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Self-reported and actual knowledge regarding the care of individuals with diabetes mellitus of nurses… Lenahan, Rose M. M. 1993

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SELF-REPORTED AND ACTUAL KNOWLEDGE REGARDINGTHE CARE OF INDIVIDUALS WITH DIABETES MELLITUSOF NURSES WORKING INHOME CARE AND HOSPITAL SETTINGSbyRose Mary Margaret LenahanB.S.N., The University of British Columbia, 1988A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF SCIENCE IN NURSINGinTHE FACULTY OF GRADUATE STUDIESSCHOOL OF NURSINGWe accept this thesis as conformingTHE UNIVERSITY OF BRITISH COLUMBIAOctober, 1993© Rose Mary Margaret Lenahan, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature) Department of ^The University of British ColumbiaVancouver, CanadaDate^/z-/ DE-6 (2/88)iiAbstractThis descriptive correlational study was designedto describe the relationship between self-reportedknowledge and skills and actual knowledge about thecare of individuals with diabetes mellitus of nursesworking in acute medical/surgical hospital units andhome care settings.Data were gathered by means of three instruments.The Demographic Data sheet was developed by theresearcher. The Diabetes Self-Report Tool (DSRT) usedto measure the self-reported knowledge and skills andthe Diabetes Basic Knowledge Test (DBKT) used tomeasure the actual knowledge were developed by Drass,Muir-Nash, Boykin, Turek & Baker (1989). Theinstruments were mailed to a random sample of 150 homecare and 150 acute medical/surgical hospital nursesthrough the computerized registry of the RegisteredNurses Association of British Columbia. A total of 81home care and 73 hospital nurses returned the completedinstruments for a combined number of 154 and a responserate of 51.3%.The majority of the sample (62.7%, n = 96) had nothad diabetic inservice education within the last twoiiiyears or had never attended diabetic inservice.However, the home care nurses had had inserviceeducation more recently and had more years of nursingexperience than the hospital nurses. The home care andhospital nurses had DSRT mean scores of 59.9 and56.3, respectively, out of a possible 88. The meanscore for home care nurses on the DBKT was 27.95 andfor hospital nurses, 28.6, out of a possible 45. Thedata suggest that there were major knowledge deficitsfor both groups in the areas of the Somogyi effect,insulin administration, oral hypoglycemic medications,urine and blood glucose testing, the treatment ofhypoglycemia and the etiology of Type I diabetes.Both groups of nurses rated their knowledge of andskills (DSRT) in caring for individuals with diabetesmellitus higher than their achieved scores on the DBKTin all 22 content areas. Scores of home care nurses onthe DSRT and DBKT were positively and significantlycorrelated. No such relationship existed between thescores of the hospital nurses.Conclusions from the findings are presented andimplications for nursing are discussed.ivTable of ContentsPageAbstract^ iiTable of Contents^ ivList of Tables viList of Figures^ viiiAcknowledgements ixChapter One: Introduction^ 1Background to Problem 1Problem^ 3Purpose 4Conceptual Framework^ 4Research Questions 5Definition of Terms 7Assumptions^ 8Limitations 8Significance of the Study^ 9Organization of the Thesis 10Chapter Two: Literature Review 12Self-reported Knowledge^ 12Actual Knowledge^ 17Summary^ 21Chapter Three: Methods^ 24Research Design^ 24Sample^ 24Instruments 25Data Collection 27Data Analysis^ 27Ethical Considerations^ 28Summary^ 28Chapter Four: Presentation and Discussionof Findings^ 29Introduction^ 29Response Rate 29Description of the Samples 30Years of Nursing Experience^ 30Years Worked in Current Setting 31VEducational Background^ 32Recency of Diabetes Education^ 33Number of Diabetics Cared For per Month^ 34General Competency in Caring For Diabetics 34Self-reported Knowledge and Skills andActual Knowledge Among Home Care Nurses 35Self-reported Knowledge and Skills^ 35Actual Knowledge^ 37Self-reported Knowledge and Skills andActual Knowledge Among Hospital Nurses 44Self-reported Knowledge and Skills^ 44Actual Knowledge^ 46Correlations Between Self-reported Knowledgeand Skills and Actual Knowledge ForHome care and Hospital Nurses^ 58Home Care Nurses^ 58Hospital Nurses 59Summary^ 60Chapter Five: Summary, Conclusions, and Implicationsfor Nursing^ 62Summary^ 62Conclusions 66Implications for Nursing 66Nursing Education^ 66Nursing Practice 67Nursing Research 68References^ 70Appendices 74A. Diabetes Self-Report Tool^  74B. Diabetes Basic Knowledge Test 78C. Letter to RNABC^ 94D. Letter to Participants 97E. Instructions to Participants for Completingand Returning the Questionnaires^ 100F. Demographic Data Sheet^ 102G. Matching Numbers or Groups of Numbersfor DSRT and DBKT Items 104viLIST OF TABLESTable^ Page1. Years of Nursing Experience^ 302. Years Worked in Current Setting 313. Educational Background ^ 324. Recency of Diabetes Education^ 335. Number of Diabetics Cared for Per Month^ 346. General Rating of Competency in Caring forDiabetics^ 357. Percentages and Numbers of Home Care NursesWho Reported Having the Knowledge and SkillsDescribed in the DSRT^ 368. Percentages and Numbers of Home CareNurses Responding Correctly to DBKT Items^ 389. Percentages of Home Care Nurses Who ReportedHaving the Knowledge and Skills Describedin the DSRT and of Those Responding Correctlyto DBKT Items^ 4210. Percentages and Numbers of Hospital NursesWho Reported Having the Knowledge and SkillsDescribed in the DSRT^ 45viiList of Tables (continued)Table^ Page11. Percentages and Numbers of HospitalNurses Responding Correctly to DBKT Items^ 4712. Percentages of Hospital Nurses Who ReportedHaving the Knowledge and Skills Describedin the DSRT and of Those Responding Correctlyto DBKT Items^ 51viiiLIST OF FIGURESFigure^ Page1. Program Planning Model^6ixAcknowledgementsI extend my sincere thanks to the members of mythesis committee, Dr. Marilyn Willman (Chairperson) andProfessor Ethel Warbinek, for their patience and guidancethroughout this study. I would like to thank ProfessorAnne Wyness and Dr. Ann Hilton for their assistance inhelping me through the proposal stage of the thesisprocess.My deepest thanks and gratitude to all the nurseswho took the time to complete and return thequestionnaires, because without you, this thesis wouldnot exist. Appreciation is also extended to ClaireKermacks and the RNABC for their help in the datagathering process.A special thanks is offered to Pauline Ursic, MaryTynski, my family and friends whose constant support andhelp gave me the encouragement to continue. Finally, I amforever indebted to my father, John Adrian Lenahan, forhis great sense of humour; his intelligent, statisticalmind; and his powerful will that would never allow me toquit.1CHAPTER ONEIntroductionBackground To ProblemNursing staff development educators investvaluable time, effort and money in planning relevantinservice education to help nurses maintain andupgrade their knowledge in order to function ascompetent professionals (Bille, 1982; Dyche, 1988;RNABC, 1990). Given the numerous demands on nurses'time and the emphasis on budget restraints in healthcare, it is critical that nurse educators developrelevant and cost effective inservice education.Frequent updating in the care and management ofindividuals with diabetes mellitus is required becauseof the rapid changes occurring in the field of diabeticcare and the prevalence of the disease in the generalpopulation (Veroba and West, 1986). A number of studieshave shown that nurses' knowledge about the care ofindividuals with diabetes mellitus is a major factorthat influences diabetic patient education andconsequently the self-care practices of diabetics(de Weerdt, Visser & van der Veen, 1989; Leichter,1986; Mazzuca, Moorman and Wheeler, 1986; Teza, Davis2and Hiss, 1988). Researchers discovered that manydiabetics received inadequate diabetic education andthat those diabetics with low knowledge levels werealso in poor metabolic control (Dunn,1986; Peyrot &McMurray, 1985; Watts, 1980). This relationshipbetween nurses' knowledge and the self-care practicesof individuals with diabetes mellitus highlights theimportance of the knowledge component included innursing inservice education.The prevalence of diabetes mellitus in societytogether with the numerous and constant changes indiabetic care require that hospital and home carenurses maintain their knowledge in order to providepatients with competent nursing care. Early hospitaldischarges may result in patients receiving limiteddiabetic teaching and increase the need forsubstantial, consistent, ongoing nursing care by homecare nurses. Therefore, home care nurses must haveknowledge about the care of individuals with diabetesmellitus to effectively assess, plan, implement andevaluate diabetic self-care practices in order tofacilitate continuing support to patients at home(Baasch, 1988; Ross, 1990).3Since home care and hospital nurses' actualknowledge plays a vital part in influencing the self-care practices of diabetics, it is essential that nurseeducators use methods to accurately diagnose nurses'educational needs in relation to knowledge aboutdiabetes mellitus.ProblemThere is a dearth of research regarding therelationship between nurses' self-reported and actualknowledge regarding the care of individuals withdiabetes mellitus. Despite the paucity of scientificsupport for learners' ability to accurately assesstheir own knowledge, self-assessment is a common methodused by nurse educators as a basis for planninginservice education. Nurse educators who use self-assessments exclusively to ascertain home care andhospital nurses' knowledge related to a complicated andchanging disease like diabetes mellitus are basingtheir judgements solely on nurses' self-reportedknowledge. This may or may not bear a relationship tohome care and hospital nurses' actual knowledge. It isimperative that educational decisions are based onknowledge assessments that ensure relevant inservice4education that promotes effective nursing care forpatients in the hospital and at home.Purpose The purpose of this study was to describe therelationship between self-reported knowledge and skillsand actual knowledge about the care of individuals withdiabetes mellitus of nurses working in acute medical/surgical hospital units and home care settings.Conceptual FrameworkKnowles's (1970) program planning model was chosenas the conceptual framework for this study. This modelspecifies the following orderly set of interrelated,progressive activities:1. Setting the climate.2. Devising organizational structure.3. Diagnosing needs.4. Setting objectives.5. Planning methods and resources.6. Implementation.7. Re-diagnosis of needs.Program planning is a dynamic continuous process thatcan be regarded as circular in nature. The relationshipbetween self-reported and actual knowledge can beviewed within the context of the model's third step,diagnosing needs.Knowles (1970) describes diagnosing needs as the5process of identifying educational needs. Aneducational need is the discrepancy between reality anda desired state related to knowledge, skills and/orvalues as defined by individuals, organizations and/orsociety. This study focused specifically on diagnosingeducational needs related to the knowledge component.There are two methods of diagnosing individuals'educational needs related to their knowledge level. Thefirst method involves self-assessment to determineself-reported knowledge while the second methodinvolves testing to determine actual knowledge(see Figure 1.). Once self-reported and/or actualknowledge are determined, they become the foundationfor planning inservice education. Therefore, accuracyin diagnosing educational needs related to knowledge isa vital step in the program planning process.Research Questions 1. What is the self-reported knowledge and skills andactual knowledge about the care of individuals withdiabetes mellitus among nurses working in home caresettings?2. What is the self-reported knowledge and skills andactual knowledge about the care of individuals withSetting the ClimateDevising Organizational StructureDiagnosing NeedsIndividualKnowledgeSelfreported^ActualSelf-assessment Testing^•Setting ObjectivesPlanning Methods and ResourcesImplementationRe-diagnosis of NeedsFigure 1. Program Planning ModelNote. Adapted from The Modern Practice of Adult Education by M.S. Knowles, 19706diabetes mellitus among nurses working in hospitalsettings?3. What is the correlation between self-reportedknowledge and skills and actual knowledge about thecare of individuals with diabetes mellitus for nursesworking in home care and nurses working in hospitalsettings?Definition of TermsSelf-reported diabetes mellitus knowledge and skills are