Diabetes knowledge levels in medical and surgical nurses

Diabetes is one of the most common metabolic disorders and affects approximately 940000 Australian adults (Australian Diabetes, Obesity and Lifestyle Study, 2001). A broad knowledge of diabetes is required by nurses to provide optimal nursing care, patient education and assist in reaching positive outcomes for hospitalised people with diabetes. Nursing care of people with diabetes is often complex and challenging, as diabetes is a condition that is associated with both acute and chronic complications. Jacober and Sowers (1999) estimate that 25–50% of people with diabetes will undergo surgery due to complications related to the disease process. Surgical ward nurses need skills and knowledge about surgical procedures, and the condition of diabetes for the provision of optimal nursing care.

Review of the literature
Several studies related to the diabetes knowledge of nurses emphasise the various roles that the nurse plays in the care of the person with diabetes during acute hospitalisation. These roles include assessment, direct nursing care and education of the person with diabetes. (Hare, 1997; Leggett-Frazier et al, 1994; Jayne and Rankin, 1993; Drass et al, 1989). 

A general consensus throughout the literature is that ward/staff nurses spend the most time with hospitalised patients and are therefore in the best position to assess patient self-care and provide education (Drass et al, 1989; Burden, 1993; Gossain et al 1993; Jayne and Rankin, 1993; Baxley et al, 1997).

The diabetes knowledge of nurses has been investigated among groups of nurses in various settings. Leggett-Frazier and colleagues (1994) reported a diabetes knowledge score of 67% among nurses employed in care facilities for older people. Adams and Cook (1994) compared home healthcare agencies with and without diabetes nurse educators (DNE). Diabetes knowledge scores were reported as being 73% with a DNE and 61% without a DNE. A study by Lipman and Mahon (1999) in a paediatric hospital yielded a diabetes knowledge score of 63.5%. Wamae and Da Costa (1999), Baxley et al (1997), Burden (1993), Gossain et al (1993) and Drass et al (1989) studied the diabetes knowledge of nurses employed in acute general hospitals and obtained knowledge scores of 78%, 73.3%, 68%, 69% and 66.8%, respectively. These scores cannot be compared but they serve to highlight that deficits in diabetes knowledge exist among nurses.

Although studies have been carried out about the diabetes knowledge of nurses in diverse settings among many specialties of nursing, only one study has directly measured and compared the knowledge of medical and surgical nurses (Scheiderich et al, 1983). Although not statistically significant the results of this study indicated that the mean knowledge scores were lower for surgical nurses than for medical nurses (p=0.055).

Diabetes is associated with both acute and long-term complications that can result in hospitalisation. People with diabetes are more likely to have surgery than are the rest of the population. Therefore, medical and surgical nurses both care for a significant number of patients with diabetes. 

Sample and setting
A convenience sample for this study was derived from registered nurses (division 1 – from an accredited university course) working in medical and surgical units of a large regional Australian hospital. Convenience sampling entails the use of the most conveniently available people or objects for use in a study. It is a form of non-probability sampling.

Measures
Two instruments developed by Drass et al (1989) were used: a demographic data sheet and the diabetes basic knowledge test (DBKT). The original DBKT consists of 45 multiple-choice items. Drass et al (1989) examined the instrument for validity and reliability. Reliability for the knowledge test items was reported as 0.79 as determined by Cronbach’s standardised α-coefficient. These instruments have been used to test the diabetes knowledge of nurses in various settings (Baxley et al, 1997; Burden 1993; Gossain et al, 1993; Jayne and Rankin, 1993).

The DBKT and the demographic data sheet used in this study were modified to reflect Australian terminology, scientific accuracy of questions and answers (as of September 2001) and a relevant local and Australian context. The modifications made to the measurement tools for the current study were completed in consultation with two DNEs employed at the facility. The instrument was pilot tested on eight nurses before the distribution to the participants in this study. The purpose of the pilot test was to identify any problems with the wording or perceived relevance of the demographic questions and for feedback on potential difficulties when answering the questions. No potential problems were identified.

Ethical considerations
The ethics committee of the facility granted permission for the study. Nurses who volunteered to participate were given a package that contained an information letter, the measurement tool and a sealable envelope. Consent was implied on completion of the questionnaire. Anonymity was ensured as no identifying codes or personal identification were required.

Data collection
Data collection took place over a period of 2 weeks between July–August 2002. The researcher attended two changes of shift periods (evening and night handover) for a period of 1 week in each participating unit. Division 1 nurses were asked to remain after handover while the researcher provided information regarding the study and requested volunteers. Volunteers were then asked to complete the forms immediately to inhibit consultation amongst each other. Participants were advised that completed instruments were to be placed in a sealed box. These were collected by the researcher at the completion of the data collection period.

Data coding and entry
The forms were scored by hand and the results were entered into SPSS. To ensure accuracy of data entry, raw data were visually scanned and checked by tabulated frequencies for all demographic and diabetes knowledge questions. The second author performed an audit of six randomly selected questionnaires and 100% agreement on data entry was found.

