Copyright eContent Management Pty Ltd. Contemporary Nurse (2014) 46(2): 234241.

Do practice nurses have the knowledge to provide

diabetes self-management education?

Margaret Hollis, Karen Glaister* and Jennifer Anne Lapsley+

CPC Medical Practice, Port Macquarie, NSW, Australia; *Curtin Teaching and Learning, Curtin
University, Perth, WA, Australia; +School of Nursing, Curtin University, Perth, WA, Australia

Abstract: Purpose: Practice nurses are ideally positioned to provide key aspects of self-management education to a large
majority of people with diabetes within a primary care setting. However, practice nurses have seldom had comprehensive
training in this field and consequently their role may have limitations. A study was designed to determine the diabetes
related knowledge levels of practice nurses in a regional/rural setting in Australia. Methods: A cross-sectional study was
undertaken using a questionnaire to identify the knowledge of practice nurses. A convenience sample of PNs (N=52)
was drawn from a Division of General Practice in a regional/rural area of NSW. Data was collected using a 14 item
knowledge survey from the National Association of Diabetes Centres. Results: Twenty-nine PNs (55%) responded to the
survey; primarily the participants were registered nurses (89.6%), only one had completed a postgraduate qualification
in diabetes, although 76% had recently completed one or more short courses in diabetes management. Pathophysiology
related knowledge was strong (M=88%) as was knowledge concerning blood glucose monitoring (87%). Less strong was
dietary knowledge (79.5%), although one particular question relating to sources of carbohydrate contributed to the lower
score. The weakest knowledge area was medication management, with PNs scoring a mean score of only 54%. Conclusion:
These findings suggest that PNs have deficits in the knowledge required for DSME and therefore, this must be addressed
through targetting continuing professional development.

Keywords: diabetes, knowledge, practice nurses, nursing

D iabetes is a chronic disease which is currently

in pandemic proportions. It is predicted that
in developed countries by 2030 there will be 82
million people over 64years of age with diabetes
(Wild, Roglic, Green, Silree, & King, 2004). In
Australia, the prevalence has been confirmed in
the 19992000 Aus-Diab study as 7.4% in the
adult population (Cameron etal., 2003), whilst a
follow-up study in 20042005 indicated that 275
people were newly diagnosed with diabetes every
day (Barr etal., 2005).
The disease is associated with significant mor-
bidity and mortality, accounting for 8% of all
deaths in Australia (Australian Institute of Health
and Welfare [AIHW], 2005). By 2003, diabetes
accounted for 5.5% of the total health-care bur-
den (AIHW, 2008) and by 2006, the Melbourne
based International Diabetes Institute (IDI) esti-
mated diabetes cost the community $3 billion
annually (IDI, 2005). The DiabCo$t study found
that costs escalated linearly as the incidence of
chronic complications rose (Colaguiri, Colaguiri,
Conway, Grainger, & Davey, 2003). Not surpris-
ingly, in 1996, diabetes became and has remained
one of the top health priorities targetted by the
Australian Government (Department of Health
and Ageing, 2006). It is imperative that health-
care services can respond to improve health
outcomes.
The chronic care model (Harris, Kidd, &
Snowdon, 2008) is proposed to address poor
health outcomes and represents a radical paradig-
matic shift in the provision of health care. Abbott
(2007), a former Australian Minister for Health,
articulated the need to manage chronic dis-
ease in the community rather than the hospital.
Accordingly, the Liberal Government expanded
Medicare to support the Enhanced Primary Care
(EPC) programme. The EPC programme sup-
ports the development of general practice man-
agement plans between patients and their general
practitioners, team care arrangements permitting
consultations with allied health professionals and
the Practice Incentive Programme, which sup-
ports annual cycles of care for patients and remu-
neration for General Practices involved in these
cycles of care (Abbott, 2007; Harris & Zwar,
2007; Medicare Australia, 2005).