the nurse's own description of theinformation she/he possesses regarding the care ofindividuals with diabetes mellitus as measured by theDiabetes Self-Report Tool (DSRT) (Drass et al., 1989)(see Appendix A).Actual diabetes mellitus knowledge is theinformation a nurse has regarding the care ofindividuals with diabetes mellitus as measured byDiabetes Basic Knowledge Test (DBKT) (Drass et al.,1989) (see Appendix B).Inservice education refers to educationalexperiences and resources provided during work time inthe employment setting for the purpose of improvingnurses' performance (Dyche, 1988).78Home care nurses are registered nurses who delivernursing care in the home setting (Keating & Kelman,1988).Hospital nurses are registered nurses working onmedical or surgical units in acute care hospitals.Assumptions In conducting this study it was assumed that amajor component of the care nurses provide individualswith diabetes mellitus is the teaching of diabeticself-care practices. It was further assumed that homecare and hospital nurses have knowledge about diabetesmellitus and would respond honestly to instrumentsdesigned to assess both self-reported and actualknowledge.Limitations The order in which the study questionnaires werefilled out and the use of resources to complete thequestionnaires could not be controlled and hence thedata gathered from the questionnaires may not be anaccurate reflection of nurses' self-reported and actualknowledge. Self-selection by the subjects may be afactor that affects the generalizability of thefindings. The predictive validity of the two9instruments used in the study in terms of quality ofnursing care has not been determined.Significance of the Study There is little published research related tonurses' self-reported and actual knowledge about thecare of individuals with diabetes mellitus. Therefore,this study's findings will begin to build a knowledgebase about home care and hospital nurses' ability toaccurately assess their own knowledge in relation toone complex disease.The limited research available on self-reportedknowledge as measured by self-assessment yieldedconflicting results with subjects over- or underratingtheir abilities (Bailey & Shaw, 1972; Fox & Denuir,1988; Lowman, 1987). These findings suggest that nurseeducators who plan inservice education using the datagathered from self-assessments could be basing theirdecisions on data that may or may not bear anyrelationship to nurses' actual knowledge. Since nurses'knowledge may affect diabetics' self-care practices,staff development educators should utilize methods thatcorrectly identify nurses' diabetic educational needs.Therefore, further investigation into the relationship10between nurses' self-reported and actual knowledge iswarranted.Previously published research has concentrated onhospital nurses' diabetic knowledge. No publishedresearch was found that studied home care nurses'knowledge about diabetes mellitus, but with increasedpatient acuity and shorter hospital stays, home carenurses cannot assume diabetic teaching has been carriedout in the hospital. This study will investigate andcompare home care and hospital nurses' knowledgerelated to diabetes mellitus. Knowing the subjects'actual diabetic knowledge may help nurse educators planrelevant diabetic education. The research outcomes mayassist nursing administrators in allocating scarceeducational resources such as inservice time and money.Organization of the Thesis This chapter has presented an overview of thebackground to the problem, the problem statement, thepurpose, the conceptual framework, the researchquestions, the definition of terms, the assumptions,limitations and the significance of the study. ChapterTwo presents a review of the literature and focuses ondiagnosing educational needs in relation to self-11reported and actual knowledge. Chapter Three describesthe research methods used in the study, while ChapterFour presents the analysis of the data and a discussionof the findings. Finally, Chapter Five presents thesummary of the findings and the conclusions andimplications for nursing.12CHAPTER TWOLiterature ReviewThe literature review focuses on diagnosingeducational needs in terms of self-reported and actualknowledge. Techniques used to assess each knowledgelevel are presented under the respective headings.Self-reported KnowledgeSelf-reported knowledge is the learners' owndescription of the information they possess about aspecific subject. Three frequently used techniques forobtaining self-reports of knowledge are described inthe literature. These include questionnaires,observations and discussions (Knowles, 1980; Monette,1977). The techniques can be formal or informal, butgenerally require learners to assess what they want tolearn.Knowles (1980) places great emphasis on learnersself-assessing their own knowledge and insists thatthey are able to assess their current performance, butthey must have the necessary tools to carry out thetask. He further contends that simply asking thelearners in questionnaires what they want to know willonly uncover the superficial interests that they13consider prudent to mention. He admits thatacknowledging learners' interests may prove tomotivate learning but insists that educators mustdevelop skills and procedures to help learnersdiscover their actual knowledge and then providelearning experiences to meet those educational needs.Finally, he maintains that educators shouldassist learners to see the things they need to learnbecause, without input from others, the learner canbecome stalled in false assumptions and self-perpetuating errors.Monette (1977) and Gronlund and Linn (1990)discuss similar ideas related to self-assessmenttechniques. Monette (1977) discusses self-assessmenttechniques as a means of discovering learners' wants,desires or interests in relation to learning. Hecontends that these techniques are inadequate formeasuring an actual knowledge deficit because learnersmay not be aware they lack knowledge. He believes thatthe identified interests of learners should be used asa basis for testing to uncover their actual knowledgelevel. Gronlund and Linn (1990) believe that self-assessment tools are more appropriate for eliciting14learners' attitudes and feelings regarding a subjectthan their knowledge of the subject. They assert thatself-assessments are not appropriate for determiningthe learners' knowledge because they are susceptibleto exaggeration or less than truthful answers. Evenwhen learners want to be truthful, their recollectionsof the facts may be inaccurate and their self-perceptions biased.MacDonald and Grogin (1991) warn against usingtechniques such as opinion polls in attempting todetermine actual knowledge of adults. They concludethat basing educational programs on nurses' self-reported knowledge will generally be nonproductive andwill create more problems than are solved. They assertthat nurses' self-reported knowledge in a given areahas little or no relationship to the actual knowledgeand contend that a self-reported learning need may besymptomatic of another deeper actual learning need.MacDonald et al. (1991) assert that the perspectives ofboth the adult learner and educator are necessary tohelp identify nurses' actual knowledge.Stuff lebeam, McCormick, Brinkerhoff, Nelson (1985)claim that an educational needs assessment that15identifies a self-reported knowledge gap can result inconfusing educational needs with preferences. Thesuccess of self-assessment for diagnosing educationalneeds is highly dependent on the extent to whichlearners are informed. If they are uninformed, theformation of invalid learning goals may be the result.However, the authors identify self-assessment as asound technique for describing knowledge levels ofadult learners.Bille (1982) offers an opposing view to those ofthe above authors. He asserts that the relevance of aneducational program is assured as long as the learneris involved in needs diagnosis and, further, that theprocess of needs diagnosis can be accomplished quitesimply by asking the learners to state their interests.He suggests that an educational need and interest arethe same and concludes that basing educational programson individuals' interests will guarantee success.Canadian research relating to self-assessment ofknowledge was not found and only minimal Americanpublished research was available. Lowman (1987) studied149 female university students and examined thevalidity of self-assessment ability on six interest16domains: mechanical intelligence, artistic ability,social skills, leadership talent, perceptual speed andaccuracy, and intellectual capacity. All subjectseither over- or under-rated themselves in the area ofintellectual capacity and in each of the other fiveareas as well. These findings support the idea thatself-reported knowledge may not be congruent withactual knowledge.Two studies examined staff nurses' and nurseadministrators' perceptions of the staff nurses'educational needs (Banfield, Brooks, Brown, Mason,Miller, Smith & Wong, 1990; Janz, 1992). Janz (1992)studied 97 nurses and 39 nursing administrators from 41hospitals and nursing homes regarding their perceptionsof the nurses' educational needs. Nursingadministrators perceived the nurses as needingknowledge in the areas of physical, legal andpsychosocial needs of the elderly at a rate of 64%compared to the nurses' rating of 32%. Banfield et al.(1990) surveyed 89 staff nurses on 30 nursing units and30 head nurses from the same units to determine theirperceptions of the staff nurses' educational needs. Theprimary educational needs identified by staff nurses17were physical assessment, conflict management andpatient teaching. The head nurses identifieddocumentation, computer training and communicationtechniques as the primary educational needs of thestaff nurses. The investigators for both of thesestudies concluded that the staff nurses perceiveddifferent educational needs than did nursingadministrators.Actual Knowledge Actual knowledge refers to information the learnerhas about a given subject. A number of ways to assessactual knowledge are described in the literature. Theseinclude observations, oral examinations, writtenpapers, simulations, standard achievement tests orteacher-made tests (Gronlund & Linn, 1990; Knowles,1980). Knowles (1985) asserts that educators should usetesting to diagnose actual knowledge because it is anobjective method to measure what people know about asubject and also highlights the knowledge they lack.One strategy commonly employed to diagnose actualknowledge is the pretest (Dyche, 1988). Standardachievement tests or teacher-made tests can be used aspretests. Pretests aid both the teacher and the learner18in assessing knowledge deficits and determininglearning readiness (Popham, 1990). Pretest results mayprovide a more sound basis for planning educationalprograms, for selecting educational experiences and fordeveloping self-assessment skills than the results ofself-assessments. The results of pretests can helplearners gain insight into current knowledge andadditional knowledge that may be needed. Monette (1977)believes pretests are a more objective method ofhelping the learner recognise that a lack of knowledgeexists whereas self-assessments are highly subjectivein nature.A number of nursing studies have used teacher-madepretests to assess nurses' knowledge about particulartopics. One study used a pretest to identify the actualknowledge level of 78 oncology nurses about graft-versus-host disease in bone marrow transplant patients(Copel & Smith, 1989). The nurses' mean score was 8.3out of a possible 20, a knowledge level considered tobe inadequate. The results of the pretest objectivelyidentified the oncology nurses' knowledge level aboutgraft-versus-host disease and provided a sound basisfor nurse educators to plan related inservice19education.Four American studies assessed students andhospital nurses' actual knowledge regarding diabetesmellitus by using a pretest. Feustel (1976) tested 144senior nursing students in the areas of diet therapy,insulin effects, symptoms of diabetes, urine testingand management of the disease. She found that thenurses were inadequately prepared to teach diabeticsbecause of knowledge deficits in the areas of urinetesting and diet therapy. Moriarty and Stephens (1990)found that 39 hospital staff nurses from adult medicalunits scored 70% on a diabetes knowledge test that wasdesigned to assess knowledge of nutrition, bloodglucose monitoring, principles of diabetic managementand insulin administration. Nurses scored the lowest onthe nutrition questions with a mean score of 56% whichis similar to the findings in the Feustel (1976) study.Scheiderich et al. (1983) surveyed 137medical/surgical nurses and the results indicated majorgaps in their