Evidence Based Practice and Policy
Evaluation of the Effectiveness of the H.A.N.D.S.SM Program: A School Nurse Diabetes Management Education Program
The Journal of School Nursing 2015, Vol. 31(6) 402-410 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840514568895 jsn.sagepub.com
Charity B. Breneman, MS1, Khosrow Heidari, MA, MS, MS2, Sarah Butler, MS, RN, CDE, NCSN3, Ryan R. Porter, MS1, and Xuewen Wang, MSEd, PhD1
Abstract The purpose of this project was to determine the effectiveness of the Helping Administer to the Needs of the Student with Diabetes in Schools (H.A.N.D.S.SM) continuing education program in improving the level of experience and competence in performing services associated with diabetes care. This program is a live course for school nurses providing clinical information about diabetes management and their professional role in the care of students with diabetes. Pre- and post-surveys were administered via e-mail to assess their level of experience and competence in diabetes care. A total of 105 nurses completed both surveys and were included in the analysis. The changes between pre- and post-survey questions were assessed. The H.A.N.D.S. participants’ levels of experience and competence for each of the four categories of diabetes care improved significantly, and a greater number of nurses reported being able to perform the services independently and having the ability to teach others. Keywords school nurse, continuing education, diabetes management, students with diabetes
Background The SEARCH for Diabetes in Youth Study projected that during 2008–2009, an estimated 18,436 children and adolescents younger than 20 years in the United States were newly diagnosed with type 1 diabetes (T1D) and 5,089 youth were newly diagnosed with type 2 diabetes (T2D) each year (Centers for Disease Control and Prevention [CDC], 2014; Pettitt et al., 2014). This shows a relative increase of 30% in the number of T1D cases since the previous estimation made in 2001 by the SEARCH study group, and a 35% increase in the number of cases for T2D (Dabelea et al., 2014). Additionally, the worldwide incidence of T1D among youth aged 0–14 years has been increasing by about 3% each year (Stanescu, Lord, & Lipman, 2012). Similarly, within the United States, a 20-year study, conducted by the Philadelphia Pediatric Diabetes Registry, demonstrated the incidence of T1D cases among children living in Philadelphia to be increasing by 1.5% per year (Lipman et al., 2013). Although T1D is the most commonly diagnosed type of diabetes within youth, a similar rise in incidence was also evident for T2D in children living in Philadelphia when compared to the overall rate from 1985 to 1989 (Lipman et al., 2013).
Optimal glycemic control is fundamental to achieve longterm health benefits by preventing short-term (hypoglycemia and hyperglycemia) and long-term complications (retinopathy, nephropathy, neuropathy, and cardiovascular disease) of diabetes (Chiang, Kirkman, Laffel, & Peters, 2014). Prior to the landmark Diabetes Control and Complications Trial (DCCT), the standard care for individuals with diabetes took on a more conventional approach that usually required one to two injections of insulin daily without adjustments in dosage (The DCCT Research Group, 1993). Poor glycemic control was found to be associated with
1
Department of Exercise Sciences, University of South Carolina, School of Public Health, Columbia, SC, USA 2 South Carolina Department of Health and Environmental Control, Columbia, SC, USA 3 National Association of School Nurses, Silver Spring, MD, USA Corresponding Author: Xuewen Wang, MSEd, PhD, Department of Exercise Sciences, University of South Carolina, Public Health Research Center 301, 921 Assembly St., Columbia, SC 29208, USA. Email: [email protected]
Downloaded from jsn.sagepub.com at University of Exeter on June 5, 2016
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microvascular complications (Stephenson & Fuller, 1994), and the DCCT trial observed a reduction in these complications among patients who used a more intensive insulin therapy that required insulin to be administered at least 3 times a day (The DCCT Research Group, 1993; Nathan, 2014). The majority of clinical guidelines have now made intensive insulin therapy the standard form of care (American Diabetes Association [ADA], 2014a; Fullerton et al., 2014). Also, a multifactorial approach is being used to individualize diabetes management using self-monitoring and hemoglobin A1c (HbA1c) levels as a measure of glycemic control over the past several months (ADA, 2014a; Fullerton et al., 2014). The recently updated ADA recommendations for youth under the age of 18 encourage HbA1c levels to be less than 7.5%; however, each goal for reaching glycemic control should be individualized to the patient (Chiang et al., 2014). The adoption of this intensified therapy for diabetes management has increased the need for additional support and education of the individual with diabetes (Fullerton et al., 2014). Additionally, maintaining glycemic control requires constant and consistent watchfulness each hour of the day by the individual, family, and/or health care provider (National Diabetes Education Program [NDEP], 2010). Each medical regimen is unique and the success of implementation is contingent upon the ability of the patient and/ or family (Chiang et al., 2014). Also, with intensive insulin therapy being the standard form of management, blood glucose levels are monitored throughout the day and insulin is administered as least 3 times daily to maintain blood glucose levels within an appropriate range (70–130 mg/dl prior to a meal and less than 180 mg/dl 1 to 2 hr after the start of the meal; Chiang et al., 2014; Inzucchi et al., 2012). During the school year, diabetes management can be particularly burdensome on the student because they spend the majority of their waking hours in school (NDEP, 2010). The capability of each student may differ and there may be some younger students between the ages of 6 and 10 years who are unable to manage their disease independently (Lange, Jackson, & Deeb, 2009; Nabors, Lehmkuhl, Christos, & Andreone, 2003). This places a greater demand on school nurses and personnel to provide the necessary care for these students with diabetes (Marks, Wilson, & Crisp, 2013). The most qualified individuals among school personnel to provide appropriate diabetes care are school nurses, and they can become an important resource and advocate for students with diabetes when properly trained (NDEP, 2010). Some of their responsibilities include developing and implementing an individualized healthcare plan (IHP) and an emergency care plan (ECP) for each student with diabetes based on the information provided in their diabetes medical management plan (DMMP; NDEP, 2010; Council on School Health, 2008). Additionally, school nurses are responsible for identifying those who should be trained among school personnel in diabetes care as well as continually updating these individuals on changes that may occur in the student’s
management plan (NDEP, 2010). This requires school nurses to coordinate and provide staff education to ensure that school personnel are able to meet the needs of each student with diabetes according to their IHP (National Association of School Nurses [NASN], 2012; NDEP, 2010). School nurses should also instruct school personnel on the symptoms of hypoglycemia and hyperglycemia so that proper actions can be taken in line with the student’s ECP (NASN, 2012). Each IHP and ECP should be evaluated regularly by the school nurse to ensure effective strategies are in place to promptly respond to the student’s needs in the school setting (NDEP, 2010). Management of diabetes at school is most effective when there is a team approach (NDEP, 2010). School districts that have a student with diabetes should form a health team with school nurses, as the overseers, who work in collaboration with its members as well as with the student’s health care team to ensure a safe and supportive environment conducive to learning (NDEP, 2010; Council on School Health, 2008). Members of the school health team should include the student, parents/guardians, teachers, school nurses, lunchroom employees, and the principal, in addition to any other staff members who are designated by the school nurse to be trained in diabetes care (NDEP, 2010). The cooperation of all team members will be of great benefit to the student with diabetes as demonstrated by Lehmkuhl and Nabors (2008) who reported that children who felt supported at school were more likely to exhibit better HbA1c levels. However, the level of support may be lacking in schools. A qualitative study examined common perceptions of children and adolescents with diabetes in relation to how much support they received at school (Nabors et al., 2003). Several areas of needed improvement were identified, including the need for improving the diabetes knowledge of all school personnel (Nabors et al., 2003). Other concerns reported by parents in additional studies were the lack of support in the school setting and inadequate numbers of trained school personnel, besides a school nurse, who were able to assist during diabetes-related emergencies (Jacquez et al., 2008; Wagner, Heapy, James, & Abbott, 2006). The school nurse provides the health expertise and care coordination needed to ensure cooperation from all partners in assisting the student toward self-management of diabetes (NASN, 2012), which may include training others to provide safe and appropriate care in a timely manner when the school nurse is unavailable (NDEP, 2010). Teachers and other school personnel may be hesitant to provide diabetes care due to feelings of inadequacy and lack of knowledge (Boden et al., 2012). Some concerns reported by teachers included the inability to identify the signs and symptoms of hypoglycemia and hyperglycemia as well as being able to properly treat either, if needed (Siminerio & Koerbel, 2000). Furthermore, parents/guardians of students with diabetes often reported a level of inadequacy of school
