Running Head: DIABETES EDUCATION ON ACUTE CARE FLOOR

Diabetes mellitus (DM) is a main public health concern in the modern age and continuing medical education (CME) on DM and insulin use is often recommended, but infrequent CME activities (such as lectures and discussions) have short-lasting effects and thusly can lead to medication errors (Diehl, Souza, Gordan, Esteves, & Coelho, 2017). In a review of 16,600 patient safety incidents regarding the use of insulin, 24% resulted in the harm of the patient, and 33% of medication error-related deaths, insulin was involved (Cobaugh, et al.

, 2014). A study done at a large teaching hospital in the North of England showed that across all areas of health care professions, significant knowledge gaps concerning insulin and its administration, as well as a low self-reported confidence level when it came to insulin knowledge, exists (Bain, Kavanagh, McCarthy, & Babar, 2019).

Negative impacts of knowledge deficit regarding insulin administration could lead to extended patient hospital stays, increased morbidity and mortality, increased hospital costs and decreased reimbursements for medication-related errors. Currently, hospitals may not practice effective, timely education of competencies regarding DM, such as insulin administration or they may not be re-educating effectively.

Initial or one-time competency education may not be adequate to maintain minimal medical errors when it comes to insulin knowledge or administration. More frequent and effective measures may be required to increase confidence levels regarding diabetes education and insulin administration which would then result in fewer medical error occurrences.

PICO Question

The PICO question formulated was: In inpatient nurses on acute care units (P), do insulin administration competencies performed annually (I) when compared to a one-time insulin competency checkoff during unit orientation (C), increase provider confidence level and knowledge (O)?

Search Strategies

To access the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Academic Search Premier, the Point Loma Nazarene University Ryan Library was utilized.

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Additionally, Google Scholar’s articles database was also utilized. In all databases accessed, keywords and keyword strings utilized alone and in combination included “insulin”, “nursing”, “diabetes”, “annually”, “confidence” and “competency.” Searching was limited to peer-reviewed, 2014-2020 scholarly publications, full text, and English language.

Evidence, Validity, and Reliability

Very few studies have been done with specific regard to diabetes education or insulin administration and the relation to the frequency of education received and its effects on healthcare professionals’ level of confidence. Wakefield and Wilson (2014) conducted a Level II evidence randomized control trial (RCT) assessing the effects of an online educational course regarding knowledge retention after three months. With the participation of a South Texas hospital health system, 118 nurses participated: 45  were in the intervention group, and 73 were controlled. Analysis of the items used for the course test showed good validity, both the intervention group and the control group showed statistically significant differentiation over time. Cronbach’s coefficient alpha was used showing good overall reliability for research, with the pretest at 0.75 and posttest at 0.79. With the test only being utilized in one hospital system, a broader population should be used to determine universal reliability. End results showed an increase in scores post-test with significant retention of knowledge and application after three months.

In another journal, Cardwell, Hardy, Ford, and O’Brien (2016) determined that through interviews of inpatients at the authors’ hospital, trained and untrained staff lacked the knowledge to manage patients with diabetes. This quasi-experimental study provided Level III research aimed at analyzing nurses at St. Helens General Hospital and two neighboring hospitals in the United Kingdom. A questionnaire was first used, cited to be validated in another journal (O’Brien, Michaels, & Hardy, 2003), to assess baseline knowledge. No mention of reliability is made within the research study, but an attempt to use neighboring hospitals to assess for isolated knowledge gaps showed minimal variance in diabetes familiarity. Participants in all three hospitals consistently showed poor results in the management of patients with diabetes. A three-month intervention of teaching sessions and more direct contact with a diabetes specialist nurse was provided and Cardwell, Hardy, Ford, and O’Brien (2016) found posttest scores improved significantly among medical registered general nurses (p = 0.002) and surgical registered general nurses (p = 0.001).