Data analysis
Descriptive statistics were used to profile the demographic characteristics of the sample. ANOVA was used to compare mean diabetes knowledge scores according to years of nursing experience, education level, diabetes education, type of employment, history of diabetes existing in self, family or friends and perception of competency. An independent samples t-test was used to compare mean knowledge scores according to unit of employment and years at the facility.

Results
A sample of 98 registered nurses (division 1) were invited to participate and 55 questionnaires were returned. Seven questionnaires were excluded; four were unsuitable (as they had too much missing data) and three were returned too late to be included in the analysis. This left a sample of 48 (49%).

The employment profiles of the 48 participants are shown in Table 1 and employment profiles according to employing units are shown in Table 2. 

The level of education and the length of time since the nurses attended diabetes education sessions/inservice is indicated in Table 3. The largest proportion of participants (54.2%) stated that an undergraduate university degree was their highest level of education obtained. Twenty-one participants (44%) reported attending no diabetes inservice/education programmes or attending an inservice/education programme for more than 2 years. 

Most respondents (45; 94%) stated that they cared for four or more patients with diabetes per month. The majority of respondents (26; 54%) stated that they had no history of diabetes themselves or within their immediate family or friends. Fifteen respondents (31%) reported having a history of diabetes in their immediate family and seven respondents (15%) reported having a friend with diabetes. In summary, there were no substantial differences between the medical and surgical units.

Knowledge scores
Participants answered a total of 45 questions on basic diabetes knowledge. The mean knowledge score of all nurses was 66.8% (SD 5.19). No nurse was able to correctly answer all questions; the number of correct answers ranged from 18–39. The scores appeared to be normally distributed (see Figure 1).

Employing unit and knowledge scores
Nurses from the medical unit had statistically significant higher knowledge scores than nurses in the surgical unit (p=0.012; t=2.627) which can be seen in Table 4.

Discussion
The diabetes knowledge scores obtained in this study could not be explained by the demographic variables that were measured. The sample in this study was derived from the medical and surgical units of an Australian regional hospital. The overall mean scores were 71% in the medical nurse group versus 63% in the surgical nurse group (p=0.012). The power of the t-test was calculated to be 0.09 (Cohen, 1988) and indicates a very small effect size. This study therefore provides a low level of evidence that these scores may reflect the broader Australian nursing population. However, Scheiderich et al (1983) found a strong trend (p=0.055) for surgical nurses to score lower than medical unit nurses on a diabetes knowledge test. 

The mean score of 71% obtained by the medical nurses in this study was comparative to previously cited studies in other groups of nurses. However, the mean score of 63% achieved by the surgical nurses in this study is low in comparison to previously cited studies and would represent an insufficient knowledge base according to the majority of cited authors. Given that the surgical nurses in the current study indicated that they cared for a significant number of patients with diabetes per month, this result is a source of concern.

The differences in diabetes knowledge scores between medical and surgical nurses in this study could not be explained by demographic variables. Perhaps the difference in knowledge scores could be attributed to the nurses in the surgical unit seeing diabetes as being a secondary diagnosis and not as important as the primary diagnosis. Possibly, medical nurses are expected to provide more diabetes education functions to people with diabetes than surgical nurses. Further investigation in the differences of knowledge levels of medical and surgical nurses is warranted.

Limitations
Drass et al (1989) originally designed the DBKT used in this study. The measuring tool used was designed to measure basic diabetes knowledge. Nurses required knowledge in many areas of diabetes to achieve a good result. Nurses who responded in this study may not have believed that such knowledge was relevant to clinical practice. It is possible that the test measured a set of theoretical concepts satisfactorily, but that the concepts measured were inappropriate. However two DNEs checked the DBKT and considered it an appropriate instrument to measure diabetes knowledge in the sample population.

The population for the current study was drawn from only two units of one Australian regional hospital. Combined with the small sample size, this makes it difficult to generalise the results beyond the sample to the wider nursing population.

Implications and recommendations for future research
This study identified that the nursing population sampled has knowledge deficits in relation to diabetes care and management. If these findings are reflective of the care provided to people with diabetes by the Australian nursing profession then there may be serious implications. It is recommended that this study be replicated to ascertain if the current findings are duplicated in other Australian nursing populations.

The rate of surgery is higher for the diabetes population than the rest of the population. It is of concern that surgical nurses scored lower than medical nurses in this study and much lower than comparative studies. Consequently, it is recommended that further research is required to examine why surgical nurses scored lower on the diabetes knowledge test in this sample and if this result represents the broader surgical nursing community. There are immediate implications for the education of surgical nurses in this study.

Conclusion
Diabetes is a serious and growing health problem in Australia. The nature of diabetes is such that nurses in medical and surgical units are likely to care for increasing numbers of patients with diabetes. Broad diabetes knowledge is necessary to ensure excellence in the nursing care of this growing population.