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personnel, specifically physical education teachers and coaches, to effectively recognize emergency situations (Nabors et al., 2003; Schwartz, Denham, Heh, Wapner, & Shubrook, 2010; Tolbert, 2009). In order for school nurses to fulfill their duties, it is necessary that they receive continuing education (CE) to ensure that they are able to provide appropriate care regardless of the challenges imposed upon them by a constantly changing work environment (Rosenblum & Sprague-McRae, 2014). Additionally, with increasing advances in diabetes care, CE becomes essential for school nurses because of their unique position as independent decision makers in providing care for the students within their schools. School nurses can no longer rely upon traditional practices or prior experience when providing care for students with diabetes. The complexity of diabetes and the individuality of each student’s DMMP require school nurses to be competent in their roles of diabetes care. The Quality and Safety Education for Nurses framework outlines six areas of competency that should be incorporated into nursing practice, which are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). Rosenblum and Sprague-McRae (2014) identified the importance of applying evidence-based research into practice. In order to increase the school nurses’ level of competence and their ability to teach others, it is necessary for nurses to receive CE that provides them with evidence-based research that can easily be incorporated into practice. In general, attending CE programs by nurses has been found to increase perceived competency in comparison to those who did not attend (Bullock, Libbus, Lewis, & Gayer, 2002). When providing care for students with diabetes, school nurses need to become competent in their roles so that they are able to develop and implement a student’s IHP and ECP in the school setting while overseeing and coordinating other school personnel (NDEP, 2010; ADA, 2014b).
Aim In 2007, the NASN developed a CE program specifically for school nurses entitled Helping Administer to the Needs of the Student with Diabetes in Schools (H.A.N.D.S.SM). The H.A.N.D.S. program was an integral component of the Managing and Preventing Diabetes and Weight Gain project funded by the CDC—NDEP. The H.A.N.D.S. program was revised in 2008, 2010, and 2014 to reflect evidence-based clinical updates and participant feedback. The education is delivered in a face-to-face course, providing up-to-date clinical information about diabetes management and the school nurses’ professional role in the care of students with diabetes. The following are the learning objectives of the H.A.N.D.S. program: 1.
‘‘Summarize current knowledge and guidelines related to diabetes and diabetes management at school.
2.
3. 4. 5. 6. 7. 8. 9.
Identify the school nurse’s role in developing and maintaining a student’s IHP for safe and effective diabetes management at school. Describe the management of hypoglycemia and hyperglycemia at school. Apply knowledge about blood glucose and ketone monitoring to managing diabetes at school. Describe the importance of nutrition and activity in diabetes management at school. Describe the role of insulin therapy in effective diabetes management at school. Identify issues unique to the school setting that can impact safe and effective diabetes management. Identify the key school personnel who will require education about diabetes management. Discuss regional considerations that relate to diabetes management at school’’ (NASN, n.d.).
This program is offered across the United States in areas where sponsorship may be available by the state school nurse association or through the local district. It is jointly presented by a registered nurse (RN) credentialed as a Certified Diabetes Educator and a school nurse (RN) who has demonstrated expertise in working with students with diabetes and their families. The national H.A.N.D.S. presenters are selected from an applicant pool and are required to attend NASN training where they are provided with detailed speaker notes. Additionally, an online discussion group is available to all H.A.N.D.S. presenters to promote regular communication on clinical updates and resources. All who attend the program receive a manual and other course materials related to diabetes care in the school setting as well as access to additional online resources to supplement the attendees with new information, tools, and resources. The overall goal of this CE program is to provide the school nurse participants’ with information to enhance their knowledge, improve their experience level, and provide skill development necessary to improve diabetes management among children with diabetes in the school setting. The purpose of this project is to determine the effectiveness of the H.A.N.D.S. CE program in increasing the level of selfrated experience and competence in performing services associated with diabetes care in the school setting. Selfrated experience and competence will be measured via 15 survey questions, and survey results before and after attending the program will be compared.
Method A one-group pre- and post-study design was used to evaluate the effectiveness of the H.A.N.D.S. program. This project was determined by the Minnesota Institute of Public Health Institutional Review Board to be exempt from full review.
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Completion of the survey before and after attending the program was voluntary and signified consent.
Procedure A survey was developed collaboratively between NASN and the South Carolina Department of Health and Environmental Control’s Division of Chronic Disease Epidemiology and Evaluation. This survey assessed the school nurses’ level of self-rated experience and competence in providing various services associated with diabetes care in the school setting. This survey was first piloted by a cohort of school nurses in South Carolina to test and evaluate the statements for clarity. Revisions were made based on the feedback prior to launching the survey using SurveyMonkey.com1. Nurses who signed up to attend the H.A.N.D.S. program received an e-mail containing a link to SurveyMonkey the week prior to the course and then 3 months following their participation in the H.A.N.D.S. program. Survey participation was voluntary and the information obtained was kept confidential. A unique identifier was created by the participant to link the computerized pre- and post-surveys. Data for this project included survey results collected between 2010 and 2013 from Chandler, Arizona, Columbus, Ohio, El Paso, Texas, Kingston, New York, Naperville, Illinois, Queensbury, New York, and San Diego, California. The overall response rate for the nurses who completed both pre- and post-surveys was approximately 18.0% (105 of 582 attendees from all seven locations). The first 15 questions out of a total of 35 questions assessed the school nurses’ level of self-rated experience and competence related to different services associated with diabetes care (including the level of experience/competence in administering insulin through different methods as well as how to interpret blood glucose levels). The participant was asked to select from a list of four levels of experience/competence for each service of diabetes care, which were Little to no experience, Needs updating, Experienced and able to perform independently, or Experienced, can perform independently and able to teach. These levels represent a continuum from no experience to a level of competence in a particular service of diabetes. The remaining questions assessed policy within the schools where they worked (seven questions), the different roles they participated in as a school nurse (five questions), and finally, demographic characteristics that included licensure status, education level, employer type, current employment title, number of years as a school nurse, number of years at current position, grade levels serviced, and prior work experience as a nurse other than in a school setting (eight questions). The first 15 questions were grouped into four categories for ease of analysis: ‘‘Identifying, monitoring, and treating symptoms’’; ‘‘Administration of medication’’; ‘‘Diet and activity management and planning’’; and ‘‘Teaching and supporting others involved in diabetes care.’’ A Likert-type scale
was created by assigning a numeric value ranging from 1 to 4 to each of the four choices of experience/competence levels with Little to no experience receiving a value of 1 and Experienced, can perform independently and able to teach receiving a 4. The values for the questions contained within each of the four categories were summed together to calculate a total sum score. This sum score could range from 4 to 16, 3 to 12, 4 to 16, or 4 to 16 for each of the four categories, respectively, depending on the number of questions incorporated. Therefore, a low total sum score was indicative of very little experience/competence in that specific category. When there were one or more questions not answered by a nurse within a category, the total sum score of that category was considered missing and not included in the analysis.
Data Analysis All statistical analyses were performed using the SAS software program (Version 9.3; SAS Institute, Inc., Cary, NC). Frequencies and percentages were calculated for all categorical variables pertaining to the demographic characteristics of the study population. Change scores between pre- and post-surveys were calculated for each category. Means and standard deviations were computed for the pre- and postsurveys as well as for the change scores for each of the four categories. The normality assumption was assessed in order to determine whether to use a paired t-test or the sign test to evaluate the change in the level of experience/competence between pre- and post-survey scores. Analysis of variance was used to determine if there was a significant difference in the change scores for each category of assessed experience and competence among school nurses with different highest degrees of obtained education and total number of years as a school health care provider. The p value was set at .05 for evaluating statistical significance.
Results A total of 105 nurses completed the pre- and post-survey assessments before and after attending the H.A.N.D.S. program. As shown in Table 1, the majority of the nurses who participated in the one-day program were RNs with a bachelor’s degree who had greater than 5 years of experience as a school health care provider and were employed by a public school district. Overall, the participating school nurses performed various services in diabetes care including developing an IHP (86.4%), participating in decisions regarding 504 plans (79.4%), and participating in the development of individual education plans (IEPs; 78.0%). Within the past 12 months prior to completing the survey, 93.1% of the school nurses had at least one student with diabetes in the schools that they serviced. Of those school nurses with at least one student with diabetes (n ¼ 89), there was no change between pre- and post-surveys in the proportion of nurses participating in the development of an IHP (from 90.9% to 89.8%) and making decisions regarding 504 plans for students with diabetes (from
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Table 1. Characteristics of the School Nurse Participants. Characteristic
n (%)
Licensure (n ¼ 104) RN APRN Other Degree (n ¼ 104) Associate’s Bachelor’s Master’s Other Number of years as a school health care provider
Evaluation of the Effectiveness of the H.A.N.D.S.SM Program: A School Nurse Diabetes Management Education Program
The Journal of School Nursing 2015, Vol. 31(6) 402-410 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1059840514568895 jsn.sagepub.com
Charity B. Breneman, MS1, Khosrow Heidari, MA, MS, MS2, Sarah Butler, MS, RN, CDE, NCSN3, Ryan R. Porter, MS1, and Xuewen Wang, MSEd, PhD1
Abstract The purpose of this project was to determine the effectiveness of the Helping Administer to the Needs of the Student with Diabetes in Schools (H.A.N.D.S.SM) continuing education program in improving the level of experience and competence in performing services associated with diabetes care. This program is a live course for school nurses providing clinical information about diabetes management and their professional role in the care of students with diabetes. Pre- and post-surveys were administered via e-mail to assess their level of experience and competence in diabetes care. A total of 105 nurses completed both surveys and were included in the analysis. The changes between pre- and post-survey questions were assessed. The H.A.N.D.S. participants’ levels of experience and competence for each of the four categories of diabetes care improved significantly, and a greater number of nurses reported being able to perform the services independently and having the ability to teach others. Keywords school nurse, continuing education, diabetes management, students with diabetes
Background The SEARCH for Diabetes in Youth Study projected that during 2008–2009, an estimated 18,436 children and adolescents younger than 20 years in the United States were newly diagnosed with type 1 diabetes (T1D) and 5,089 youth were newly diagnosed with type 2 diabetes (T2D) each year (Centers for Disease Control and Prevention [CDC], 2014; Pettitt et al., 2014). This shows a relative increase of 30% in the number of T1D cases since the previous estimation made in 2001 by the SEARCH study group, and a 35% increase in the number of cases for T2D (Dabelea et al., 2014). Additionally, the worldwide incidence of T1D among youth aged 0–14 years has been increasing by about 3% each year (Stanescu, Lord, & Lipman, 2012). Similarly, within the United States, a 20-year study, conducted by the Philadelphia Pediatric Diabetes Registry, demonstrated the incidence of T1D cases among children living in Philadelphia to be increasing by 1.5% per year (Lipman et al., 2013). Although T1D is the most commonly diagnosed type of diabetes within youth, a similar rise in incidence was also evident for T2D in children living in Philadelphia when compared to the overall rate from 1985 to 1989 (Lipman et al., 2013).
Optimal glycemic control is fundamental to achieve longterm health benefits by preventing short-term (hypoglycemia and hyperglycemia) and long-term complications (retinopathy, nephropathy, neuropathy, and cardiovascular disease) of diabetes (Chiang, Kirkman, Laffel, & Peters, 2014). Prior to the landmark Diabetes Control and Complications Trial (DCCT), the standard care for individuals with diabetes took on a more conventional approach that usually required one to two injections of insulin daily without adjustments in dosage (The DCCT Research Group, 1993). Poor glycemic control was found to be associated with
1
Department of Exercise Sciences, University of South Carolina, School of Public Health, Columbia, SC, USA 2 South Carolina Department of Health and Environmental Control, Columbia, SC, USA 3 National Association of School Nurses, Silver Spring, MD, USA Corresponding Author: Xuewen Wang, MSEd, PhD, Department of Exercise Sciences, University of South Carolina, Public Health Research Center 301, 921 Assembly St., Columbia, SC 29208, USA. Email: [email protected]
Downloaded from jsn.sagepub.com at University of Exeter on June 5, 2016
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microvascular complications (Stephenson & Fuller, 1994), and the DCCT trial observed a reduction in these complications among patients who used a more intensive insulin therapy that required insulin to be administered at least 3 times a day (The DCCT Research Group, 1993; Nathan, 2014). The majority of clinical guidelines have now made intensive insulin therapy the standard form of care (American Diabetes Association [ADA], 2014a; Fullerton et al., 2014). Also, a multifactorial approach is being used to individualize diabetes management using self-monitoring and hemoglobin A1c (HbA1c) levels as a measure of glycemic control over the past several months (ADA, 2014a; Fullerton et al., 2014). The recently updated ADA recommendations for youth under the age of 18 encourage HbA1c levels to be less than 7.5%; however, each goal for reaching glycemic control should be individualized to the patient (Chiang et al., 2014). The adoption of this intensified therapy for diabetes management has increased the need for additional support and education of the individual with diabetes (Fullerton et al., 2014). Additionally, maintaining glycemic control requires constant and consistent watchfulness each hour of the day by the individual, family, and/or health care provider (National Diabetes Education Program [NDEP], 2010). Each medical regimen is unique and the success of implementation is contingent upon the ability of the patient and/ or family (Chiang et al., 2014). Also, with intensive insulin therapy being the standard form of management, blood glucose levels are monitored throughout the day and insulin is administered as least 3 times daily to maintain blood glucose levels within an appropriate range (70–130 mg/dl prior to a meal and less than 180 mg/dl 1 to 2 hr after the start of the meal; Chiang et al., 2014; Inzucchi et al., 2012). During the school year, diabetes management can be particularly burdensome on the student because they spend the majority of their waking hours in school (NDEP, 2010). The capability of each student may differ and there may be some younger students between the ages of 6 and 10 years who are unable to manage their disease independently (Lange, Jackson, & Deeb, 2009; Nabors, Lehmkuhl, Christos, & Andreone, 2003). This places a greater demand on school nurses and personnel to provide the necessary care for these students with diabetes (Marks, Wilson, & Crisp, 2013). The most qualified individuals among school personnel to provide appropriate diabetes care are school nurses, and they can become an important resource and advocate for students with diabetes when properly trained (NDEP, 2010). Some of their responsibilities include developing and implementing an individualized healthcare plan (IHP) and an emergency care plan (ECP) for each student with diabetes based on the information provided in their diabetes medical management plan (DMMP; NDEP, 2010; Council on School Health, 2008). Additionally, school nurses are responsible for identifying those who should be trained among school personnel in diabetes care as well as continually updating these individuals on changes that may occur in the student’s
management plan (NDEP, 2010). This requires school nurses to coordinate and provide staff education to ensure that school personnel are able to meet the needs of each student with diabetes according to their IHP (National Association of School Nurses [NASN], 2012; NDEP, 2010). School nurses should also instruct school personnel on the symptoms of hypoglycemia and hyperglycemia so that proper actions can be taken in line with the student’s ECP (NASN, 2012). Each IHP and ECP should be evaluated regularly by the school nurse to ensure effective strategies are in place to promptly respond to the student’s needs in the school setting (NDEP, 2010). Management of diabetes at school is most effective when there is a team approach (NDEP, 2010). School districts that have a student with diabetes should form a health team with school nurses, as the overseers, who work in collaboration with its members as well as with the student’s health care team to ensure a safe and supportive environment conducive to learning (NDEP, 2010; Council on School Health, 2008). Members of the school health team should include the student, parents/guardians, teachers, school nurses, lunchroom employees, and the principal, in addition to any other staff members who are designated by the school nurse to be trained in diabetes care (NDEP, 2010). The cooperation of all team members will be of great benefit to the student with diabetes as demonstrated by Lehmkuhl and Nabors (2008) who reported that children who felt supported at school were more likely to exhibit better HbA1c levels. However, the level of support may be lacking in schools. A qualitative study examined common perceptions of children and adolescents with diabetes in relation to how much support they received at school (Nabors et al., 2003). Several areas of needed improvement were identified, including the need for improving the diabetes knowledge of all school personnel (Nabors et al., 2003). Other concerns reported by parents in additional studies were the lack of support in the school setting and inadequate numbers of trained school personnel, besides a school nurse, who were able to assist during diabetes-related emergencies (Jacquez et al., 2008; Wagner, Heapy, James, & Abbott, 2006). The school nurse provides the health expertise and care coordination needed to ensure cooperation from all partners in assisting the student toward self-management of diabetes (NASN, 2012), which may include training others to provide safe and appropriate care in a timely manner when the school nurse is unavailable (NDEP, 2010). Teachers and other school personnel may be hesitant to provide diabetes care due to feelings of inadequacy and lack of knowledge (Boden et al., 2012). Some concerns reported by teachers included the inability to identify the signs and symptoms of hypoglycemia and hyperglycemia as well as being able to properly treat either, if needed (Siminerio & Koerbel, 2000). Furthermore, parents/guardians of students with diabetes often reported a level of inadequacy of school
Downloaded from jsn.sagepub.com at University of Exeter on June 5, 2016
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personnel, specifically physical education teachers and coaches, to effectively recognize emergency situations (Nabors et al., 2003; Schwartz, Denham, Heh, Wapner, & Shubrook, 2010; Tolbert, 2009). In order for school nurses to fulfill their duties, it is necessary that they receive continuing education (CE) to ensure that they are able to provide appropriate care regardless of the challenges imposed upon them by a constantly changing work environment (Rosenblum & Sprague-McRae, 2014). Additionally, with increasing advances in diabetes care, CE becomes essential for school nurses because of their unique position as independent decision makers in providing care for the students within their schools. School nurses can no longer rely upon traditional practices or prior experience when providing care for students with diabetes. The complexity of diabetes and the individuality of each student’s DMMP require school nurses to be competent in their roles of diabetes care. The Quality and Safety Education for Nurses framework outlines six areas of competency that should be incorporated into nursing practice, which are patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). Rosenblum and Sprague-McRae (2014) identified the importance of applying evidence-based research into practice. In order to increase the school nurses’ level of competence and their ability to teach others, it is necessary for nurses to receive CE that provides them with evidence-based research that can easily be incorporated into practice. In general, attending CE programs by nurses has been found to increase perceived competency in comparison to those who did not attend (Bullock, Libbus, Lewis, & Gayer, 2002). When providing care for students with diabetes, school nurses need to become competent in their roles so that they are able to develop and implement a student’s IHP and ECP in the school setting while overseeing and coordinating other school personnel (NDEP, 2010; ADA, 2014b).
Aim In 2007, the NASN developed a CE program specifically for school nurses entitled Helping Administer to the Needs of the Student with Diabetes in Schools (H.A.N.D.S.SM). The H.A.N.D.S. program was an integral component of the Managing and Preventing Diabetes and Weight Gain project funded by the CDC—NDEP. The H.A.N.D.S. program was revised in 2008, 2010, and 2014 to reflect evidence-based clinical updates and participant feedback. The education is delivered in a face-to-face course, providing up-to-date clinical information about diabetes management and the school nurses’ professional role in the care of students with diabetes. The following are the learning objectives of the H.A.N.D.S. program: 1.
‘‘Summarize current knowledge and guidelines related to diabetes and diabetes management at school.
2.
3. 4. 5. 6. 7. 8. 9.
Identify the school nurse’s role in developing and maintaining a student’s IHP for safe and effective diabetes management at school. Describe the management of hypoglycemia and hyperglycemia at school. Apply knowledge about blood glucose and ketone monitoring to managing diabetes at school. Describe the importance of nutrition and activity in diabetes management at school. Describe the role of insulin therapy in effective diabetes management at school. Identify issues unique to the school setting that can impact safe and effective diabetes management. Identify the key school personnel who will require education about diabetes management. Discuss regional considerations that relate to diabetes management at school’’ (NASN, n.d.).
This program is offered across the United States in areas where sponsorship may be available by the state school nurse association or through the local district. It is jointly presented by a registered nurse (RN) credentialed as a Certified Diabetes Educator and a school nurse (RN) who has demonstrated expertise in working with students with diabetes and their families. The national H.A.N.D.S. presenters are selected from an applicant pool and are required to attend NASN training where they are provided with detailed speaker notes. Additionally, an online discussion group is available to all H.A.N.D.S. presenters to promote regular communication on clinical updates and resources. All who attend the program receive a manual and other course materials related to diabetes care in the school setting as well as access to additional online resources to supplement the attendees with new information, tools, and resources. The overall goal of this CE program is to provide the school nurse participants’ with information to enhance their knowledge, improve their experience level, and provide skill development necessary to improve diabetes management among children with diabetes in the school setting. The purpose of this project is to determine the effectiveness of the H.A.N.D.S. CE program in increasing the level of selfrated experience and competence in performing services associated with diabetes care in the school setting. Selfrated experience and competence will be measured via 15 survey questions, and survey results before and after attending the program will be compared.
Method A one-group pre- and post-study design was used to evaluate the effectiveness of the H.A.N.D.S. program. This project was determined by the Minnesota Institute of Public Health Institutional Review Board to be exempt from full review.
Downloaded from jsn.sagepub.com at University of Exeter on June 5, 2016
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Completion of the survey before and after attending the program was voluntary and signified consent.