Another quasi-experimental study done by Moattari, Moosavinasab, Dabbaghmanesh, and Zarifsanaiey (2014), utilized an E-learning module to meet a modern nurse’s educational needs. This Level III evidence study utilized just a single group of 31 nurses within the Shiraz University of Medical Sciences. The two-month module included interactive modules, tests, and learning activities. A pretest was administered using 125 multiple choice questions, validated by five professors of the Medical-Surgical nursing faculty. The reliability of the test was confirmed using 20 nurses who completed the test and the results were confirmed using Kuder-Richardson formula 20 (kr=0.81). After the two-month intervention, Moattari, Moosavinasab, Dabbaghmanesh, and Zarifsanaiey (2014) found positive significant differences in posttest knowledge scores (p < 0.001) and posttest clinical competencies (p < 0.001).

In a Level IV evidence cohort study done by Corl, Mccliment, Thompson, Suhr, and Wisse (2014), from 2008 to 2010, nurses at Harborview Medical Center affiliated with the University of Washington were invited to join the Diabetes Nurse Expert Team (DNET) program in which 78 nurses participated, at least joining one voluntary half-day workshop offered four times a year. In 2011, follow-up surveys with case scenario questions were sent out to all inpatient registered nurses. The primary instrument used was cited (Benner, 2001) to have good validity. Questions regarding confidence level utilized the Likert scale to increase the validity and reliability of the survey. Additionally, the survey also utilized multiple questions that tested the same areas in need of additional education to increase reliability. It was found by Corl, Mccliment, Thompson, Suhr, and Wisse (2014) that nurses who participated in the DNET workshops found increased confidence in caring for diabetic patients (p < 0.001). Survey scenario questions included in the survey showed significantly lower mean scores in non-DNET nurses (p < 0.001).

Conclusion

The clinical problem of best practice when it comes to utilizing educational resources to boost confidence, familiarity, and retention of diabetes care and insulin administration can vary from system to system. These studies indicated that knowledge pre-intervention was poor and that a need for education beyond that of an orientation check-off exists. Of the studies selected, all showed significant improvement in confidence level and knowledge retention post-intervention be it an E-learning module, specialized programs, or teaching sessions. Studies that spanned out over two to three months show significant improvement in retention of knowledge following three months post-intervention. With the existence of current practice refresher courses being administrated to nurses through CME programs, emphasis on a diabetes training module could be developed and distributed through these CME platforms. Other interventions could utilize a specialist team formed to champion units on proper diabetic practice and provide themselves as a resource for questions regarding the care of patients with diabetes. Organizations should promote and emphasize the best practice of diabetes care as this could prevent extended hospitals stays, transfers to higher acuity units, adverse medical events and possibly even death. Studies highlight significant knowledge gaps and combined with self-reported low levels of confidence regarding insulin and diabetes care, further demonstrate the need for further intervention (Bain, Kavanagh, McCarthy, & Babar, 2019). Continued work and study to develop proper practice is ongoing with emphasis on individual attributes of nurses and construction of knowledge, but also based on the demands and real situations of the nurses’ labor practice (Sade & Peres, 2015). Utilizing Lewin’s Change Theory and supporting research, this author shall develop proper options to develop a diabetes education course or program to implement on acute care units in the Capstone course. Should this new practice provide significant results, the administration of proper program options across the nation should be utilized to improve diabetes and insulin knowledge.

References

1. Bain, A., Kavanagh, S., McCarthy, S., & Babar, Z. (2019, January 30). Assessment of insulin-related knowledge among healthcare professionals in a large teaching hospital in the United Kingdom. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6473239/#__ffn_sectitle
2. Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice. Commemorative edition. Upper Saddle River, NJ: Prentis Hall Health
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12. Wakefield, P. L., & Wilson, M. A. (2014). Enhancing nurses’ knowledge regarding the complex care of hospitalized patients on insulin. Journal for Nurses in Professional Development, 30(4), 174–180. DOI: 10.1097/nnd.0000000000000037