Equipping School Health Personnel for Diabetes Care with a Competency Framework and Pilot Education Program

Development of a School Health Policy Implementation Survey: A Delphi Study

Data on school health policy implementation are limited due to the absence of a validated measurement tool. The purpose of this study was to create and pilot a school health policy implementation survey. A modified, four-round Delphi process was used to achieve consensus on content and format of the survey. The final 76-item survey was piloted in 655 schools with a return rate of 57.1% (n  =  378). Seven schools participated in environmental audits. Based on the audits, survey responses represented an accurate description of school practices for 84.2% (n  =  64) of questions. The remaining 15.8% (n  =  12) of survey items were eliminated or revised. This measurement tool begins to fill the research gap between the evaluation of written school health policy and implementation. Further, this tool may be used by school nurses in alignment with the Framework for 21st Century School Nursing Practice.

School Health Teachers as Partners in Diabetes Caring: Maternal Perspectives

BACKGROUND

The absence of primary care providers' participation in school health care may require close collaboration between school health teachers and parents. This study explores maternal perspectives on obstacles and improvements in partnerships with school health teachers of children with type 1 diabetes.

METHODS

Participants were recruited using purposive sampling through an online type 1 diabetes self-help group in South Korea. Twenty-two mothers whose children were aged between 7 and 13 and had been diagnosed with type 1 diabetes at least 1 year ago were included. Individual interviews were conducted based on a semi-structured interview guide from February to June 2019. Qualitative data were analyzed using inductive content analysis comprising open coding, coding sheets, grouping, categorization, and abstraction.

RESULTS

Mothers recognized obstacles in eight categories and improvements in nine categories under institutional, interpersonal, and intrapersonal aspects of the partnership with school health teachers. Respondents recognized insufficient legal coverage and guidelines, and also health teacher shortage and workload as obstacles in the institutional dimension. Mothers perceived building trust, compromising to balance responsibilities, and constant and open communication as improvements in the interpersonal dimension. They recognized practical competency and tailored care for ordinary school life as school health teacher-related improvements.

CONCLUSIONS

The findings indicate that school health teachers should compromise to balance responsibilities to improve partnerships with parents in the school health care setting. Institutional improvements, such as establishing robust laws and clear guidelines and increasing the number of school health teachers, should be prioritized.

School Nurse Confidence with Diabetes Devices in Relation to Diabetes Knowledge and Prior Training: A Study of Convergent Validity

Objective

The Diabetes Device Confidence Scale (DDCS) is a new scale designed to evaluate school nurse confidence with diabetes devices. We hypothesized that DDCS score would be associated with related constructs of school nurse diabetes knowledge, experience, and training.

Research Design and Methods

In a cross-sectional study, we co-administered the DDCS and Diabetes Knowledge Test 2 (DKT2) questionnaires to school nurses in Pennsylvania. We summarized DDCS scores (range 1-5) descriptively. We evaluated the relationship between DKT2 percent score and DDCS mean score with the Spearman correlation coefficient. Simple linear regression examined school nurse characteristics as predictors of DDCS score.

Results

A total of 271 completed surveys were received. Mean DDCS score was 3.16±0.94, indicating moderate confidence with devices overall. School nurses frequently reported low confidence in items representing specific skills, including suspending insulin delivery (40%), giving a manual bolus (42%), knowing when to calibrate a continuous glucose monitor (48%), changing an insulin pump site (54%), and setting a temporary basal rate (58%). Mean DKT2 score was 89.5±0.1%, which was weakly but not significantly correlated with DDCS score (r=0.12, p=0.06). Formal device training (p<0.001), assisting ≥5 students with diabetes devices in the past 5 years (p<0.01), and a student caseload between 1000-1500 students (p<0.001) were associated with higher mean DDCS score.

Conclusions

DDCS score is related to prior training and experience, providing evidence for the scale's convergent validity. The DDCS may be a useful tool for assessing school nurse readiness to use devices and identify areas to enhance knowledge and practical skills.

Knowledge of School Nurses on the Basic Principles of Type 1 Diabetes Mellitus Self-Control and Treatment in Children

School nurses should participate in the care of children with type 1 diabetes mellitus. The aim of this study was to assess the level of knowledge of school nurses about the basic principles of self-control and the treatment of type 1 diabetes mellitus and to attempt to determine the factors that influence this level of knowledge. A cross-sectional survey was conducted among school nurses from October 2018 to November 2019 in the Pomeranian Voivodeship. The study was conducted using a self-constructed questionnaire. The survey included questions about the sociodemographic characteristics of the respondents, and a test of the knowledge and skills regarding the principles of self-control and the treatment of type 1 diabetes mellitus (16 test questions). This study included 168 Polish school nurses (mean age ± SD = 55.1 ± 8.9 years). Most of the nurses had a secondary education (81%), worked in a municipal educational institution (78.6%), and provided care to more than one student with type 1 diabetes mellitus at school (70.2%). The average level of knowledge of school nurses was 12.5 ± 2.0 points (maximum 16). The nurses working in a village school and those who worked only in one school had lower levels of knowledge. Only 85.7% of nurses reported that they could independently perform a blood glucose measurement with a glucometer, and as many as 56.5% were unable to determine the level of ketone bodies in the urine with Keto-Diastix test strips. Only 62.5% of nurses had a glucometer and glucometer strips in their nursing office. A total of 19.6% of nurses did not have glucagon (1 mg GlucaGen HypoKit^®, Novo Nordisk A/S, Bagsværd, Denmark) or an ampoule with 20% glucose for an intravenous administration. The knowledge of school nurses about the principles of self-control and the treatment of type 1 diabetes mellitus is insufficient. Due to the strong increase in the incidence of type 1 diabetes mellitus among children and adolescents, it is important to organize permanent, continuous, and mandatory training on the principles of self-control and the treatment of type 1 diabetes mellitus for school nurses. The equipment in Polish school nurses' offices should be supplemented with a working glucometer and blood glucose test strips, and the set of obligatory medications in the school nurse's office should be supplemented with glucagon for students with type 1 diabetes mellitus.

Development and psychometric analysis of the Diabetes Device Confidence Scale for school nurses

BACKGROUND

School nurses need to be equipped to help students with diabetes devices. No existing tools assess school nurse self-efficacy in using devices.

OBJECTIVE

To develop and evaluate the psychometric properties of a novel scale to measure school nurse confidence with diabetes devices.

RESEARCH DESIGN AND METHODS

We generated a list of items with community partners and examined logical validity. We then revised and distributed the item set to school nurses in Pennsylvania to examine aspects of structural validity, convergent validity, and internal consistency reliability. We used item response theory to refine the scale.

RESULTS

Facilitated discussion with collaborators generated an initial list of 50 potential items. Based upon the item-content validity index, we revised/eliminated 13 items. School nurses (n = 310) in Pennsylvania completed an updated 38-item scale; the majority had experience with insulin pumps or continuous glucose monitors. Exploratory factor analysis identified a one-factor solution, suggesting a unidimensional scale. We eliminated 13 additional items based upon significant inter-item correlation or skewed response patterns. Item response theory did not identify additional candidate items for removal. Despite a high degree of redundancy (Cronbach's alpha > 0.90), we retained all remaining items to maximize the future utility of the scale.

CONCLUSION

The 25-item, unidimensional Diabetes Device Confidence Scale is a new tool to measure school nurse confidence with diabetes devices. This scale has future clinical, programmatic, and research applications. Combined with knowledge assessments, this scale can serve to evaluate school nurse device use readiness, assess training gaps, and tailor interventions.

Implementation of School Diabetes Care in the United States: A Scoping Review

Diabetes management at school demands close collaboration of multiple stakeholders, including students with diabetes and parents, school nurses, teachers/staff, and local health care providers. This scoping review identified and synthesized evidence concerning factors that contributed to the quality and effectiveness of diabetes care implementation in U.S. K-12 schools. Forty-six studies met the eligibility criteria and were included. Five common factors emerged surrounding training and experiences, communications, parent engagement, resource allocations, and school environment. Complex interactions between multiple stakeholders jointly determined the quality of school diabetes care. A conceptual model was established to elucidate the complex interactions between multiple stakeholders and the relevant facilitators and barriers. Future research should improve sample representativeness, contrast school diabetes care practices to the national guidelines, and assess the impact of the social, economic, and political environment at federal, state, local/district levels on school diabetes care implementation.

Role of theories in school-based diabetes care interventions: A critical review

BACKGROUND

Diabetes is one of the most common chronic diseases of childhood. School plays an essential role in the management of student diabetes, which reduces the risk of short- and long-term diabetes complications and ensures that students are well-positioned for optimal academic performance and growth.

AIM

The aim of this review was to systematically identify and synthesize the literature concerning theory-based diabetes care interventions in K-12 schools in the United States. It critically assessed the specific role of theories and associated essential constructs in intervention design, implementation, outcome measurement, and evaluation.

METHODS

Relevant literature was identified by keyword searches of the Cochrane Library, PubMed, and Web of Science.

RESULTS

Four interventions met the eligibility criteria and were included in the review. Of those, two evaluated online diabetes education programs for school personnel and the other two assessed in-person interventions. Three studies adopted a one-group pre-post study design, and the remaining one adopted a one-shot case-study design. Three of the interventions adopted social cognitive theory, and the remaining one was guided by the diffusion of innovations theory. Three studies identified core constructs of a theory as predictors of behavioral change. Two used theory to select or develop intervention techniques. Two studies used theory to customize participant intervention techniques. Two studies discussed their findings in the context of theory. No study used theory to select potential intervention participants.

CONCLUSION

In conclusion, despite the value of theory in intervention design and evaluation, theory-based diabetes interventions at school remain scarce. Future research may seek ways to better integrate theory and empirical research.

Actual and perceived knowledge of type 1 diabetes mellitus among school nurses

BACKGROUND

In general, school nurses are aware that it is important to have knowledge of type 1 diabetes to give adequate care to children with the disease. Many studies assessing diabetes knowledge have found different deficits among nurses. To our knowledge, however, no study has assessed the knowledge of type 1 diabetes among school nurses.

OBJECTIVE

To assess actual and perceived diabetes knowledge among school nurses.

DESIGN

Cross-sectional studies.

SETTINGS

Seventeen primary care facilities in Warsaw that employed school nurses.

PARTICIPANTS

Two hundred and thirty school nurses.

METHODS

With the Diabetes Knowledge Questionnaire (DKQ), we assessed actual diabetes knowledge. With the Self-Assessed Diabetes Knowledge (SADK), we assessed perceived diabetes knowledge. Both the DKQ and SADK assessed seven domains of diabetes knowledge: general diabetes knowledge; insulin and glucagon; insulin pumps; diabetes complications; nutrition; physical activity, stress, and comorbidities; and glycemia measurements. We related DKQ and SADK scores to each other and to sociodemographic and work-related factors.

RESULTS

The rate of correct responses in the DKQ was 46.7%, with the lowest rate regarding knowledge of insulin pumps (36.5%), nutrition (37.4%), and insulin and glucagon (37.9%). Actual and perceived diabetes knowledge were moderately positively correlated (rho = 0.18, p =.009). In six of the seven knowledge domains examined, school nurses perceived their diabetes knowledge better compared with their actual knowledge. DKQ scores were higher in nurses with higher education (p = .024), those who had relatives or friends with diabetes (p = .032), and those who had prior diabetes training (p = .050). Interestingly, DKQ scores were higher among nurses with fewer years of experience (rho = - 0.18, p = .011).

CONCLUSIONS

There is a need for additional diabetes training among nursing students and practicing nurses to provide safe and effective care for children with type 1 diabetes.