It has been estimated that 6% of hospital inpatients have diabetes, although this may not be the primary reason for admission (BDA, 1996). Within this setting, general nursing staff spend the most time with these patients and may be expected to plan and provide care for them (BDA, 1996). Yet they may not possess the knowledge, skills or confidence to do so (Callaghan and Williams, 1994).
Reporting on the poor quality of diabetes knowledge and the need for more diabetes education within healthcare professions, Heller and MacKinnon (1998) identify nursing as being particularly difficult due to the large workforce and high staff turnover. They describe a number of approaches to nurse education, including:
- Writing guidelines and standard hospital protocols of care for people with diabetes
- Employing a member of the diabetes team specifically for in-service training and development of standards of care in diabetes
- Having a system of ‘link nurses’ in each clinical area.
The author’s experience of clinical guidelines is that, however well written, they may not be referred to. Some of these documents can be rather unwieldy and consequently some important information may not be easily accessible. While guidelines are necessary for supporting clinical practice, perhaps the challenge for specialist nurses is to provide educational material on diabetes for general nursing staff that is readable, relevant and useful in clinical practice.
Many traditional methods of nurse education have been used at the author’s hospital (a satellite hospital within the trust). However, not all are always feasible for various reasons, e.g. nurse specialists were only able to offer infrequent study days due to understaffing and increasing demands on the service. Short training sessions for nurses on the wards had been tried but had been unsatisfactory as often pre-planned meetings with ward nurses resulted in a nurse specialist arriving to find only one or two ward staff attending due to patient demands. This was clearly not an efficient use of limited resources in diabetes specialist nursing.
Ward staff often do not have access to diabetes literature produced by manufacturers except in specialist areas and most of this is not easily photocopied.
Adapting programmes to needs
At a meeting of senior nurses at the hospital, a brainstorming session was carried out to determine what methods of disseminating diabetes information would be practical for busy ward staff. Suggestions included:
- Study days
- Small group teaching on the wards
- Lunchtime or evening seminars
- A flyer or newsletter.
The last idea was popular and the group were asked what information they would want to be included on a flyer. This concurred with the information that the nurse specialists were frequently asked about, e.g. blood testing, oral hypoglycaemics agents, insulin treatment and hypoglycaemia.
The idea was that nursing staff, who may be unable to attend study days, could quickly glance at a single sheet displaying information about diabetes while at the nurses’ station. It was intended as a supplement to wider teaching programmes, not as a substitute.
Birth of Diabyte
Diabyte was conceived as a novel and relatively simple approach to educating and updating nurses in practical elements of diabetes care. As the concept developed, Diabyte was subsequently modified to enable it to be used for patient education. Originally, the intention was for the flyer to be distributed by email then printed out but, at the time, many wards did not have printers.
Diabyte was produced with all the educational material deliberately kept to one side of an A4 sheet so that it would be more likely to be read by busy nurses.
The name reflects the style of the flyer and is a play on sound bites. Furthermore, the notion was that Diabyte was ‘easily digestible’, i.e. in a non-technical style with the information, as suggested by the logo, ‘on a plate’. This was meant to be novel and fun. Although there were some concerns that Diabyte might be perceived as patronising or too simple, this did not appear to be the case on evaluation. Figure 1 (viewable in the PDF of this article) shows an example of an issue of Diabyte.
‘What I see I remember, what I hear I forget’ is an old adage and one which certainly holds true for printed educational material for supporting and enhancing verbal instructions (Glasper, 1992). With this in mind, Diabyte was designed to be used by ward nurses for teaching patients. Therefore the information had to be user-friendly for patients. With regard to the wording, it was a challenge to make Diabyte usable for patients, particularly to avoid using the term ‘patient’ in the third person.
Main references were given on the reverse side of each Diabyte to provide:
- Further reading for those nurses who were interested
- An evidence base for the information.
Where possible, the references were generally available, although there were some texts that are specifically produced for those working in diabetes. Staff have always been encouraged to use the diabetes centre and our books and journals as a resource – a reminder of this was included on each Diabyte.
Each Diabyte was proofread and peer-reviewed by a colleague to ensure that the style and content were accurate. While Diabyte looks simple, each one took 3–4 hours to produce as each flyer was carefully designed so that a maximum of 10 ‘bytes’ would fit the A4 format and be readable by both nurses and patients.
Different font styles and sizes were chosen to enhance the appearance and readability of the sheet.
The Gunning Fog Index (Gunning, 1968) was used to achieve ease of reading. The index can be used to give a grade which reflects sentence length and frequency of words containing more than three syllables (three 100-word samples from the beginning, middle and end of articles are used for this purpose). In order to provide easy reading for patients, a grade of 6–10 was aimed for – this equates to Readers’ Digest or consumer magazines (for comparison, a grade of 13 related to undergraduate level). Diabyte scored mostly 10 or 11.
Deciding to produce material for both patients and staff meant there had to be some compromises. These were mainly in details such as drug actions and dosages and the use of terminology which may be familiar to nurses but not to patients. However, when I started my post I had found much of the patient literature a good place to start learning more about diabetes before moving onto more academic writings.
Each Diabyte was produced in a clear plastic wallet because single sheets can go missing or become tatty.
Piloting the project
Diabyte was piloted at a satellite hospital within the trust where the original idea was conceived. The clinical areas used were six wards chosen from elderly daycare and continuing care, and the rheumatology unit. Approval was gained from the nurse manager for each unit before a covering letter explaining the project was sent out with the first of five monthly Diabytes. The topics covered by each issue were those for which information was requested most frequently from nursing staff. They were:
- Blood glucose monitoring
- Insulin therapy
- Administration of insulin
- Oral medication
The final Diabyte included an evaluation form (Figure 2) to be completed by nursing staff within 10 days (later extended by 10 days). The forms were collected in person from each ward area, as this method appeared to be the most effective guarantee of ensuring evaluations were actually completed on time.
In five out of six clinical areas, Diabyte was on prominent display at the nurses’ station. Nursing staff were asked if they knew what Diabyte was and it was evident that most were aware of the contents of at least one issue.
Nine evaluations were received (out of a possible twenty-four). Barker (1991) reports a low response rate for questionnaires and the difficulty in making valid generalisations from what may not be a representative sample. This is acknowledged as a limitation of the study and may indicate that only those nurses who had read and used Diabyte may have responded. However, within the time frame and resources available, it would have been impractical to use another method, e.g. a structured interview.
All nurses evaluated Diabyte as easy to read and useful, covering some of the basic essential information that staff required. Five respondents made suggestions for areas that could be covered; including hyperglycaemia, management of illness and diabetic foot care. Of the nine respondents, eight indicated that students had read Diabyte and most areas had photocopied the information for patients and students. It was encouraging that some nurses had read more widely from the references.
Overall, the response to Diabyte was favourable. Diabetes information for staff in non-specialist areas should be easily obtainable. Many of them will probably not always have the time or inclination to seek out such information during work time.
Diabyte represents a pragmatic approach to diabetes education at a time when there have been limited resources to pursue more formal teaching with ward staff. Diabyte is not intended, and never has been intended, to replace more formal teaching strategies and methods of delivering diabetes education. It is merely one way of quickly providing ‘at a glance’ information and perhaps stimulating nursing staff to read further around a subject.
We intend to revise Diabyte to include specific instruction on the use of insulin analogues, new insulin delivery devices and evidence supporting changes in diabetes care. The number of subjects covered will be increased and Diabyte will be reissued more widely across the hospital trust and also into the community.
Since more clinical areas are using information technology, it should be possible to produce Diabyte as an email attachment that can be downloaded and a hard copy printed off. Ultimately, it should be possible for the diabetes centre to produce its own webpage which would be accessible by any trust staff on the intranet and which contains more diverse information, e.g. electronic journals or instructions on how to use equipment such as blood glucose meters and insulin pens.
General nurses need skills and knowledge in diabetes care so that they may provide competent care for patients with diabetes. Educating nursing staff is an essential component of the role of the diabetes nurse specialist yet clinical commitments for both ward staff and the nurse specialist may limit the provision of formal training and there is need to use a variety of educational methods.
The development of a novel and quick reference guide to the areas of diabetes care most commonly identified by both nurses and patients was an attempt to disseminate information efficiently and effectively. Although a small pilot project, Diabyte been positively evaluated as a resource for nursing staff and students and used as a supplement to patient teaching.
There is now scope to expand the format of Diabyte to make use of information technology, particularly by sending it as an email attachment, and to circulate this more widely.