understanding of the treatment ofcomplications of diabetes mellitus and insulinadministration. The nurses' knowledge was satisfactoryin the areas of urine testing, physiology of diabetes20mellitus, the effects of insulin and diet therapy.Drass et al. (1989) compared hospital nurses'self-reported knowledge and skills and actual knowledgeabout diabetes mellitus. The sample consisted of 184nurses from one large, metropolitan hospitalrepresenting the following specialties: oncology;haematology; paediatrics; neurology; gerontology;rheumatology; and critical care. These subjectsaveraged 64% on a basic knowledge test. Content areasincluded urine and blood glucose testing, exercise anddiet therapy, complications and treatments for diabetesas well as insulin administration. The investigatorsnoted that 82% of the subjects answered a questionabout blood glucose monitoring incorrectly and 72%incorrectly answered an item on the Somogyi effect.Over half of the nurses incorrectly answered questionsabout insulin administration, findings consistent withthose of Scheiderich et al. (1983). The researchersestablished that the self-reported knowledge of thenurses was higher than their actual knowledge level.There was a low but statistically significant negativecorrelation indicating that the more the nurses thoughtthey knew, the less they actually knew about diabetes21mellitus. These findings further support the beliefthat nurses have difficulty accurately assessing theirown knowledge levels. Drass et al. (1989) discoveredthat the subjects reported an increased realizationthat they lacked knowledge after completing theDiabetes Basic Knowledge Test and a renewed interest inacquiring current diabetic knowledge.SummaryA review of the literature revealed littleresearch related to the relationship between self-reported and actual knowledge. One author (Bille, 1982)believes that self-reported knowledge is a goodindication of learners' educational needs while others(Knowles, 1980; Monette, 1977) contend that a self-reported knowledge level alone is too subjective ameasure on which to base educational decisions. Thelimited research on self-assessment ability supportsthe notion that people do not accurately assess theirknowledge. Teacher-made pretests to determine actualknowledge are believed to provide a more objectivemeasurement upon which to base educational decisionsthan are self-assessments, but minimal research isavailable to support this belief.22Several nursing studies used teacher-made preteststo determine nurses' actual knowledge and thefindings indicated a lack of knowledge among hospitalnurses related to diabetes mellitus. In one study,nurses' self-reported knowledge and skills werecompared with their actual knowledge. The resultsindicated that the nurses had difficulty accuratelyassessing their own knowledge. Canadian researchrelating to self-reported or actual knowledge aboutdiabetes mellitus among any group of nurses was notfound.Hospital nurses' knowledge about diabetes mellitushas been studied; however, no published research wasfound that examined home care nurses' knowledge relatedto diabetes mellitus. This is an important aspect toexamine because of the increasing trend toward earlyhospital discharge with many diabetics in need ofcontinuing care by home care nurses (Moriarty &Stephens, 1990).In summary, there is little information about homecare and acute medical/surgical hospital nurses' self-reported and actual knowledge relating to diabetesmellitus. This study will help to determine if nurses'23self-reported knowledge is an accurate reflection oftheir actual knowledge. Ascertaining nurses' actualknowledge about diabetes mellitus will help nurseeducators plan and provide relevant learningexperiences to meet nurses' diabetic educational needsand, ultimately, to improve patient care.24CHAPTER THREEMETHODSResearch Design A descriptive correlational design was selectedbecause it achieved the purpose and addressed theresearch questions of the study.SampleThe population for this study included allpractising home care and acute medical/surgicalhospital nurses who were registered with the RegisteredNurses Association of British Columbia (RNABC). Arandom sample of a minimum of 45 hospital and 45 homecare nurses who met the study's criteria was sought.This number of 90 subjects was established usingCohen's d Table for correlation with a medium effectsize of 0.5, a power of .80 and an alpha of 0.5(Shavelson, 1988). However, 150 home care and 150hospital nurses were contacted through the computerizedregistry of the RNABC to help ensure a response rateof 45 nurses per group.The criteria for participant selection were full-or part-time employment as staff/general duty nurse inan acute medical/surgical hospital unit or in home care25with a practicing membership in the RNABC.Instruments Relevant demographic data were collected using aDemographic Data Sheet developed by the researcher (seeAppendix C).Self-reported knowledge was measured by theDiabetes Self-Report Tool (DSRT) developed by Drass etal. (1989). The DSRT is a 22-item, four-point Likertscale instrument in which respondents indicateagreement or disagreement with statements reflectingknowledge of and skills in diabetes care (1 indicatingstrong disagreement and 4 indicating strong agreement).A response of 1 or 2 on the Likert scale constitutes alack of knowledge and skills and responses of 3 or 4indicate that the subject reports having knowledge andskills. The DSRT is scored by summing up the numericalscale value assigned to each item and has a scoringrange of 22 to 88, higher scores indicating higherlevels of self-reported knowledge of and skills indiabetic care. During its development, six experts fromthe field of diabetes education reviewed the instrumentfor content validity, item construction and testformat. No changes were made to the DSRT which had a26Cronbach's alpha of .91 for internal consistency(Drass et al. 1989). The DSRT reliability coefficientin this study was .86.Nurses' actual knowledge was measured by theDiabetes Basic Knowledge Test (DBKT) which was modifiedby Drass et al. (1989) from the Diabetes Knowledge Test(Scheiderich et al., 1983) to reflect updatedinformation. The DBKT is a 45-item multiple choiceinstrument that is scored by assigning one mark foreach correct answer and has a score range of 0 to 45.The "I do not know response" is scored as a wronganswer. Six experts in diabetes education reviewed theDBKT for content validity, item construction and testformat and a Cronbach's alpha of .79 for internalconsistency was reported. Reliability for internalconsistency on the DBKT was .73 for this study.Permission to use both the DSRT and the DBKT wasobtained from the authors prior to their use in thestudy. This investigator made only one minor revisionto the DBKT that related to converting the unitmeasurement of blood glucose from milligrams per 100millilitres (mg/d1) to millimole per litre (mmo1/1).27Data CollectionThe RNABC generated a random sample of 300 nursesthrough the computerized registry of whom 150 were homecare and 150 were acute medical/surgical nurses.Mailing labels were produced and the packages weremailed by the RNABC at the end of March, 1992. Each ofthe nurses was sent a package that included:1. a covering letter (see Appendix D) explainingthe purpose of the study, provisions forprotection of subjects' rights and directionsfor completing the instruments(see Appendix E).2. the Demographic Data Sheet3. the Diabetes Self-Report Tool in an envelopelabelled "Document #1"4. the Diabetes Basic Knowledge Testin a sealed envelope labelled "Document #2"5. one large stamped preaddressed envelopeA total of 154 completed packages was returned, 73from the acute medical/surgical hospital nurses and 81from the home care group.Data Analysis Demographic data were described using percentagesand means. Means, percentages and ranges were used todescribe the DSRT and the DBKT results. To correlatethe results of the DSRT with the DBKT, the Pearson28product-moment correlation coefficient was utilized.The level of significance for correlating the scores ofthe 22 individual items on the DSRT to content-relatedgrouped items' scores on the DBKT was set atalpha = 0.002 to correct for the high number of testsbeing compared (Shavelson, 1988). The level ofsignificance for the remaining statistical tests wasset at 0.05. The investigator was assisted in theanalyses by a computer analyst and Systat Computerprogram, 1989 was used.Ethical Considerations Prior to implementation of the study, provisionsfor protection of subjects' rights were approved by theUniversity of British Columbia Behaviourial ScienceScreening Committee for Research and other StudiesInvolving Human Subjects. Subjects were informed of theprovisions for protection of their rights in thecovering letter.SummaryThis chapter has described the study sample, theinstruments, the data collection procedure, and theanalysis. Procedures for protection of theparticipants' human rights were also addressed.29CHAPTER FOURPresentation and Discussion of FindingsIntroductionThis chapter is organized into five sections. Thefirst section presents the response rate and the secondpresents the demographic information about thesubjects. In sections three and four, the self-reportedknowledge and skills and actual knowledge of the homecare and acute medical/surgical nurses as measured bythe DSRT and DBKT are presented and discussed. Insection five, the correlations between self-reportedknowledge and skills and actual knowledge about thecare of individuals with diabetes mellitus for homecare and acute medical/surgical hospital nurses aredescribed and discussed.Response RateA total of 161 questionnaires out of a possible300 was returned, a return rate of 53.6%. The acutemedical/surgical hospital nurses returned 74questionnaires, one of which was incomplete, for auseable total of 73 (48.6%). The home care nursesreturned 87 questionnaires, with six incomplete, for auseable total of 81 (54%).30Description of the Samples Years of Nursing Experience The years of experience of the respondents arepresented in Table 1. Years of experience for home carenurses ranged from 2 to 37 with 29.6% (n = 24) in the11 to 15 years range. The years of experience for acutemedical/ surgical hospital nurses ranged from 1 to 36with 28.7% (n = 21) in the 1 to 5 years range. The homecare nurses had more years of experience (X = 16.8)than did the acute medical/surgical hospital nurses(X = 13.1).Table 1Years of Nursing ExperienceSamplesYears^Home Care Nurses^Hospital Nursesn(n=81)% n(n=73)1-5 8 9.8 21 28.76-10 7 8.6 10 13.711-15 24 29.6 13 17.816-20 16 19.7 17 23.221-25 15 18.5 4 5.426-30 10 12.3 3 4.131+ 1 1.2 5 6.831Years Worked in Current SettingThe number of years the respondents had worked intheir current settings are presented in Table 2. Homecare nurses had worked in their respective settingsfrom 1 to 29 years (7 = 7.6). A total of 48.1% of homecare nurses (n = 39) had worked in home care for 1 to 5years.The number of years the acute medical/surgicalhospital nurses had worked in their respective settingsranged from 1 to 25 ( = 7.3). A total of 57.5% ofhospital nurses (n = 42) had worked in acute medical/surgical settings for 1 to 5 years. The two groups wererelatively homogeneous in relation to the number ofyears they had worked in their respective settings.Table 2Years Worked in Current SettingYears SamplesHome Care Nurses^Hospital Nurses(n=81)^(n=73)n^% n^%1-5 39 48.1 42 57.56-10 16 19.7 14 19.111-15 14 17.2 4 5.416-20 11 13.5 7 9.521+ 1 1.2 6 8.23 2Educational BackgroundThe educational backgrounds of the respondents arepresented in Table 3. A total of 59 home care (72.1%)and 56 hospital (76.7%) nurses indicated that a diplomain nursing was their highest educational preparationwhile 22 home care (27.2%) and 17 acute medical/surgical hospital (23.3%) nurses had obtained abaccalaureate degree. One home care nurse had obtaineda degree in public health together with a diploma innursing. None of the respondents indicated they hadobtained a Masters degree in nursing.Table 3Educational BackgroundEducation^ SamplesHome Care Nurses^Hospital Nurses(n=81)^(n=73)n^% nDiploma^59^72.1^56^76.7Baccalaureate^22^27.2^17^23.3Masters^0^0 0^0Other 1^0^0^033Recency of Diabetes EducationThe recency of diabetes education for therespondents is outlined in Table 4. A total of 38.3%of home care nurses (n = 31) had had diabetes educationmore than two years ago and 14.8% (n = 12) had neverattended diabetes classes. A total of 42.4% of acutemedical/surgical hospital nurses (n = 31) indicatedthat it had been more than two years since they hadparticipated in diabetes inservice and 31.5% (n = 23)said they had never attended classes. More home carenurses (46.7%, n = 38) had attended