Procedure A survey was developed collaboratively between NASN and the South Carolina Department of Health and Environmental Control’s Division of Chronic Disease Epidemiology and Evaluation. This survey assessed the school nurses’ level of self-rated experience and competence in providing various services associated with diabetes care in the school setting. This survey was first piloted by a cohort of school nurses in South Carolina to test and evaluate the statements for clarity. Revisions were made based on the feedback prior to launching the survey using SurveyMonkey.com1. Nurses who signed up to attend the H.A.N.D.S. program received an e-mail containing a link to SurveyMonkey the week prior to the course and then 3 months following their participation in the H.A.N.D.S. program. Survey participation was voluntary and the information obtained was kept confidential. A unique identifier was created by the participant to link the computerized pre- and post-surveys. Data for this project included survey results collected between 2010 and 2013 from Chandler, Arizona, Columbus, Ohio, El Paso, Texas, Kingston, New York, Naperville, Illinois, Queensbury, New York, and San Diego, California. The overall response rate for the nurses who completed both pre- and post-surveys was approximately 18.0% (105 of 582 attendees from all seven locations). The first 15 questions out of a total of 35 questions assessed the school nurses’ level of self-rated experience and competence related to different services associated with diabetes care (including the level of experience/competence in administering insulin through different methods as well as how to interpret blood glucose levels). The participant was asked to select from a list of four levels of experience/competence for each service of diabetes care, which were Little to no experience, Needs updating, Experienced and able to perform independently, or Experienced, can perform independently and able to teach. These levels represent a continuum from no experience to a level of competence in a particular service of diabetes. The remaining questions assessed policy within the schools where they worked (seven questions), the different roles they participated in as a school nurse (five questions), and finally, demographic characteristics that included licensure status, education level, employer type, current employment title, number of years as a school nurse, number of years at current position, grade levels serviced, and prior work experience as a nurse other than in a school setting (eight questions). The first 15 questions were grouped into four categories for ease of analysis: ‘‘Identifying, monitoring, and treating symptoms’’; ‘‘Administration of medication’’; ‘‘Diet and activity management and planning’’; and ‘‘Teaching and supporting others involved in diabetes care.’’ A Likert-type scale
was created by assigning a numeric value ranging from 1 to 4 to each of the four choices of experience/competence levels with Little to no experience receiving a value of 1 and Experienced, can perform independently and able to teach receiving a 4. The values for the questions contained within each of the four categories were summed together to calculate a total sum score. This sum score could range from 4 to 16, 3 to 12, 4 to 16, or 4 to 16 for each of the four categories, respectively, depending on the number of questions incorporated. Therefore, a low total sum score was indicative of very little experience/competence in that specific category. When there were one or more questions not answered by a nurse within a category, the total sum score of that category was considered missing and not included in the analysis.
Data Analysis All statistical analyses were performed using the SAS software program (Version 9.3; SAS Institute, Inc., Cary, NC). Frequencies and percentages were calculated for all categorical variables pertaining to the demographic characteristics of the study population. Change scores between pre- and post-surveys were calculated for each category. Means and standard deviations were computed for the pre- and postsurveys as well as for the change scores for each of the four categories. The normality assumption was assessed in order to determine whether to use a paired t-test or the sign test to evaluate the change in the level of experience/competence between pre- and post-survey scores. Analysis of variance was used to determine if there was a significant difference in the change scores for each category of assessed experience and competence among school nurses with different highest degrees of obtained education and total number of years as a school health care provider. The p value was set at .05 for evaluating statistical significance.
Results A total of 105 nurses completed the pre- and post-survey assessments before and after attending the H.A.N.D.S. program. As shown in Table 1, the majority of the nurses who participated in the one-day program were RNs with a bachelor’s degree who had greater than 5 years of experience as a school health care provider and were employed by a public school district. Overall, the participating school nurses performed various services in diabetes care including developing an IHP (86.4%), participating in decisions regarding 504 plans (79.4%), and participating in the development of individual education plans (IEPs; 78.0%). Within the past 12 months prior to completing the survey, 93.1% of the school nurses had at least one student with diabetes in the schools that they serviced. Of those school nurses with at least one student with diabetes (n ¼ 89), there was no change between pre- and post-surveys in the proportion of nurses participating in the development of an IHP (from 90.9% to 89.8%) and making decisions regarding 504 plans for students with diabetes (from
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The Journal of School Nursing 31(6)
Table 1. Characteristics of the School Nurse Participants. Characteristic
n (%)
Licensure (n ¼ 104) RN APRN Other Degree (n ¼ 104) Associate’s Bachelor’s Master’s Other Number of years as a school health care provider
