Nurses want education to improve diabetes care
Nurses want education to improve diabetes care
Health care professionals are rarely asked what would help them do their jobs better. So when a group of registered nurses a got the ear of researchers, they had a lot to say. Their biggest concern: their need for more education to improve their care of diabetic patients.
Patricia B. McDonald, PhD, RN, assistant professor of nursing at the Francis Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, surveyed 103 nurses.
McDonald says she was "appalled" when one-third of the original 200 general practice nurses solicited to participate in the study said they never provide care for diabetics, when actually, chances are very good the nurses are caring for patients with the disease but are unaware they are diabetics. McDonald says she was encouraged, however, when she found 41% of her respondents wanted more education in caring for diabetics.
More than a quarter of the nurses dealing with diabetic patients on a daily basis said they had no diabetes education updates in the past two to 15 years, and 63% said they had no practice guidelines available to them.
"The management of diabetes is changing very rapidly with the results of studies like the [Diabetes Control and Complications Trial] and the new drugs available," says McDonald. "It’s hard to keep up with the latest developments in diabetes and dozens of other diseases, but that’s what we need to do to stay on top of this."
McDonald says the answers to the 53 questions on her survey, some of them open-ended, were "very straightforward." The nurses are requesting upgraded nursing education and inservice programs on unusual patient situations by certified diabetes educators, diabetes specialists, and nutritionists. Those nurses surveyed want to know more about these issues:
- blood glucose control during pre- and post-surgical procedures;
- phases of acute illness including infusing intravenous fluids with dextrose;
- sick day management of diabetes;
- management of hypo- and hyperglycemic reactions;
- management of complications and high-risk case management;
- counseling to help patients deal with the chronic nature of the disease and its long-term management.
Why did some of the responses to her survey upset McDonald so much? Of the original sample of 200 registered nurses working in inpatient settings, outpatient clinics, emergency departments, medical centers, and home health care, 33% said they never worked with diabetic patients.
"That’s simply not possible," she says. "I don’t know why, because they did not respond to our query beyond that, but I can only guess that when a patient comes in with a sprained ankle, they don’t even pay attention to fact he is a diabetic. It’s a travesty that nurses can work for two to 15 years with no updates in their diabetes education."
She lists the sources of education: local medical societies, seminars sponsored by drug companies in virtually every city of any size, on-line resources such as those offered by the American Diabetes Association (ADA) and the American Association of Diabetes Educators. (See ADA’s list of competencies, inserted in this issue.)
She offers only two explanations for nurses’ lack of awareness of diabetes: "Either they’re not interested, or they don’t think it’s important."
"Diabetes has been here forever, and it’ll be here forever," she says. "Many people would rather look at more exciting things like AIDS."
McDonald says she had a jolting experience seven years ago when she visited a Veterans Affairs hospital. "I saw a 46-year-old African-American gentleman with diabetes sitting in a wheelchair — a double amputee who lost his legs to diabetic neuropathy. He said no one had ever told him this might happen. Something happened to me at that moment; I developed a passion about this — about educating nurses so they can educate their patients."
Diabetes Management asked two other preeminent nurses in the field what they think nurses need to better care for their diabetic patients.
"I think this survey nailed a few things right on the head," says Claire Paras, RN, MBA, program manager for disease management at the Joslin Diabetes Center in Boston. "Diabetes is a moving target, since things are changing so quickly in this field. I feel like I am looking up the mountain in terms of the content of what nurses need to know."
Under Paras’ direction, Joslin is reaching out to the offices of primary care providers to help their staffs update their diabetes management skills. "We need to find ways for caregivers to feel comfortable with their own knowledge levels, and that makes them confident in giving away that information to help their patients manage their disease," she says.
That means going to the providers’ offices, being flexible on hours, providing small group sessions, often with lunchtime modules and roundtable discussions that offer ample opportunities for nurses to ask questions.
She calls Joslin’s outreach education programs a "sort of nurturing process" to keep nurses updated. Paras says nurse burnout is widespread because of the enormity of the impact of diabetes in view of almost certain complications. "I am so struck by how profoundly dangerous this disease is," she says. "For nurses, it is extremely difficult to dealing with this disease that has no light at the end of the tunnel."
Even when a patient is doing everything right, he or she may still go downhill. "Nurses come here to heal people, and there’s such a huge feeling of the overwhelmingness of it all," she says.
The lack of financial support for education programs for patients adds to the problem, says Paras. "Care providers and patients don’t get a lot of help from insurers. Not much of that sort of assistance is reimbursable from insurance." And then, she asks, what does a nurse do to help a patient who can’t afford supplies? "It doesn’t matter how much education you get if the system works against you and your patients," Paras adds.
The most powerful solution might be the least formal training, says Elizabeth Walker, DNSc, RN, CDE, president of health care and education for the American Diabetes Association in Alexandria, VA. The key lies in almost continuous informal training in the clinical setting by staff nurses, certified diabetes educators (CDE), and whoever has the knowledge of diabetes, coupled with some additional formal training sessions. "Knowledge isn’t enough," she says. "When it comes to diabetes care for themselves and for the patients, nurses need knowledge, beliefs, attitudes, problem solving, and coping skills."
Those skills are best learned in the clinical setting, she says, from CDEs or staff nurses who have more experience with diabetes and see it as part of their job to pass their knowledge on to their colleagues. Most nurses don’t think of themselves as teachers, says Walker, who is also an associate professor of epidemiology and social medicine at Albert Einstein College of Medicine in New York City, but if each nurse becomes a teacher to colleagues and patients, the effect would be profound.
"In any health care system, it takes someone there to become a champion to make sure nurses in that system are kept up to date and to make sure that changes in guidelines are institutionalized. [Someone has to] get into the system so everyone is up to date on the newest techniques for teaching patients and the newest treatments," Walker says.
More formally, most health care systems have periodic training sessions in diabetes for nurses. Most managed care plans have inservice training in diabetes. And most have practice guidelines even though the vast majority of the nurses were not aware of them, says Walker.
There are on-line sources of continuing education and a vast amount of printed material through which nurses can receive continuing medical education credits. (See box, p. 112.)
And, in the most informal sense, says Walker, "Most general medical clinics have brochures and patient literature such as Diabetes Forecast in their waiting rooms. It’s well-written, clear, and easy to understand. Staff nurses can learn from these materials as well as their patients."
[Contact Patricia McDonald at (216) 368-3345, Claire Paras at (617) 732-2400, and Elizabeth Walker at (718) 430-3242.]
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