diabetic inserviceswithin the last two years than had hospital nurses(25.9%, n = 19).Table 4Recency of Diabetes EducationMonths/^ SamplesYears Home Care Nurses(n=81)n^%Hospital Nurses(n=73)n^%Never 12 14.8 23 31.5Last 6 Months 14 17.2 4 5.4>6 months <lyr 13 16.0 6 8.2>lyr but <2yrs 11 13.5 9 12.3> 2 years 31 38.3 31 42.434Number of Diabetics Cared for per Month The usual number of diabetics cared for per monthby the respondents is presented in Table 5. A total of77 (95%) of the home care nurses and 72 (98.6%) of theacute medical/surgical hospital nurses cared for one ormore diabetics per month.Table 5Number of Diabetics Cared for per Month Number^ SamplesHome care Nurses^Hospital Nursesn(n=81)% n(n=73)%None 4 4 1 11-3 39 48.1 46 63.04 or more 38 46.9 26 35.6General Competency in Caring for Diabetics The ratings of general competency in caring fordiabetics are presented in Table 6. The two groups weresimilar in their ratings.A total of 77.7% of home care nurses (n = 63)rated themselves competent and 19.7% (n = 16) felt thatthey were very competent in caring for diabetics. Noneof the group indicated she/he was not competent.A total of 73.9% of acute medical/surgical35hospital nurses (n = 54) felt they were competent tocare for diabetics and 23.2% (17) rated themselves asvery competent. None reported being not very competentor not competent.Table 6General Competency in Caring for Diabetics Competency^ SamplesRating Home Care Nurses^Hospital Nurses(n=81)^(n=73)n^% n^%Very Competent 16 19.7 17 23.2Competent 63 77.7 54 73.9Somewhat Competent 1 1.2 2 2.7Not Very Competent 1 1.2 0 0Not Competent 0 0 0 0Self-reported Knowledge and Skills and Actual KnowledgeAmong Home Care Nurses Self-reported Knowledge and Skills Home care nurses' self-reported knowledge andskills related to the care of individuals with diabetesmellitus was measured by the Diabetes Self-Report Tool(DSRT). The DSRT is a 22-item, four-point Likert scaleinstrument that the subjects were asked to completebefore they responded to the Diabetes Basic Knowledge36Test (DEKT).The home care nurses' DSRT scores ranged from 39to 73 with a mean score of 59.9, out of a possible 88.The percentages and numbers of home care nurses whoindicated they had the diabetic knowledge and skillsdescribed in each DSRT item are presented in Table 7.Table 7Percentages and Numbers of Home Care Nurses WhoReported Having the Knowledge and Skills Described inthe DSRTContent Area Self-reported Knowledge(n = 81)%^n1. Etiology I 96.3 782. Etiology II 96.3 783. Treatment I 98.8 804. Treatment II 98.8 805. Surgical Patient 95.3 776. Mild Hypoglycemia 100 817. Severe Hypoglycemia 90.1 738. Urine Testing 97.5 799. "Sick Day" Care 90.1 7310. Actions of Insulin 93.8 7611. Insulin Admin. 98.8 8012. Oral Hypoglycemics 95.1 7737Table 7 (continued)13. DKA 90.2 7314. Stress 82.8 6715. Complications 92.8 7516. Exercise 84.6 6817. Diet Type I 90.1 7318. Diet Type II 95.2 7719. Blood Glucose Test 85.2 6920. Personal Care 95.3 7721. Injection Sites 98.5 8022. Hyperglycemia 98.8 80Over 90% of the home care nurses reported that theypossessed the knowledge and skills related to 19 out of22 items on the DSRT. A range between 82% and 86% ofthe group reported knowledge of and skills in areasincluded in the remaining three DSRT items.Actual Knowledge The home care nurses' actual knowledge about thecare of individuals with diabetes mellitus was measuredby the a 45-item multiple choice instrument called theDBKT. Subjects were asked to fill out the DBKT aftercompletion of the DSRT. The percentages and numbers ofhome care nurses with correct answers for each38individual item on the DBKT are presented in Table 8.Table 8Percentages and Numbers of Home Care Nurses RespondingCorrectly to DBKT Items Content Area^ Correct Responses(N = 81)1. Etiology I 41.9 342. Treatment I 59.2 483. Etiology II 56.8 454. Treatment II 60.5 495. Insulin 88.9 726. Insulin 39.5 327. Severe Hypoglycemia 60.5 498. Blood Glucose Test 67.9 559. Blood Glucose Test 30.9 2510. Urine Testing 41.9 3411. Blood Glucose Test 60.5 4912. Blood Glucose Test 69.1 5613. Urine Testing 80.3 6514. Urine Testing 65.4 5315. Urine Testing 73.3 6116. Insulin 81.2 6617. Insulin 88.9 7218. Insulin Admin. 60.5 49Table 8 (continued)19. Insulin Admin. 72.8 5920. Insulin Admin. 70.4 5721. Oral Hypoglycemics 30.9 2522. Oral Hypoglycemics 56.8 4623. Mild Hypoglycemia 58.0 4724. Hyperglycemia 60.5 4925. Mild Hypoglycemia 72.9 5926. "Sick Day" Care 72.9 5927. DKA 75.3 6128. DKA 69.1 5629. "Sick Day" Care 37.0 3030. Surgical Patient 58.0 4731. Complications 71.6 5832. Stress 69.1 5633. Personal Care 75.1 6134. Personal Care 80.2 6535. Personal Care 70.4 5736. Exercise 66.7 5437. Exercise 56.8 4638. Mild Hypoglycemia 41.8 3439. Diet Type I 71.6 5840. Diet Type II 67.9 553940Table 8 (continued)41. Diet 75.3 6142 Diet Type I 69.1 5643. Diet Type I 70.4 5744. Somogyi Effect 17.3 1445. Injection Sites 27.2 22The home care nurses' DBKT scores ranged from 7 to 43with a mean score of 27.95, out of a possible 45. TheDBKT questions answered correctly most frequently, by88.9% (n = 72) of the home care nurses, were #5 and #17relating to insulin.Only 17.3% of the home care nurses (n = 14)correctly answered item #44 regarding the Somogyieffect. Other DBKT items answered correctly by lessthan 50% of the home care nurses were #1 about theetiology of Type I diabetes (41.9%, n = 34), #6 and #45related to insulin administration (39.5%, n = 32 and27.2%, n = 22, respectively), #9 and #10 regardingblood and urine testing (30.9%, n = 25 and 41.9%,n = 34, respectively), #21 on the duration of oralhypoglycemics (30.9%, n = 25), #29 about insulinrequirement during an acute illness (37.0%, n = 30) and41#38 on how to treat mild hypoglycemia (41.8%, n = 34).The number of home care nurses who answered "I donot know" ranged from 0 to 45. The item to which 45home care nurses answered "I do not know" was question#44 about the Somogyi effect. The other questions towhich the home care nurses most frequently answered "Ido not know" were #10 (17.3%, n = 14) relating to urinetesting; #11 (27.2%, n = 22) about blood glucosemonitoring; #30 (23.6%, n = 19) regarding insulinrequirements for the diabetic surgical patient; and#45 (32.2%, n = 29) pertaining to insulin injectionsites. Question #5, related to the effects of insulinwas the only question to which none of the subjectsresponded "I do not know."Percentages of home care nurses who reportedhaving the knowledge and skills described in the DSRTand of those responding correctly to DBKT items arepresented in Table 9. For the purposes of comparingthe percentages, individual items on the DSRT werematched with single items and/or content-relatedgrouped items on the DBKT, as described by J.A. Drass(personal communication, March 16, 1992) (see AppendixG). Mean percentages were calculated for grouped items.42Percentages for self-reported knowledge and skills(DSRT) were higher than those for actual knowledge(DBKT) in all 22 content areas.As shown in Table 9, large percentages of homecare nurses, ranging between 82.8% and 98.9%, reportedthat they had diabetic knowledge and skills in all 22content areas on the DSRT. However, the DBKTpercentages ranged from 27.2% to 75.2%.Table 9Percentages of Home Care Nurses Who Reported Having theKnowledge and Skills Described in the DSRT and of ThoseResponding Correctly^to DBKT ItemsContent Area DSRT%DBKT%1. Etiology I 96.3 41.92. Etiology II 96.3 56.83. Treatment I 98.8 59.24. Treatment II 98.8 60.55. Surgical Patient 95.3 58.06. Mild Hypoglycemia 100 57.67. Severe Hypoglycemia 90.1 60.58. Urine Testing 97.5 55.69. "Sick Day" Care 90.1 55.010. Actions of Insulin 93.8 74.711. Insulin Admin. 98.8 57.7Table 9 continued12. Oral Hypoglycemics^95.113. DKA^ 90.214. Stress 82.815. Complications^92.816. Exercise^84.617. Diet Type I 90.118. Diet Type II^95.219. Blood Glucose Test^85.220. Personal Care^95.321. Injection Sites^98.522. Hyperglycemia^98.843.972.269.171.661.869.671.657.175.227.246.943There were five areas on the DBKT to which the homecare nurses most frequently answered "I do not know,"but over 85% of them reported that they knew thecontent on the DSRT. These related to urine testing(DSRT = 97.5%, DBKT = 55.6%); blood glucose monitoring(DSRT = 85.2%, DBKT = 57.1%); the surgical diabeticpatient (DSRT = 95.3%, DBKT = 58%); hyperglycemia(DSRT = 98.8%, DBKT = 46.9%) and insulin injectionsites (DSRT = 98.5%, DBKT = 27.2%).In four areas of the DBKT, less than 50% of thehome care nurses responded correctly, but over 95% of44them reported on the DSRT that they possessed theknowledge and skills related to the care of diabetics.These related to the etiology of Type I diabetesmellitus (DSRT = 96.3%, DBKT = 41.9%); oralhypoglycemic agents (DSRT = 95.1%, DBKT = 43.9%);hyperglycemia (DSRT = 98.8%, DBKT = 46.9%) and insulininjection sites (DSRT = 98.5%, DBKT = 27.2%).Self-reported Knowledge and Skills and Actual KnowledgeAmong Hospital Nurses Self-reported Knowledge and Skills Acute medical/surgical hospital nurses' self-reported knowledge and skills related to the care ofindividuals with diabetes mellitus was measured by theDSRT. The subjects were asked to complete the DSRTbefore they responded to the DBKT. The acutemedical/surgical hospital nurses' DSRT scores rangedfrom 37 to 73 with a mean score of 56.3, out of apossible 88.The percentages and numbers of acute medical/surgical hospital nurses who reported they had thediabetic knowledge and skills described in each DSRTitem are presented in Table 10. The three items that98.6% (n = 72) of the nurses indicated that they knew45Table 10Percentages and Numbers of Hospital Nurses Who ReportedHaving the Knowledge and Skills Described in the DSRT Content Area^Self-reported Knowledge(n = 73)%^n1. Etiology I 95.5 702. Etiology II 95.9 703. Treatment I 97.3 714. Treatment II 97.3 715. Surgical Patient 84.9 626. Mild Hypoglycemia 95.9 707. Severe Hypoglycemia 90.4 668. Urine Testing 95.9 709. "Sick Day" Care 79.5 5810. Actions of Insulin 95.9 7011. Insulin Admin. 97.3 7112. Oral Hypoglycemics 94.5 6913. DKA 89.0 6514. Stress 79.4 5815. Complications 93.1 6816. Exercise 80.9 5917. Diet Type I 87.3 6418. Diet Type II 86.2 6319. Blood Glucose Test 75.3 5546Table 10 (continued)20. Personal Care 98.6 7221. Injection Sites 98.6 7222. Hyperglycemia 98.6 72about and had skills related to instructing patients ondaily personal care, selecting insulin injection sitesand managing the nursing care of a diabeticexperiencing hyperglycemia. Only 75.3% (n = 55) of thegroup reported knowing and having skills related toperforming one method of blood glucose monitoring.Actual Knowledge The acute medical/surgical hospital nurses' actualknowledge about the care of individuals with diabetesmellitus was measured by the DBKT. The subjects wereasked to fill out the DBKT after completion of theDSRT. The percentages and numbers of acute medical/surgical hospital nurses with correct answers for eachindividual item on the DBKT are presented in Table 11.The nurses' DBKT scores ranged from 13 to 41 witha mean score of 28.6, out of a possible 45. The DBKTquestion answered correctly most frequently, 90.4%(n = 66) of the hospital nurses, was #33 relating topersonal care. Only 19.2% of the hospital nurses47Table 11Percentages and Numbers of Hospital Nurses RespondingCorrectly to DBKT ItemsContent Area Correct Responses(N = 73)%^n1. Etiology I 34.2 252. Treatment I 68.4 503. Etiology II 64.4 474. Treatment II 64.4 475. Insulin 78.1 576. Insulin 50.7 377. Severe Hypoglycemia 63.0 468. Blood Glucose Test 60.3 449. Blood Glucose Test 27.4 2010. Urine Testing 45.2 3311. Blood Glucose Test 45.2 3312. Blood Glucose Test 45.2 3313. Urine Testing 71.2 5214. Urine Testing 56.2 4115. Urine Testing 80.8 5916. Insulin 86.3 6317. Insulin 86.3 6318. Insulin Admin. 57.5 42Table 11 (continued)19. Insulin Admin. 75.3 5520. Insulin Admin. 