and post tests Marks (%) Pre test Post test I Pre test II n (%) n (%) n (%) <50 18 (37.5) (39.6) 01 (2.1) 03 (6.3) (18.7) 01 (2.1 ) 04 (8.3) (4.2) 08 (16.7) 22 (45.8) (27.1) 18 (37.5) (52.0) 01 (2.1 ) Discussion Diabetes mellitus is a disease which can be very well controlled but at times can be life threatening if it is not properly taken care of. Although there is no cure of this disease, but a great progress has been made in controlling and managing diabetes. The nurse encounters patients of all ages with diabetes in all clinical settings including the outpatient and home settings. Thus she is expected to plan, organize and coordinate care among the various health care providers and also is expected to provide care and education and thus to promote the health and well being of all the diabetic patients. Education is not only a par t of treatment but it is the treatment in diabetes. Therefore nurses need to identify the needs of the diabetics, as health education is an integral part of nursing care. The value of diabetes education is evident from a study where it is reported that the patients who never received diabetes education showed four fold increased risk for major complications. 10 In the current study it was observed that the mean knowledge score of the par ticipants before star ting the workshop was 21.9, and about one third of the participants scored even less than 50% which is quite less to manage patient independently. As has been reported in a study in which a level of 80% in diet nutrition was considered 33

5 necessary for proper management of diet for diabetic patients and this level was reached by only 26% of nursing personnel. 11 Another study indicated deficit in senior nursing students knowledge about diabetes mellitus in which they considered a student to be eligible to teach diabetic patients if she could answer all the questions correctly and there was no one who could answer all the questions correctly. 12 In another crosssectional study 13 the attitude of first, second and third year undergraduate nursing students regarding care of diabetic patients was studied. They found that the attitude of graduating students to the care for people with diabetes was significantly more appropriate than those of beginning students as the senior students had experience to diabetes related education. Since nurses play a significant role in empowering the patients to understand their disease, there is need to sensitize and train them to provide quality care. The mean knowledge score of all the par ticipants improved significantly after attending the workshop irrespective of age. Although there was decrease in mean knowledge score in post test II i.e. after three months of workshop, even then it was significantly more than the pre test score. In post test I, more than 50% participants scored between % and about half of the participants scored between 71-90%. In post test II, only one participant could score between % and about one third scored between 81-90%. Approximately half were in between 71-80% of score. No one had the score less than 50% both in the post I and post II. These results show the importance of continuing education. As has been emphasized by Dunn 14 that to provide quality diabetes care and education the nurses should obtain continuing professional education. In one of the studies 15 an education program on diabetes was implemented for the nurses and the results indicated that the nurses were more confident in providing health education to the diabetic patients after attending the program. In another study 16 it is reported that continuing education and years of experience had positive impact on exercise teaching program and methods used. Similar findings have also been revealed by Anderson 9 in which there was increase in knowledge and skill amongst nurses who attended symposium on diabetes and also considered it the preferred method for obtaining continuing education. Anderson 17 in another study has also reported that the par ticipants who underwent 3 days diabetes care regimen followed by a 3-day intensive skills based workshop showed significant gains in their counseling skills and demonstrated a positive change in their attitude. Conclusion Education for self-management is an integral part of diabetes care and is an evolving process especially in India. It is the cornerstone of care for all individuals with diabetes who want to achieve successful health related outcomes. Therefore all the individuals suffering from diabetes mellitus must learn self-management skills. Patients can manage their disease well if they have 34

6 knowledge of 'what and how' of the disease and self care management. As education is the important part of nursing care, to provide quality information to the diabetic patients it is very important for all the nursing personnel to keep updating their knowledge. References 1. Wild S, Roglic G, Green A, Sicre R, King H. Global prevalence of diabetes: estimates for the year 2000 and projections for Diabetes Care 2004; 27: Zimmet PZ. Diabetes epidemiology as a tool to trigger diabetes research and care. Diabetologia 1999; 42: Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development of long term complications in insulin dependent diabetes mellitus. N Engl J Med 1993; 14: Mensing C, Boucher J, Cypress M. National Standards for Diabetes Self Management Education. Diabetes Care 2000; 23: Weinberger M, Kirkman MS, Samsa GP. A nurse-coordinated intervention for primary care patients with non insulin dependent diabetes mellitus: Impact on glycemic control and health related quality of life. J Gen Intern Med 1995; 10: Resler MM. Teaching strategies that promote adherence. Nursing Clinic of North America 1983; 18: Drass JA, Muirvash J, Boykin P, Turek J, Baker K. Perceived and actual level of knowledge of diabetes mellitus among nurses. Diabetes Care 1989; 12: Moriarty 0, Stephens L. Factore that influence diabetes patient teaching performed by hospital staff nurses. Diabetes Education 1990; 16: Anderson RM, Donnelly MB, Funnell MM, Johnson PD. The continuing education needs of diabetes nurse educators. J Continuing Educ Nurs 1991; 22: Nicolucci A, Cavaliere D, Scorpigliane N, Carinci F, Capani F, Tognoni Get al. A comprehensive assessment of the avoidability of long term complications of diabetes. Diabetes Care 1996; 19: Karlander SG, Alinder I, Hellstrom K. Knowledge of diabetes mellitus, diets and nutrition in diabetic patients. Acta Med Scand 1980; 207: Feustel DE. Nursing students knowledge about diabetes mellitus. Nurs Res 1976; 25: King M, Shute R, Lehmann J. Changing students attitudes to diabetes. Aust J Adv Nurs 1996 Dec to 1997 Feb; 14: Dunn SM. Rethinking the models and modes of diabetes education. Patient Education Counseling 1990; 16: Thompson A, Gibbon C. Setting standards in diabetes education. Nursing Standards 1993; July 14-20: Ruby KL, Blainey CA, Haas LB, Patrick M. The knowledge and practices of registered nurse, certified diabetes educators: teaching elderly clients about exercise. Diabetes Education 1993; 19: Anderson RM, Funnell MM, Barr PA, Dedrick RF, Davis WK. Learning to empower patients. Results of professional education program for diabetes educators. Diabetes Care 1991; 14: