Ma. Eugenia Pérez-Robledo,1 Ma. del Carmen Pérez-Rodríguez,2 Alejandra Hernández-Castañón,3 María Teresa Guerrero-Hernández,1 Laura López-Torres,1 Alberta Hernández-Rodríguez4
1Universidad Autónoma de San Luis Potosí, Facultad de Enfermería; 2Universidad Autónoma de San Luis Potosí, Facultad de Enfermería, Unidad de Investigación y Posgrado; 3Universidad Autónoma de Querétaro, Facultad de Enfermería, Unidad de Investigación y Posgrado, Querétaro, Querétaro. 4Servicios de Salud de San Luis Potosí, Hospital Central Dr. Ignacio Morones Prieto. San Luis Potosí, San Luis Potosí, México
Correspondence: Ma. del Carmen Pérez-Rodríguez
Received: December 1st 2015
Judged: April 20th 2016
Accepted: June 27th 2016
Introduction: Training is an active and ongoing process for the development of intellectual, technical and relational skills nurses are identified as responsible for patient education and treatment management, in fact the patient professional nurse is the primary source of knowledge.
Objective: To evaluate the effect of self-care training of adult patients with DM2 in the level of knowledge of nurses.
Methods: A quasi-experimental study before / after, in a group formed by 23 nurses of internal medicine, a training program on self-care of adult patients with DM2 was implemented. The overall weight of the test to determine the level of knowledge was based on categories: Very High (36-46), High (29-35), Medium (18-28), Low (9-17) and Very Low (<8).
Results: In the pre-training evaluation, between 85% and 95% of nurses obtained knowledge levels low and very low, in the dimensions of physical activity, eating habits and self-monitoring of blood glucose levels. In the post-training evaluation, knowledge levels high and very high were recorded in five of the six dimensions evaluated, the highest percentages are found in very high level.
Conclusions: The training had a positive effect on knowledge of nurses on self-care of patients with DM2.
Keywords: Inservice training; Continuing education; Nursing education; Self care; Type 2 diabetes mellitus
Several studies address the importance of training as the main premise for the development of skills in professional nursing. In this context, Cadena1 defines training as an active and ongoing process, which is to acquire, maintain, renovate, enhance, update and increase knowledge, skills and attitudes that allow the nurse to confront and resolve or, where appropriate, contribute to the improvement of health problems. Essentially, it focuses on skill development to acquaint staff with innovations and technological changes and put them into professional practice.
For Puntunet,2 training is a teaching-learning process that facilitates the development of knowledge and skills to work on a labor competence unit. From this definition, an improved organizational climate and quality of patient care is established by the relationship between training and skills development in nursing practice, with regard to high productivity.
In the clinical setting, Aponte3 identifies nurses as the professionals responsible for patient education and treatment management. They also note that the nurse is the primary source of knowledge for the patient. In turn, this knowledge can be applied in everyday life in their home and work environments.
Diabetes is a chronic-degenerative disease of high prevalence that requires continuous effective, accessible, comprehensive, and quality care at reasonable cost throughout the life of the person. Its magnitude is the result of the aging population, urbanization and associated changes in lifestyles. Diabetes is one of the most serious health problems of the 21st century, and is the leading cause of morbidity and mortality worldwide. The Encuesta Nacional de Salud y Nutrición (ENSANUT-2012)4 reported a 9.2% prevalence of diagnosed diabetes in adults, of these 47% were diagnosed with hypertension. This means that 4.3% of the population over 20 years has comorbidity of diabetes and hypertension. Moreover, the Instituto Nacional de Estadística y Geografía (INEGI 2011)5 estimated in May that the incidence of diabetes in Mexico has increased between 60 and 64 years old, and 70 out of every 100,000 people die from diabetes mellitus type 2.
Therefore, the participation of diabetic patients in self-care is essential. In order to ensure the positive impact of education, it is necessary to intervene from the moment the patient is aware of their diagnosis. Major interventions are not needed, but a collaborative approach, and adequate practitioner training and experience are. On the contrary, its implementation, through a reflection-action process, involves engagement and holding the diabetic patient accountable for their own disease, more than just the action of taking medication. Diabetes education and behavioral control are the components that relate to the effectiveness of an intervention. Under this premise, the importance of incorporating diabetes education falls under the provision of health services.
In order to evaluate the effect of self-care training of adult patients with DM2 on the level of knowledge by nursing staff, this investigation was done at Hospital Central Dr. Ignacio Morones Prieto, a third care level regional referral institution. The hospital has 76 medical specialties and a record of healthcare, academics, and research, as a teaching hospital which trains undergraduate and graduate students from the Universidad Autónoma de San Luis Potosí, the Universidad Nacional Autónoma de México, as well as other national institutions, both public and private. It serves the population of San Luis Potosi and surrounding states regarded as low income, without health insurance and affiliated with the public insurance program.6
Quasi-experimental before/after study was implemented on a group of 23 nurses, who underwent a training program on self-care of patients with diabetes mellitus 2 (DM2). The internal medicine department was selected because of the admission of patients with acute and chronic complications of type 2 diabetes, and for its increased early readmissions, and an average length of stay, 9 to 12 days.
The study group was selected for convenience, with nursing staff of both genders, any educational level, with a minimum of one year in the department. Staff was assigned to the internal medicine department for the three shifts. They accepted participation in the research with informed consent.
The training program was developed in ten sessions, in the morning, afternoon and night shifts, totaling 36 hours. The training was provided in the internal medicine classroom with the following nursing schedule: morning shift and night-B, from 7:30 to 8:45 am, Monday to Saturday; afternoon shift from 15:00 to 16:45 pm, Monday to Friday; night-A from 22:00 to 24:00 pm, on Mondays, Wednesdays and Fridays.
The thematic content of the program was based on Dorothea Elizabeth Orem's7 theory of nursing on self-care, and linked with David Paul Ausubel’s pedagogical model of meaningful learning.8
The program structure includes the epidemiological panorama of DM2 in the national and international context and eight dimensions of knowledge:
The specialized test of nursing knowledge about self-care in people with DM2 consists of 46 items validated by a doctor of nursing science and two care clinical nurses from government healthcare institutions. The dimensions of knowledge about DM2, eating habits, self-monitoring, and special care were assessed with seven items each; and exercise habits, drug treatment and acute and chronic complications, were assessed with six items each.
The global weighting of the test to determine knowledge had the following cutoffs and categories: 36-46 points (very high) 29-35 points (high), 18-28 points (medium), 9-17 points (low), and less than 8 points (very low).
The pilot test was conducted in the same hospital, in the men's surgery department, with nursing staff serving diabetic patients with surgical conditions.
For data analysis, we used Statistical Package for the Social Sciences (SPSS) version 18.0, in Spanish, for absolute frequency measurements, relative and central tendency (mean and median).
With regard to the ethical implications, this study adhered to the provisions of the Ley General de Salud,9 specifically Health Research Regulations; with application of Articles 13, 17, 16, 20, 21, 22 and 50. It is classified as minimal risk.
Also, there is no conflict of interest in the dissemination of results. Registration was obtained from the Ethics Committees of the Universidad Autónoma de Querétaro and the Hospital Central Dr. Ignacio Morones Prieto.
Age ranged from 36 to 56, with an average age of 42.2. The highest percentage was concentrated in the 40 to 44 age group. 52.1% and 47.8% are professionals and non-professionals, respectively, yet all nurses were assigned the same functions.
The total nursing staff has seniority that exceeds 10 years, and more than half have a length of service in internal medicine between 11 and 15 years, followed by those with between 6 and 10 years. It is important to consider that the factor of seniority can be a strength in the knowledge and experience of the staff for the care and education of patients with DM2; however, it should be noted that 100% of the staff concerned had not received training on self-care for diabetic patients.
In this respect, the results of the pre-test reported low to very low levels, mainly in the area of drug treatment, where 100% of staff received the very low level. Also in the exercise and diet areas, 95.6% and 95.3%, respectively, had a very low level; and for self-monitoring, 86.9% had a low level.
In the post-test results in the areas of special care and complications, the very high level was achieved by all nurses in self-monitoring of glucose, where the result increased by 91.3%, and 78.3% of staff reached high level in the exercise area (Figure 1).
Figure 1. Knowledge level of nurses on self-care of patients with DM2 pre- and post-training
More than 90% of staff responded correctly to questions about the definition of diabetes, influence of unhealthy lifestyles, symptoms used in identifying diabetes, and the normal fasting glucose figures.