67.1 4921. Oral Hypoglycemics 27.4 2022. Oral Hypoglycemics 60.2 4423. Mild Hypoglycemia 68.5 5024. Hyperglycemia 67.1 4925. Mild Hypoglycemia 69.9 5126. "Sick Day" Care 79.5 5827. DKA 87.7 6428. DKA 57.5 4229. "Sick Day" Care 57.5 4230. Surgical Patient 67.1 4931. Complications 69.9 5132. Stress 72.6 5433. Personal Care 90.4 6634. Personal Care 79.4 5835. Personal Care 64.4 4736. Exercise 84.9 6237. Exercise 68.5 5038. Mild Hypoglycemia 45.2 3339. Diet Type I 73.9 5440. Diet Type II 67.1 494849Table 11 (continued)41. Diet 73.9 5442 Diet Type I 72.6 5343. Diet Type I 54.8 4044. Somogyi Effect 19.2 1445. Injection Sites 20.5 15(n = 14) correctly answered item #44 regarding theSomogyi effect. Other DBKT items answered correctly byless than 50% of the hospital nurses were #1 about theetiology of Type I diabetes (34.2%, n = 25), #6 and #45related to insulin administration (50.7%, n = 37 and20.5%, n = 15, respectively), #9, #10, #11 and #12regarding blood and urine testing (27.4%, n = 20,45.2%, n = 33, 45.2%, n = 33, and 45.2%, n = 33,respectively), #21 on the duration of oralhypoglycemics (27.4%, n = 20), and #38 on how to treatmild hypoglycemia (45.2%, n = 33).The number of hospital nurses who answered "I donot know" ranged from 0 to 46. Item #44 regarding theSomogyi effect was the question to which the largestnumber (46) answered "I do not know."The other questions to which the hospital nurses50most frequently answered "I do not know" were #10(28.3%, n = 21) relating to urine testing; #11 (42.5%,n = 31) about blood glucose monitoring; #30 (38.2%,n = 28) regarding insulin requirements for the diabeticsurgical patient; and #45 (26.8%, n = 20) pertaining toinsulin injection sites. Questions #5 and #6 related tothe effects of insulin and questions #34 and #35 aboutpersonal care were the items to which none of thehospital nurses responded "I do not know."Percentages of hospital nurses who reported havingthe knowledge and skills described in the DSRT and ofthose responding correctly to DBKT items are presentedin Table 12. For the purposes of comparing thepercentages, individual items on the DSRT were matchedwith single items and/or content-related grouped itemson the DBKT, as described by J.A. Drass (personalcommunication, March 16, 1992). Mean percentages werecalculated for grouped items. Percentages for self-reported knowledge (DSRT) were higher than those foractual knowledge (DBKT) in all 22 content areas.As shown in Table 12, large percentages ofhospital nurses ranging between 75.3% and 98.6%reported that they had diabetic knowledge and skills51Table 12Percentages of Hospital Nurses Who Reported Having the Knowledge and Skills Described in the DSRT and of ThoseResponding Correctly to DBKT Items Content Area^ DSRT^DBKT1. Etiology I 95.5 34.22. Etiology II 95.9 64.43. Treatment I 97.3 68.44. Treatment II 97.3 64.45. Surgical Patient 84.9 67.16. Mild Hypoglycemia 95.9 61.27. Severe Hypoglycemia 90.4 63.08. Urine Testing 95.9 54.59. "Sick Day" Care 79.5 68.510. Actions of Insulin 95.9 75.411. Insulin Admin. 97.3 55.112. Oral Hypoglycemics 94.5 43.813. DKA 89.0 72.614. Stress 79.4 72.615. Complications 93.1 69.916. Exercise 80.9 76.717. Diet Type I 87.3 68.718. Diet Type II 86.2 70.5Table 12 (continued)19. Blood Glucose Test20. Personal Care21. Injection Sites22. Hyperglycemia75.398.698.698.644.578.120.555.852in all 22 content areas on the DSRT. However, the DBKTpercentages ranged from 20.5% to 78.1%. There were fiveareas on the DBKT to which the acute medical/surgicalhospital nurses most frequently answered "I do notknow," but over 75% of them reported that theypossessed the knowledge and skills on the DSRT. Theserelated to urine testing (DSRT = 95.9%, DBKT = 54.5%);blood glucose monitoring (DSRT = 75.3%, DBKT = 44.5%);the surgical diabetic patient (DSRT = 84.9%, DBKT =67.1%); hyperglycemia (DSRT = 98.6%, DBKT = 55.8%); andinsulin injection sites (DSRT = 98.6%, DBKT = 20.5%).In three areas of the DBKT, less than 50% of thehospital nurses responded correctly, but over 94% ofthem reported on the DSRT that they possessed theknowledge and skills. These related to the etiology ofType I diabetes (DSRT = 95.5%, DBKT = 34.2%); oralhypoglycemic agents (DSRT = 94.5%, DBKT = 43.8%); andinsulin injection sites (DSRT = 98.6%, DBKT = 20.5%).53Over 90% of the home care nurses reported thatthey possessed the knowledge and skills in 19 of the 22DSRT items but scored much lower on the DBKT. The twoitems that most of them answered correctly related toinsulin yet the group scored low on the question aboutinsulin injection sites, an important aspect ofdiabetic care.The DSRT item about which most hospital nursesreported knowing the least or having the least skill inrelated to performing blood glucose monitoring which issurprising because it is a common nursing procedureperformed frequently on medical/ surgical units. One ofthe DSRT items hospital nurses reported knowing mostabout related to selecting insulin injection sites yetit was one of the items most of them answeredincorrectly on the DBKT.Home care nurses reported having more knowledgeand skills about diabetic care than did the hospitalnurses, but the hospital nurses scored slightly higheron the DBKT. Home care nurses had attended diabeticinservice education more recently than hospital nursesand this may have influenced their perceptions of theirknowledge and skills.54Basically, the knowledge deficits suggested inthis study were in the same content areas for bothgroups of nurses, but the hospital nurses scored loweron more items related to blood and urine testing thandid the home care nurses. Some hospitals in BritishColumbia employ technicians to perform blood glucosemonitoring and nurses may, therefore, not know theskill. Urine testing is not done as routinely as itonce was in diabetic care, although it still isnecessary when checking for ketosis. Thus, hospitalnurses may not have current experience in this area.Both groups scored lowest on the items about theSomogyi effect and insulin injection sites. These areboth critical aspects in the care of individuals withdiabetes mellitus and lack of knowledge may haveprofound consequences for patient care.The DBKT items to which both groups of nurses mostfrequently responded "I do not know" were also theitems on the DSRT for which over 85% reported havingknowledge and skills. One might assume that afterreading the specific DBKT questions, the nursesrealized they did not know the answers. Both groups ofnurses' apparent lack of recognition of gaps in55knowledge and skills prior to their completing the DBKTmay indicate that they are making false assumptionsabout their educational needs and may, therefore, notbe making efforts to update their knowledge base. Boththe home care and the acute medical/surgical hospitalnurses rated their diabetic knowledge and skills asextremely high in all areas on the DSRT, yet achievedlower scores on the multiple choice test (DBKT). Thissuggests that the nurses may unwittingly be providingless than optimal patient care.The DBKT mean scores of 28.6 (63.5%) for hospitalnurses and 27.95 (62.1%) for the home care nursesreflect their actual knowledge. These scores aresimilar to that of 28.6 (64%) reported in the Drass etal. (1989) study, but slightly lower than thosereported in another study that investigated hospitalnurses' diabetic knowledge. A total of 137medical/surgical nurses scored 74% on the almostidentical diabetic knowledge test developed byScheiderich et al.(1983).The major knowledge deficits suggested by the datafor the both the home care and acute medical/surgicalhospital nurses were in the areas of the Somogyi56effect, the etiology of Type I diabetes, insulinadministration, blood and urine testing, oralhypoglycemics, and treatment of mild hypoglycemia.These findings are consistent with those of Drass etal. (1989) who reported that over 58% of hospitalnurses studied demonstrated a lack of knowledge in allthe foregoing areas. Scheiderich et al.(1983) alsofound knowledge gaps in the content related to insulinadministration and treating hypoglycemia.The self-reported knowledge and skills level(DSRT X = 59.9) for home care nurses was found to be12.9 points higher than in the Drass et al. (1989)study. It should be noted that all subjects in theDrass et al. (1989) study were hospital nurses and notfrom home care settings. The hospital nurses' self-reported knowledge and skills level (DSRT )7 = 56.3) was9.7 points higher than that in the Drass et al. (1989)study.Knowledge deficits, such as those suggested inthis study could have serious consequences for patientcare related to patient/family teaching, preventing andmanaging short- and long-term complications of diabetesmellitus and providing day-to-day care for the diabetic57patient/family. Critical implications for patients withdiabetes mellitus if the nurse lacks knowledge aboutdiabetes Type I etiology may include inadequatecollection of assessment data and incorrectpatient/family teaching. Lack of knowledge about theduration of action for oral hypoglycemic agents canlead to unrecognised and, therefore, untreated glycemicreactions that can have serious short- and long-termconsequences for patients with diabetes mellitus.Injecting insulin into improper sites can alterabsorption rates and lead to numerous physical andpsychological complications.Interpreting urine glucose tests and accuratelyperforming blood glucose monitoring are common nursingprocedures and considered the foundation for planningdiabetic care. Yet approximately 50% of the home careand acute medical/surgical hospital nurses did notanswer these questions correctly. Patients who are athome trying to cope with diabetes mellitus often relysolely on the home care nurse as their link to thehealth care system. If the nurse lacks knowledge,patients may become critically ill in their homes, notreceive the appropriate care, and may ultimately58require hospitalization to help control the disease. Alack of knowledge by both home care and hospital nursesrelated to the Somogyi effect and the treatment of mildhypoglycemia can lead an individual with diabetesmellitus into severe rebound hyperglycemia and avicious cycle of hypo- and hyperglycemic reactions.Correlations Between Self-reported Knowledge and Skills and Actual Knowledge For Home Care and Hospital Nurses Each nurse's DSRT score was correlated with theDBKT score to obtain a Pearson product-momentcorrelation for the group. For the purposes ofcorrelating content-related scores for both home careand hospital nurses, individual items on the DSRT werematched with single items and/or content-relatedgrouped items on the DBKT. A single DBKT mean score wasderived from content-related grouped items' scores byaveraging the scores of the content-related DBKT items.Home Care Nurses A statistically significant correlation(r = 0.44, p = 0.000) was found between the DSRT andthe DBKT scores for the home care nurses (Shavelson,1988). The correlations between the 22 individualscores on the DSRT and the averaged mean scores on the59DBKT were not significant.The statistically significant, positivecorrelation between the DSRT and the DBKT scores forhome care nurses is inconsistent with the findings ofDrass et al. (1989) in which the correlation wasnegative. However, their study did not include homecare nurses.Hospital Nurses There was no correlation between the DSRT and theDBKT scores for the hospital nurses. The correlationsbetween the 22 individual scores on the DSRT and thescores or averaged mean scores on the DBKT were notsignificant.The significant correlation between the DSRT andthe DBKT mean scores for home care nurses may berelated to the recency of diabetic education. Homecare nurses had participated in diabetic inserviceeducation more recently than the acute medical/surgicalhospital nurses had, possibly giving the home carenurses a more accurate perception of their actualknowledge level.60SummaryThe home care and acute medical/surgical hospitalnurses were similar with regard to the demographic dataexcept for years of nursing experience and recency ofdiabetic education. The home care nurses had moreyears of nursing experience and had attended diabeticinservice education more recently than had the hospitalnurses.Both home care and acute medical/surgical hospitalnurses reported responses on the DSRT that were higherthan their responses on the DBKT for all 22 contentareas. Most nurses reported knowing about the etiologyof Type I diabetes, oral hypoglycemic agents andinsulin injection sites; however, only a smallpercentage of nurses answered these questions correctlyon the DBKT.The areas in which both groups of nurses scoredthe lowest on the DBKT were the Somogyi effect,etiology of Type I diabetes, insulin administration,urine and blood glucose testing, oral hypoglycemicagents and treating mild hypoglycemia. The areas inwhich both groups of nurses scored the highest on theDBKT were those related to diabetic complications, the61effects of stress, the diabetic diet, personal care,actions of insulin, and diabetic ketoacidosis.There was a statistically significant correlationbetween DSRT and DBKT scores for home care nurses, butno correlation between scores for the hospital nurses.62Chapter FiveSummary, Conclusions and Implications For NursingSummaryThis descriptive correlational study was designedto describe the relationship between the self-reportedknowledge and skills and actual knowledge about thecare of individuals with diabetes mellitus for nursesworking in home care settings and acute medical/surgical hospital units.A review of the literature indicated that staffdevelopment nurse educators frequently use self-assessment techniques to identify nurses' self-reportedknowledge as a basis for program planning. However,there was little research demonstrating that nurses'self-reported knowledge is an accurate reflection oftheir actual knowledge. Given these findings, staffdevelopment educators who plan nursing inserviceeducation using data gathered from nurses' self-assessments may not be basing their educationaldecisions on nurses' actual knowledge needs. It iscrucial that nurse educators use methods thataccurately diagnose nurses' educational needs to helpensure relevant inservice education that fosters63competent nursing care for patients in the hospital andat home.Hospital nurses' knowledge about diabetes mellitushas been examined, but no published research was foundregarding home care nurses' diabetic knowledge. Homecare nurses should have adequate knowledge to nursediabetics because, with increased patient acuity andearly hospital releases, patients are being dischargedfrom hospital with the need for substantial, continuouscare by home care nurses.Data were gathered using a Demographic Data Sheet,the Diabetes Self-Report Tool (DSRT) and the DiabetesBasic Knowledge Test (DBKT). The three instruments weremailed to a random sample of 150 home care and 150acute medical/surgical hospital nurses through thecomputerized registry of the RNABC. A total of 81 homecare and 73 acute medical/surgical hospital nursesreturned the completed instruments for a response rateof 51.3%.Means, percentages and ranges were used todescribe the demographic data and the DBKT and DSRTresults. The Pearson product-moment correlationcoefficient was utilized to determine the relationship64between the nurses' scores on the DSRT and the DBKT.Demographic data revealed that the home carenurses had more years of nursing experience than theacute medical/surgical hospital nurses. The majority ofboth the home care and hospital nurses had neverattended diabetic inservice education or had attendedinservice more than two years ago. However, home carenurses had taken part in diabetic inservice educationmore recently than the acute medical/surgical hospitalnurses.The home care nurses' self-reported knowledge andskills (DSRT) scores ranged from 39 to 73 with a meanscore of 59.0, out of a possible 88. DBKT scoresranged from 7 to 43 with a mean score of 27.96, out ofa possible 45. The two DBKT items answered correctlymost often (88.9%) by the home care nurses concernedthe effects of insulin. Only 17.3% of the home carenurses answered the item related to the Somogyi effectcorrectly.Hospital nurses' self-reported knowledge andskills (DSRT) scores ranged from 37 to 73 with a meanscore of 56.3, out of a possible 88. The hospitalnurses' actual knowledge (DBKT) scores ranged from 1365to 41 with a mean score of 28.6, out of a possible 45.The DBKT item answered correctly most often (90.4%) bythe acute medical/surgical hospital nurses concerneddaily personal care. Only 19.2% of the hospital nursescorrectly answered the item related to the Somogyieffect.It should be noted that the DSRT and DBKT may notdirectly correspond. The DSRT asks the nurse toappraise her/his own knowledge and skills associatedwith the care of individuals with diabetes mellitus.The DBKT is concerned only with the nurse's knowledge.Low scores on the DBKT are not necessarily conclusiveevidence of a knowledge deficit but may instead beindicative of other factors such as difficulties withthe format of the instrument or problems withindividual test items.There was a positive, statistically significant,moderate correlation between the DSRT and DBKT scoresfor home care nurses. There was no relationship betweenthe scores for hospital nurses. None of thecorrelations between individual item scores on theDSRT and scores or averaged mean scores for content-related item/s on the DBKT was statistically66significant for either home care and hospital nurses.Conclusions The following conclusions can be drawn from the studyfindings:1. Responses on the DSRT for home care andhospital nurses suggest that the nurses believe thatthey know more about the care of individuals withdiabetes mellitus than indicated by their responses onthe DBKT.2. Scores on the DBKT for both home care andhospital nurses suggest a lack of knowledge inimportant areas about the care of individuals withdiabetes mellitus.3.^In certain situations, nurse educators shouldprobably not rely solely on nurses' self-reportedknowledge in planning educational programs.Implications for NursingNursing EducationThe findings of this study have severalimplications for nursing education. The economicconstraints in health care today demand that nursingeducators plan programs based on accurate assessmentsof educational needs. This study suggests that nursing67educators cannot rely solely on nurses' self-assessments for planning diabetic education.The findings also reinforce the need for regulareducational updates every one to two years for bothhome care and acute medical/surgical hospital nursesworking with individuals with diabetes mellitus. Nurseeducators must also ensure that educational resourcessuch as patient care manuals and textbooks are readilyaccessible and kept up to date so those nurses who lackknowledge can still provide safe patient care.Educational programs should address the actualeducational needs of the nurses being served.Nursing Practice Nurses involved in the care of individuals withdiabetes mellitus can influence diabetics' self-carepractices by demonstrating current and accurateknowledge about diabetes mellitus. Knowledge deficits,such as those suggested by the findings of this study,can have serious consequences for diabetic patients andfamilies. Home care and acute medical/surgical hospitalnurses should realize they may lack knowledge in theseareas and utilize all available resources such asmedication and policy manuals, textbooks and clinical68experts to ensure that safe care is being provided toindividuals with diabetes mellitus. Awareness of suchknowledge deficits may motivate the nurses to accessand participate in appropriate educational resources.Both home care and hospital nursing administratorsshould be committed to supporting diabetes educationalprograms for nurses employed in those settingsconsidering the number of individuals with diabetesmellitus requiring health care and the potentiallynegative impact that the home care and hospital nurses'lack of knowledge could have on the quality of care andthe welfare of patients.Nursing ResearchBased on the findings of the study, the followingare recommendations for further research:1. Administer the instruments in a controlledsetting with a similar sample and compare the resultsto the Drass et al. (1989) and Scheiderich et al.(1983) studies.2. Study the effect of the testing procedureitself on recognition of knowledge deficits.3.^Examine the validity of the DSRT and DBKTbeyond the content validity established by the69developers.4. Study the relationship between nursingperformance and responses on the DSRT and DBKT.5. Study the relationship of nurses' knowledgeabout diabetes mellitus to the self-care practices ofdiabetics.6. Replicate this study with nurses from otherclinical areas such as ambulatory care, critical careand long term care.7. Study the predisposing factors that maycontribute to the differences between self-reported andactual knowledge of nurses.This study has described home care and acutemedical/surgical hospital nurses' self-reportedknowledge and skills and actual knowledge about thecare of individuals with diabetes mellitus. Both groupsof nurses' reported their knowledge and skills ashigher than actual knowledge scores and the findingssuggest that both groups had knowledge deficits in anumber of areas that could have a major impact onpatient care.70ReferencesAbbott, S. D., Carswell, R., McGuire, M. & Best, M.(1988). Self-evaluation and its relationship toclinical evaluation. Journal of NursingEducation, 27(5), 219-224.Baasch, L. A. (1988). Assessing the integrated approachto diabetes patient education: A case study.Patient Education and Counseling, 12, 199-212.Bailey, R. C. & Shaw, W. R. (1971). Direction of self-estimate of college ability. Psychological Reports, 29, 959-964.Banfield, V.A., Brooks, E., Brown, J., Mason,B.P.,Miller, D.M., Smith, D.L. and Wong, P. (1990). Astrategy to identify the learning needs of staffnurses. Journal of Continuing Education inNursing, 21(5), 209-211.Bille, D. A. (1982). Staff development: A systemsapproach. Thorofare, NJ: Charles Slack.Chase, C. I. (1978). Measurement for educationalevaluation. Don Mills, Ont: Addison-Wesley.Copel, L. C. & Smith, M. E. (1989). Oncology nurses'knowledge of graft-versus-host disease in bonemarrow transplant patients. Cancer Nursing, 12(4),243-249.de Weerdt, I., Visser, A. P. & van der Veen, E. A.(1989). Attitude behavior theories and diabeteseducation programs. Patient Education andCounseling, 14, 3-19.Dunn, S.M. (1986). Reactions to educational techniques.Diabetes Medicine, 3(1), 419-429.Drass, J. A., Muir-Nash, J., Boykin, P. C., Turek, J.M. & Baker, K.L. (1989).Perceived and actuallevels of knowledge of diabetes mellitus amongnurses.^Diabetes Care, 12(5), 351-356.71Dyche, J. (1988). Educational program development for employees in health care agencies. Murfreesboro,TN: Tr-Oak.Farb, J. L. & Werbel, J. D. (1986). Effects of purposeof the appraisal and expectation of validation onself-appraisal leniency. Journal of AppliedPsychology, 71(3), 527-529.Feustel, D.E. (1976). Nursing students' knowledge aboutdiabetes mellitus. Nursing Research, 25(1), 4-8.Fox, S. & Denuir, Y. (1988). Validity of self-assessment; A field study. Personnel Psychology, 41, 581-592.Gronlund, N. E. & Linn, R. L. (1990). Measurement andevaluation in teaching. (6th ed.). New York:Collier Macmillan.Janz, M. (1992). Perception of knowledge: What nursingadministrators and nurses know. Journal of Gerontological Nursing, 18(8), 7-12.Keating, S. B. & Kelman, G. B. (1988). Home health carenursing. Philadelphia: Lippincott.Knowles, M. S. (1970). The modern practice of adulteducation. New York: Cambridge.Knowles, M. S. (1980). The modern practice of adulteducation: Revised and updated. New York:Cambridge.Knowles, M. S. (1985). Applications in continuingeducation for health professions. Mobius, 5(2),80-100.Kristjansen, L. J. & Scanlan, J. M. (1989). Assessmentof continuing nursing educational needs: Aliterature review. Journal of Continuing Education in Nursing, 20(3), 118-123.Leichter, S. B. (1986). Diabetes patient education inhospital settings. The Diabetes Educator,12(3), 277-279.72Linn, B. S., Arostequi, M. & Zeppa, R. (1975).Performance rating scale for peer and self-assessment. British Journal of Medical Education, 9, 98-100.Lowman, R. L. (1987). Validity of self-ratings ofabilities and competencies. Journal of Vocational Behavior, 31, 1-13.Mabe, P. A. & West, S. G. (1982). Validity of self-evaluation of ability: A review and meta analysis.Journal of Applied Psychology, 67(3), 280-296.Mazzuca, S. A., Moorman, N. H., & Wheeler, R. D.(1986). The diabetes education study: A controlledtrial of the effects of diabetes patienteducation. Diabetes Care, 9(1), 1-10.MacDonald, R. I. & Grogin, E. R. (1991) Personalaccounts of satisfying and unsatisfying nursingexperiences as a needs assessment strategy. TheJournal of Continuing Education in Nursing, 22(1), 11-15.Monette, M. L. (1977). The concept of educational need:An analysis of selected literature. Adult Education, 27(2), 116-127.Moriarty, D. R. & Stephens, L. C. (1990). Factors thatinfluence diabetes patient teaching by hospitalstaff nurses. The Diabetes Educator, 16(1), 31-35.Morton, J. & MacBeth, W. (1977). Correlations betweenstaff, peer and self-evaluation. Medical Education11, 167-170.Peyrot, M. & McMurray, J.F. (1985). Psychosocialfactors in diabetic control. HealthPsychology, 6, 542-547.Popham, W. J. (1990). Modern educational measurement: Apractitioner's perspective. (2nd ed.). EnglewoodCliffs, NJ: Prentice Hall.73Ross, G. (1990). Developing a quality assurance programin an outpatient diabetes centre. Beta Release,14(4), 107-110.Registered Nurses Association of British Columbia.(1990). Standards for nursing practice in BritishColumbia. Vancouver,BC: AuthorScheidrich, S. D., Freibaum, C. N. & Peterson, L. M.(1983). RNs' knowledge about diabetes mellitus.Diabetes Care, 6(4), 57-61.Shavelson, R. J. (1988). Statistical reasoning for thebehavioral sciences. (2nd ed.) Toronto:Allyn & Bacon.Stuff lebeam, D. L., McCormick, C. H., Brinkerhoff, R.O.& Nelson, C. 0. (1985). Conducting educational needs assessment. Boston: Kluwer Nijhoff.Teza, S. L., Davis, W. K. & Hiss, R. G. (1988). Patientknowledge compared to national guidelines fordiabetes care. The Diabetes Educator, 14(3),207- 211.Vanetzian, E. V. & Higgins, M. G. (1990). A comparisonof new graduate and evaluator appraisals ofnursing performance. Journal of NursingEducation, 29(6), 269-275.Veroba, M. & West, R. (1986). Diabetes in Canada: Areview. Chronic Diseases in Canada, 7(3), 55-58.Watts, F.N. (1980). Behavioral aspects of themanagement of diabetes mellitus. Behavioral Research Therapy, 18(6), 171-180.Woods, N. F. & Catanzaro, M. (1988). Nursing research: Theory and practice. Toronto: Mosby.Appendix ADiabetes Self-Report Tool7475Diabetes Self-Report ToolbyJ. Drass RN, BSN^K. Baker RN, BSNP. Boykin RN, MSN J. Muir-Nash RN, BSNA. Schafer RD J. Turek RN, MSNDO NOT DUPLICATE WITHOUT PERMISSION OF AUTHORS.Instructions: 1. Please answer ALL the questions.2. Please CIRCLE the appropriate response to eachstatement. Please be as honest as you can inevaluating your knowledge and skills in caringfor individuals with diabetes3. Once you have completed this questionnaire,seal it in the envelope marked "Document #1"and then open the envelope marked "Document #2"and complete that questionnaire.4 = strongly agree^3 = agree2 = disagree^ 1 = strongly disagree1. I can describe the etiology of Type I diabetes.1^2^3^42. I can describe the etiology of Type II diabetes.13. I can describe the basic treatment plan forType I diabetes.14. I can describe the basic treatment plan forType II diabetes.^ 15. I can identify the nursing needs of thediabetic patient undergoing surgery.^12 3 42 3 42 3 42 3 476Diabetes Self-Report Tool4 = strongly agree^3 = agree2 = disagree^ 1 = strongly disagree6. I can manage the nursing care of a diabeticexperiencing mild hypoglycemia.^1^2^3 47. I can manage the nursing care of a diabeticwith loss of consciousness.^1^2^3^48. I can interpret urine results for a diabetic.1^2^3^49. I can instruct a diabetic on self-caremanagement for a "sick day".^1^2^310. I can describe the action and effect of insulin.41 2 3 411. I can list the steps of the procedure foradministering insulin.1 2 3 412. I can describe the action and effect oforal hypoglycemic agents.1 2 3 413. I can assess the diabetic for the developmentof diabetic ketoacidosis.1^2 3 414. I can explain how stress affects diabetescontrol.1 2 3 415. I can identify the long-term complicationsassociated with diabetes.1 2 3 477Diabetes Self-Report Tool4 = strongly agree^3 = agree2 = disagree^ 1 = strongly disagree16. I can explain how exercise affectsdiabetes control.1 2 3 417. I can describe the diet recommended forType I diabetes.1 2 3 418. I can describe the diet recommended forType II diabetes.1 2 3 419. I can perform one method of bloodglucose monitoring.1 2 3 420. I can instruct a diabetic on daily personalcare.1^2 3 421. I can identify three sites for insulinadministration.1 2 3 422. I can manage the nursing needs of thediabetic patient experiencinghyperglycemia without ketosis.^1 2 3 4Appendix BDiabetes Basic Knowledge Test7879Diabetes Basic Knowledge TestbyJ. Drass RN, BSN^K. Baker RN, BSNP. Boykin RN, MSN J. Muir-Nash RN, BSNA. Schafer RD J. Turek RN, MSNDrass,J.A., Muir-Nash,J., Boykin,P.C., Turek, J.M. andBaker, K.L. (1989).Perceived and actual levels ofknowledge of diabetes mellitus among nurses.Diabetes Care,12(5),351-356.Instructions: 1. Please answer ALL the questions.2. For each item, select the one bestanswer to the question.3. Circle the letter for your answer onthe separate answer sheet provided.4. The last answer to each question, "Ido not know" should be used only ifyou truly do not know the answer.For example, you would choose "I do notknow" if:a) you could not logically reason outwhich is the correct response orb) all other responses would be pureguesses for you.5. Once you have completed thisquestionnaire, place all the completedquestionnaires in the stamped,preaddressed envelope and mail it tome.Thank you for your cooperation.DO NOT DUPLICATE WITHOUT PERMISSION OF AUTHORS.Source of test: The Diabetes Basic Knowledge Test is amodified version of the "DiabetesKnowledge Test" by S. Scheiderich etal. (1983)80Diabetes Basic Knowledge Test1. Which statement is characteristic of the etiology ofType I diabetes?a. Strongly associated with obesity.b. Predominately genetic.c. Autoimmune, viral or toxic destruction of the betacells.d. I do not know.2. Which of these statements about the management of TypeI diabetes is true?a. Insulin injections are necessary to maintain life.b. Insulin injections are not always necessary if dietand exercise are well controlled.c. Oral hypoglycemic agents are sufficient for bloodcontrol in most patients.d. I do not know.3. Which statement is characteristic of the etiology ofType II diabetes?a. Predominately non-genetic.b. Frequently associated with obesity and resistance toinsulin.c. Autoimmune, viral or toxic destruction of the betacells.d. I do not know.4. Which of these statement about management of Type IIdiabetes is true?a. Insulin injections are necessary to maintain life.b. A controlled diet and exercise program is the mosteffective treatment.c. Oral hypoglycemic agents are always effective.d. I do not know.5. What effect does insulin have on blood glucose?a. Insulin causes blood glucose to increase.b. Insulin causes blood glucose to decrease.c. Insulin has no effect on blood glucose.d. I do not know.81Diabetes Basic Knowledge Test6. Which are the physiological actions of insulin?1. Transports glucose across cell membrane for useby the cells2. Enhances the formation of proteins from aminoacids3. Enhances the breakdown of fats for energya. 1 & 2.b. 1, 2 &^3.c. 2 & 3.d. I do not know.7. If a known diabetic is found unresponsive, which ofthese assumptions about the person's blood glucose shouldguide your initial actions?a. It may be very high.b. It may be very low.c. It may be normal.d. I do not know.8. Normal fasting blood glucose level can best bedescribed asa. Below 8.3 mmo1/1.b. Between 5.5 and 11.1 mmo1/1.c. Between 3.8 and 6.6 mmo1/1.d. I do not know.82Diabetes Basic Knowledge Test9. Which of the following affect the accuracy andprecision of tests results obtained with most of theblood glucose monitoring strips?1. Size and placement of the blood sample on thereagent pad.2. Timing of the test.3. Method of removal of blood from the reagentpad.4. The patient's haematocrit level.a. 1, 2 & 3.b. 1, 2 & 4.c. 1, 2, 3 & 4.d. I do not know.10. What would a negative urine glucose test indicateabout the blood glucose level in a diabetic with a normalrenal threshold?a. It is less than 10 mmo1/1.b. It is more than 11.1 mmo1/1c. It is less than 3.3 mmo1/1.d. I do not know.11. Which of the following tests can determine thepatient's average blood glucose over an extended periodof time?a. Glycosylated haemoglobin.b. Plasma Renin Activity.c. Insulin antibodies.d. I do not know.83Diabetes Basic Knowledge Test12. Which of these statements indicate one of the bestreasons for utilizing blood glucose monitoring ratherthan urine testing?a. Drugs such as penicillin, ASA, cephalosporins, andbarbiturates can create falsely negative urine testsresults.b. Urine retention and changes in kidney function canincrease the lag time between blood glucose rise andspill over of glucose into the urine.c. The diagnosis of diabetes can be more readilyconfirmed at the patient's bedside than bylaboratory testing.d. I do not know.13. A "double voided" urine specimen can best bedescribed as:a. Urine that is collected and tested 30 to 60 minutesafter the bladder has been emptied.b. Urine that is collected and tested twice a day, inthe morning and at bedtime.c. Urine that is collected and tested twice before theresult is recorded.d. I do not know.14. When should well controlled diabetics always checktheir urine for ketone?a. Whenever exercising.b. Whenever testing urine for glucose.c. Whenever urine glucose is 2% or blood glucose isgreater than 13.3 mmo1/1.d. I do not know.84Diabetes Basic Knowledge Test15. What should a diabetic do when he/she has beenshowing 2% urine glucose or blood glucose greater that13.3 mmo1/1 for two consecutive days and now has positiveketone urine tests?a. Omit the next dose of insulin or oral hypoglycemicmedication and test urine/blood as usual.b. Call the doctor, continue to test urine/blood everyfour hours or as directed by a physician andcontinue insulin or oral hypoglycemia medication.c. Continue with insulin or oral hypoglycemiamedication and urine/blood testing as usual. Theseare normal for diabetics.d. I do not know.16. The maximum effect (peak) of regular insulin occursa. 2-4 hours after injection.b. 8-12 hours after injection.c. 24-28 hours after injection.d. I do not know.17. The maximum effect (peak) of both NPH and Lenteinsulin occursa. 2-4 hours after injection.b. 8-12 hours after injection.c. 24-28 hours after injection.d. I do not know.18. Where should one store insulin that is PRESENTLYbeing used?a. In the fridge near the freezer.b. In the fridge away from the freezer.c. At room temperature and away from excess light.d. I do not know.85Diabetes Basic Knowledge Test19. A diabetic contaminates the needle while preparing aninsulin injection. What would be the best action to take?a. Dispose of needle even if this means disposing ofthe insulin and syringe and starting preparationfrom the beginning.b. Wipe the needle with an alcohol sponge and continuepreparing the injection.c. Continue preparing the injection but wipe theinjection site thoroughly with alcohol.d. I do not know.20. When short-acting (regular) and intermediate-acting(NPH) are ordered to be given by injection at the sametime, the nurse should:a. Use separate syringes to administer each insulin.b. Mix them in the same syringe drawing up theintermediate-acting insulin first.c. Notify the doctor since these two insulins are notcompatible.d. Mix them in the same syringe drawing up the short-acting first.e. I do not know.21. The duration of action of chlorpropamide (Diabinese)isa. 6-12 hours.b. 12-24 hours.c. 24-60 hours.d. I do not know.22. Which is NOT a reported side effect of oralhypoglycemic agents?a. Gastrointestinal upset.b. Allergic reaction.c. Skin rash.d. Constipation.e. I do not know.86Diabetes Basic Knowledge Test23. A symptom of hypoglycemia (low blood sugar) isa. Frequent urination.b. Dry mouth and dry skin.c. Nervousness.d. I do not know.24. A symptom of hyperglycemia (high blood sugar) isa. Frequent urination.b. Low grade fever.c. Cool, clammy skin.d. I do not know.25. What is one cause of hypoglycemia (low blood sugar)in a diabetic who is taking insulin or oral hypoglycemicagents?a. Skipping a meal.b. Emotional stress.c. Too little exercise.d. I do not know.26. What is one cause of hyperglycemia (high bloodsugar)?a. Decreased food intake.b. Infection.c. Negative urine for glucose.d. I do not know.27. One symptom associated with diabetic ketoacidosis(coma) is:a. Cold, clammy skin.b. Acetone (fruity) breath.c. Negative urine for glucose.d. I do not know.87Diabetes Basic Knowledge Test28. What is one cause of diabetic ketoacidosis (diabeticcoma) in the Type I diabetic?a. Excessive exercise.b. Excessive intake of diet soft drinks over aprolonged period.c. Failure to take daily insulin dose.d. I do not know.29. What effect does illness (for example, a "sick day")have on a diabetic's insulin requirements?a. Illness causes a decrease in insulin requirements.b. Illness causes an increase in insulin requirements.c. Illness causes no changes in insulin requirements.d. I do not know.30. In general, changes in the pattern of insulinadministration for the diabetic undergoing surgery mightinclude:a. Increase the dose of long acting insulin the nightbefore and the morning of surgery.b. Discontinue all subcutaneous insulin the day ofsurgery and infuse long-acting insulin intravenouslyat a constant drip.c. On the day of surgery, reduce the usual a.m. dose ofinsulin and give subcutaneous or IV boluses of shortacting insulin per frequent blood glucose monitoringresults.d. I do not know.31. Which of the following long term complications areassociated with diabetes?a. Eye changes.b. Renal and cardiovascular changes.c. Nervous system changes.d. All of the above.e. I do not know.88Diabetes Basic Knowledge Test32. The effect of physical & emotional stress on diabetescontrol includesa. The secretion of stress hormones that cause anelevation in blood glucose levels.b. The secretion of stress hormones that cause adecrease in blood glucose levels.c. The secretion of stress hormones has no effect onblood glucose levels.d. I do not know.33. Why is it necessary that diabetics pay specialattention to proper care of their feet?a. Several years of injecting insulin into the thighscan cause edema in both the legs and the feet.b. Flat feet are commonly associated with diabetesunless preventive measures are routinely used.c. Persons with diabetes often have changes insensation and poor circulation to their feet.d. I do not know.34. A diabetic has a small corn on the right foot andwants it removed. What should be done first?a. Use a liquid corn remover, following directionscarefully.b. Refer the diabetic to a podiatrist.c. Carefully trim the corn with a sterile cuttinginstruments.d. I do not know.35. A diabetic just received an abrasion on the left leg.What should be done to treat the abrasion?a. Wash gently with mild soap and water, dry with aclean towel, and observe carefully for any signs ofinfection.b. Wash gently with mild soap and water, apply a smallamount of iodine and observe carefully for any signsof infection.c. Apply a small amount of iodine and call the doctor.d. I do not know.89Diabetes Basic Knowledge Test36. What effect does exercise have on blood glucose whenthe diabetic's glucose is less than 16.6 mmo1/1?a. Decreases blood glucose.b. Increases blood glucose.c. Has little effect on blood glucose.d. I do not know.37. What effect does increased exercise have on adiabetic's food intake needs if the patient has a well-controlled Type I diabetes?a. Decreases the need for food.b. Increases the need for food.c. Has little effect on the need for food.d. I do not know.38. Which is the most appropriate INITIAL action to takefor the Type I diabetic who is having a hypoglycemicreaction (low blood sugar)?a. Drink 4 oz. of regular soda.b. Drink 4 oz. of orange juice with 2 teaspoons ofsugar.c. Eat 4 crackers with butter or margarine.d. I do not know.39. A Type I diabetic does not like one of the food itemson the meal tray. What would be the best action for thenurse to take?a. Advise the patient to eat all other items on thetray and omit the one item.b. Advise the patient to omit that one item and adjustthe next scheduled insulin dose to accommodate thisdeletion.c. Explain to the patient that the diabetic diet iscarefully calculated and that the dietician will beconsulted about exchanging this item for another.d. I do not know.90Diabetes Basic Knowledge Test40. Which of these is the main objective when developinga meal plan for the person with Type II diabetes?a. A calorie-controlled diet that will achieve andmaintain ideal body weight.b. A high-carbohydrate, high-protein diet thatencourages an increase in body protein reserves.c. A low-carbohydrate, high-protein diet that willprevent fluctuations in blood glucose levels.d. I do not know.41. A diabetic diet is calculated for which of thefollowing nutrients:1. Carbohydrates.2. Protein.3. Fat.a. 1 & 2.b. 1 & 3.c. 1, 2 & 3.d. 2 & 3.e. I do not know.42. Which of these is the main objective when developinga meal plan for the person with Type I diabetes?a. A nutritionally balanced, 6 small meals/day planthat will prevent delayed stomach emptying.b. An individualized diet plan that will maintaineuglycemia and normal growth and development toinclude foods from the 4 food groups while ensuringthat calories are evenly distributed.c. A low fat, low fibre diet to prevent excessiveweight gain and minimize the risk of cardiovasculardisease.d. I do not know.91Diabetes Basic Knowledge Test43. A diabetic has refused an evening snack of fruitjuice and 1/2 of a sandwich. You should substitute witha. 5 Graham crackers and 8 oz. of plain yogurt.b. 6 crackers and 2 oz. of cheese.c. A piece of fresh fruit, 1 oz. of peanut butter and 4crackers.d. I do not know.44. For the past 2 days, a diabetic has demonstrated thefollowing:-Urine test results for glucose and ketone that jump fromnegative/negative to 1-2%/moderate to large in just a fewhours-Wide fluctuations in blood glucose levels over severalhours, often unrelated to meals-2% glycosuria occurring upon wakening; preceded bynocturnal sweating, nightmares or headacheBased on this assessment data, what is the persondemonstrating?a. Pass-through or flashback phenomenonb. Somogyi or reboundc. Dawn phenomenond. I do not know45. Which of the following sets of figures bestillustrates the correct sites for subcutaneous insulinadministration?Diabetes Basic Knowledge Test92Front BackFront Back8) d 0 nok- kr■ow93Diabetes Basic Knowledge TestAnswer sheet1. a. b. c. d. 23.^a.^b.^c.^d.2. a. b. c. d. 24.^a.^b.^c.^d.3. a. b. c. d. 25.^a.^b.^c.^d.4. a. b. c. d. 26.^a.^b.^c.^d.5. a. b. c. d. 27.^a.^b.^c.^d.6. a. b. C. d.e. 28.^a.^b.^c.^d.7. a. b. c. d. 29.^a.^b.^c.^d.8. a. b. c. d. 30.^a.^b.^c.^d.9. a. b. c. d. 31.^a.^b.^c.^d.e.10. a. b. c. d. 32.^a.^b.^C.^d.11. a. b. c. d. 33.^a.^b.^c.^d.12. a. b. c. d. 34.^a.^b.^c.^d.13. a. b. c. d. 35.^a.^b.^c.^d.14. a. b. c. d. 36.^a.^b.^c.^d.15. a. b. c. d. 37.^a.^b.^c.^d.16. a. b. c. 38.^a.^b.^C.^d.17. a. b. c. d. 39.^a.^b.^c.^d.18. a. b. c. d. 40.^a.^b.^c.^d.19. a. b. c. d. 41. a.^b.^c.^d.e.28. a..b.42. a.^b.^c.^d.21. a. b. c d. 43.^a.^b.^c.^d.22. a. b. c. d.e. 44.^a.^b.^c.^d.45.^a.^b.^c.^d.Appendix CLetter to RNABC9495R.M. Lenahan#208 - 1107 West 14th Ave.Vancouver, B.C. V6H IP5Claire KermacksDirectorDivision of Regulatory ServicesRegistered Nurses Association of British ColumbiaDear Claire Kermacks,My name is Rose Mary Lenahan and I am a graduate studentin the Master's Degree Program in Nursing at theUniversity of British Columbia. Recently, I worked as aNursing Staff Development Educator and became interestedin improving inservice education for nurses. As a result,I am conducting a nursing education research study and Iam requesting the use of the services of the RNABC togenerate a random sample of 150 medical/surgical nursesand 150 home care nurses to send research questionnairesthrough the mail.The purpose of my research is to compare two methods ofdetermining nurses' knowledge about diabetes mellitus.The criteria for participant selection are:1. nurses employed full or part time in home care oracute medical/surgical hospital units.2. nurses holding an active, practising membership in theRNABC.3. nurses providing direct patient care.4. nurses working as staff/general duty nurses inhospital settings.The data will be collected using three questionnairessent out in a package that includes:1. a covering letter explaining the purpose, directionsfor completing the forms and the time commitment2. the demographic data sheet3. the Diabetes Self-Report Tool and envelope4. the Diabetes Basic Knowledge Test in a sealedenvelope5. one large stamped preaddressed envelope96Reminder letters will be sent out to all 300 participantsfour weeks after the initial mailing. Copies of the threequestionnaires and two letters are included for yourinformation.Voluntary participation will be requested of thesenurses. The subjects will be assured of anonymity,confidentiality and informed the time commitment would beapproximately 30 to 45 minutes.I will forward the fee for service and the 300 stampedpackages once I receive approval for using the service.I will also supply a copy of my completed study to theRNABC library as per your request. Approval for thisstudy by the University of British Columbia BehaviourialSciences Screening Committee is contingent upon theability to use the RNABC to generate the sample. I amasking if you would write a letter to me when myapplication to use the service is accepted indicatingtentative permission has been granted. I will thenpresent this letter to the UBC Behaviourial SciencesScreening Committee and will forward to the RNABC aletter indicating final acceptance of the study. I hopethis will meet with your approval. Thank you for yourconsideration.Sincerely,Rose Mary Lenahan RNEthel Warbinek R.N., M.S.N.Associate ProfessorFaculty AdvisorPhone # 822-7483Appendix DLetter to Participants9798#208 - 1107 West 14th Ave.Vancouver, B.C. V6H IP5Dear Colleague,My name is Rose Mary Lenahan and I am in theMaster's Degree Program in Nursing at the University ofBritish Columbia. Recently, I worked as a Nursing StaffDevelopment Educator and became interested in improvinginservice education for nurses. As a result, I amconducting a study called "Perceived and Actual Levelsof Knowledge Regarding the Care of Individuals withDiabetes Mellitus Among Nurses working in Home Care andHospital settings". This study will assess two methodsfor determining nurses' knowledge related to diabetesmellitus that nurse educators use to develop inserviceeducation.The findings of the study will be of benefit tonurse educators in assisting them to provide morerelevant inservice education by identifying howaccurate nurses are in determining their own learningneeds. It will provide an assessment of the subjects'actual diabetes knowledge level and the findings willshow how congruent hospital and home care nurses are inrelation to their knowledge about diabetes mellitus.The results may help nurse administrators decideappropriate use of scare educational resources such asinservice time and money. The study has been approvedby the University of British Columbia BehaviourialSciences Screening Committee.Your name was one of 300 selected randomly throughthe RNABC registry of practising nurses. Address labelswere applied and packages distributed by the RNABCstaff and I have personally incurred all the costs forthis service. No record has been kept of the mailinglist to ensure the anonymity of all participants.Please do not indicate your name on any of thequestionnaires. The questionnaires are numericallycoded to help ensure that they do not mistakenly getswitched with someone else's questionnaires.99Participation in this research is voluntary.Completion of the questionnaires will require 30 - 45minutes of your time. I will assume that yourcompletion and return of the questionnaires impliesconsent to participate in the study. Your choice toparticipate or not will in no way be recorded.Participation involves the reading of this letter,completion of two questionnaires and a demographic datasheet. These materials are included with specificinstructions for completion. Please do not use anyresources to help you answer the questions. All thequestionnaires will be destroyed following dataanalysis. Should you choose to participate, pleasereturn the completed questionnaires by April 23, 1992.A copy of the completed study will be available fromthe RNABC's library if you are interested in theresults of the study. Your efforts and time aregratefully appreciated. If you have questions orinquiries I can be reached at 734-5023, or at the aboveaddress.Sincerely,Rose Mary Lenahan RNEthel Warbinek R.N., M.S.N.Associate ProfessorFaculty AdvisorPhone # 822-7483Appendix EInstructions for Completing and ReturningQuestionnaires100101Instructions:1. Please do not use any resources to help you answerthe questions.2. Open the envelope marked "Document #1" and completethe Demographic Data Sheet and the Diabetes Self-Report questionnaire.3. Once these questionnaires are completed, SEAL themin the envelope marked "Document #1".4. Then open the envelope marked "Document #2" andcomplete that questionnaire called the DiabetesBasic Knowledge Test.4. When all the questionnaires are filled out, placethem in the stamped, preaddressed envelope and mailit to me.Thank you for your cooperation.Appendix FDemographic Data Sheet102Demographic Data SheetPlease fill in the blank or circle the numbercorresponding to your response.1. Number of years of Nursing Experience sincegraduation from basic nursing education program2. Please indicate the area in which you currentlywork.1) Acute Medical/Surgical hospital unit2) Home Care3. Number of Years worked in current setting.4. Please indicate your highest educational preparationobtained:1) Diploma in nursing2) Baccalaureate degree in nursing3) Master Degree in nursing4) other5. Please indicate the most recent inservice/continuingeducation class you attended about Diabetes Mellitus.1) never2) within the last 6 months3) more than 6 months ago but less than 1 year ago4) more than 1 year ago but less than 2 years ago5) more than 2 years ago6. Please indicate the usual number of diabetics youcare for per month:1) none2) 1-3 diabetics3) 4 or more7. Generally speaking, how competent do you feel aboutcaring for a person with Diabetes Mellitus?1) very competent2) competent3) somewhat competent4) not very competent5) not competent103Appendix GMatching Numbers or Groups of Numbersfor DSRT and DBKT Items104105Matching Numbers or Groups of Numbers for DSRT and DBKTItemsContent^Area^DSRT Item # DBKT Item #Etiology I 1 1Etiology II 2 3Treatment I 3 2Treatment II 4 4Surgical Patient 5 30Mild Hypoglycemia 6 23,25,38Severe Hypoglycemia 7 7Urine Testing 8 10,13,14,15,44"Sick Day" Care 9 26,29Actions of Insulin 10 5,6,16,17Insulin Administration 11 18,19,20,45Oral Hypoglycemic Agents 12 21,22DKA 13 27,28Stress 14 32Complications 15 31Exercise 16 36,37Diet Type I 17 37,39,41,42,43Diet Type II 18 40,41Blood Glucose Testing 19 8,9,11,12106Personal Care 20 33,34,35Injection Sites 21 45Hyperglycemia 22 24,26,29(J.A. Drass, personal communication, March 16, 1992)

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