In relation to the recommendations on the importance of diet to control diabetes with intake of three major meals a day, two snacks between meals, and the consumption of alcoholic drinks that are not sweet, the answers were correct in 82.6% of staff.
Regarding DM2 patients who perform strenuous physical activity, who must self-monitor blood glucose, 100% of staff were knowledgeable. 95.7% correctly identified the recommendation that 30 minutes of exercise helps the body metabolize more carbohydrates, lowering glucose levels.
In the area of drug treatment, insulin application at the waist area should be avoided because of the presence of sensitive nerves and the possibility of irritation. Only 47.8% of staff had the correct answer. Oral medication with sulfonylureas (glyburide, tolbutamide and diabinese) stimulates the beta cells to release insulin, and this was correctly answered by 91.3%. When 5-alpha glucosidase inhibitors such as acarbose are taken, they can cause hypoglycemia, allergic reactions and digestive intolerance; when an insulin bottle or cartridge is opened, it is recommended to change it every 28 days, as it loses its effect and there is more risk of contamination. In both of these questions, 100% correct answers were obtained.
Also 100% answered correctly about monitoring blood glucose levels at home using the same lancet up to three times. 100% answered correctly about measuring glucose before eating and two hours after eating, as these measurements are important obtaining a greater control over glucose levels.
Regarding the acute complications of DM2 as hypoglycemia, hyperglycemia and diabetic ketoacidosis and chronic complications such as hypertension, nephropathy, neuropathy, peripheral vascular disease, retinopathy and diabetic foot, 100% correct answers were obtained.
In the special care area concerning personal hygiene, lubrication of the skin, nail trimming, grooming feet, using special footwear, regular ophthalmologic and stomatology checks, the answers were 100% correct.
One of the biggest challenges to the care and attention of the person with type 2 diabetes is to solve real and potential health problems, so it is imperative that health personnel and particularly nursing staff are up to date on the care of people with chronic degenerative diseases such as type 2 diabetes mellitus.
Although nursing staff has a minimum of 10 years' experience, they have limited knowledge of the areas assessed, which is not consistent with the time spent in the institution and in the department. Such a condition may not have positive repercussions, as Zapata10 and Alvarez,11 who agree that routinization of activities can have a negative impact and bring about risks to the health of patients under their care.
It is important that nurses have not received training during their working life in the hospital. A totally opposite situation is reported by Cadena,12 in Mexican national referral institutes, which held on average six courses per year and almost total coverage. In Colombia, Arboleda13 recorded a high frequency of attendance at training courses and updates. To a lesser extent, Flores14 found in Nuevo Leon, Mexico, attendance of 2 to 4 courses per year and Alba,15 in the Hospital General de Mexico, reports that at least half of the nursing staff have received training and updates.
About the limitations found in the pre-test in the areas of drug therapy, exercise, nutrition, self-monitoring of glucose, complications and special care, we found similar results to those Aponte16 reported, major limitations in metabolic control, prevention and care of complications were recorded. In Martinez's17 study in the state of Nuevo Leon, low levels of knowledge were obtained in half the nurses on the management of the feet, diet, recognition of complications, procedure, and effects of medication. Contrasting were the results of Oliveira18 in Brazil, where nursing staff has extensive knowledge of acute complications of diabetes.
It is important to highlight the post-training results of this study, since knowledge was increased to very high in special care, complications, self-monitoring and high-level exercise. Likewise, Uriarte19 reports that nurses’ degree of knowledge increased to a high level after the educational intervention. Suárez20 also notes that at the end of the intervention knowledge was increased almost in its entirety.
In this context, the relevance of these study results is the need for nurses to have updated knowledge through in-service training, which shows a significant increase in knowledge in all areas assessed. Therefore, these results should be analyzed by the institution directors to take responsibility for improving the organizational climate in the hospital, specifically with nursing staff, and to establish necessary strategies to promote a culture of continuing education and encourage the quality of patient care.
In this context, it is noteworthy that Chiodelli21 states that health institutions should undertake educational activities in order to stimulate the team growth so they can meet the daily, urgent and emerging demands of healthcare, and link situational practice to reality, building knowledge and creating transformations necessary to the environment.
These results show that in-service training during working hours positively impacts the knowledge of nurses, and the importance of training and updates in meeting their learning and transformation needs in everyday practice.