234 CN Volume 46, Issue 2, February 2014

 Do practice nurses have the knowledge to provide diabetes education?
Given the Medicare Benefit Schedule changes
it is increasingly likely that PNs are or will have a
greater role in diabetes care. Hence, it is important
that the scope of practice of PNs is evidence based.
In order to provide diabetes self-management edu-
cation (DSME), PNs require knowledge of diabe-
tes and its management, together with teaching
and counselling skills. However, PNs have seldom
had any specific training in DSME (Drass, Muir-
Nash, Boykin, Turek, & Baker, 1989). As Peters
etal. attest the delivery of a first class service of
diabetes depends partly on the views, practices
and attitudes of those health-care professionals
who provide hands-on care for patients (Peters,
Hutchinson, McIntosh, MacKinnon, & Jones,
2000, p. 844). In response, a study was conducted
to determine the diabetes-specific knowledge base
of practice nurses employed in a regional rural area
on the Mid North Coast of New South Wales. The
particular objectives of the study were to:
1. Determine practice nurses knowledge of dia-
betes care and management.
2. Identify variables which mediate practice
nurses diabetes related knowledge.
Literature review
A diagnosis of diabetes requires extensive lifestyle
modifications and the application of skills to gain
glycaemic control. The American Association of
Diabetes Educators (AADE, 2008) identified
seven self-care behaviours: Healthy eating, being
active, monitoring, taking medication, prob-
lem solving, reducing risks and healthy coping,
which have since been endorsed by the Australian
Diabetes Educators Association (ADEA, 2008).
These behaviours are all considered funda-
mental to successful self-management and pro-
vide a framework to guide DSME programmes
(AADE,2008).
Diabetes self-management education
Diabetes self-management education is the
method of instructing people with diabetes to
assist the individual to make behavioural and life-
style changes (Mensing etal., 2000). As an educa-
tional intervention it is client centred, and requires
active participation by the individual, with sup-
port from a collaborative health-care team, to
eContent Management Pty Ltd
CN
work towards clinical targets (ADEA, 2007).
The American Association of Diabetes published
a landmark document National Standards for
Diabetes Self-Management Education which
identified essential content that should be
included in DSME programmes (Mensing etal.,
2000). In particular, they identified content tradi-
tionally covered in education programmes, such as
information on disease process, nutritional man-
agement, physical activity, medications, monitor-
ing blood glucose and urinary ketones, preventing,
detecting, and treating acute and chronic compli-
cations. However, the critical difference between
traditional educational approaches and DSME is
the emphasis on empowering the person to take
control of their diabetes rather than it controlling
them. To this end, DSME specifically focuses on
psychosocial adjustment through self-beliefs and
skills such as coping, problem solving and person-
alised goal setting (Lorig, 2003; Mensing etal.,
2000; Norris etal., 2002).
Despite DSME being shown to be critical, as
it is recognised as the cornerstone of care many
people with diabetes fail to be offered formal dia-
betes education (Mensing etal., 2000). Clearly
nurses who have not had specialised training in
diabetes education may lack the ability to provide
such education. A study as early as 1989 by Drass
and colleagues confirmed that clients with diabe-
tes are not being managed appropriately, due to
health professionals having insufficient knowl-
edge and since this time nurses level of diabetes
related knowledge has remained questionable.
Diabetes knowledge base of practice nurses
Several American studies have examined diabetes-
specific knowledge of nurses. The study by Drass
etal. (1989), demonstrated that American nurses
had insufficient knowledge in diabetes care, espe-
cially in the treatment of hypoglycaemia, with
almost 94% unsure of correct hypoglycaemia
management. More recently, a study involving
acute hospital nurses reported an average score
of 75% on a diabetes knowledge test (Baxley,
Brown, Pokorny, & Swanson, 1997), whilst
another found that registered nurses (RNs) scored
an average of 64.3% on a diabetes knowledge test
(Lipman & Mahon, 1999). Analysis of test items
Volume 46, Issue 2, February 2014 CN 235
CN Margaret Hollis, Karen Glaister and Jennifer Anne Lapsley
showed that nurses lacked understanding of the
action of insulin, manifestations and treatment of
hyperglycaemia (high blood glucose levels). The
researchers concluded that nurses should not be
expected to educate patients with diabetes, or even
to care for their patients, without i ntensive educa-
tion and careful precepting (p. 94). A comparable
United Kingdom study, also noted nurses scored
weakly on knowledge concerning timing of insu-
lin administration, care of feet and the diabetes
associated precautions for safe driving (OBrien,
Michaels, & Hardy, 2003). These landmark stud-
ies clearly highlight knowledge deficits in key
management areas of diabetes care. Although,
one recent American study indicated that nurses
scored higher than physicians on insulin prepara-
tion, hypoglycaemia and perioperative manage-
ment (Rubin, Moshang, & Jabbour, 2007). In
particular, Kenealy etal. (2004) showed that PNs
in New Zealand with post registration experience
in diabetes believed that they could make a bigger
difference to the quality of life of their clients with
diabetes.
Educating the practice nurse
Several studies have shown that nurses recognise
the importance of education to equip them with
the knowledge and skills to provide optimum care
for people with diabetes in hospital, outpatient and
community settings (Anderson, Fitzgerald, Funnel,
& Gruppen, 1998; Drass etal., 1989; McDonald,
Tilley, & Havstad, 1999; OBrien etal., 2003;
Peters, McIntosh, & Hutchinson, 2003; Shute,
King, & Lehmann, 1997). Furthermore, nurses
realise that their confidence and competence to
provide diabetes related care and education was
adversely affected when they lacked the pertinent
knowledge. Several studies have shown that nurses
perceived knowledge of diabetes was positively
correlated with actual knowledge (Chan & Zang,
2007; El-Deirawi & Zuraikat, 2001; Gossain,
Bowman, & Rovner, 1993).
Continuing professional development oppor-
tunities have generally resulted in increased knowl-
edge relating to diabetes care and management
post-completion of the programme (Graham,
Blain, & Gavin-Wear, 1998; Peters etal., 2001).
One pertinent study, involving the delivery of
236 CN Volume 46, Issue 2, February 2014
an education programme to PNs and GPs in
the United Kingdom found nurses increased
knowledge scores from 66% pre-programme to
86% post-programme (Hearnshaw etal., 2001).
Further, increased confidence and competence in
managing people with diabetes was also reported.
Post-intervention, GPs allowed PNs more time to
run diabetes clinics and nurses reported spending
more time with patients with diabetes, with better
follow-up of patients.
Despite improving skills, knowledge and
confidence, there may be resistance to changing
practice, due to the limited time PNs have for cli-
ent education. Many nurses believe that diabetes
education should be provided by trained diabetes
educators (Lipman & Mahon, 1999; McDonald
etal., 1999; Peters etal., 2001). However, access
to specialised health professionals in the general
practice settings is not always available. Thus, it
is imperative that PNs have sufficient general dia-
betes knowledge to enable them to proficiently
provide aspects of DSME.
Few studies have been conducted in Australia.
One notable study considered diabetes related
attitudes of 629 South Australian nurses. These
attitudes could be considered to reflect diabe-
tes knowledge of some DSME concepts. The
researchers concluded that whilst scores on test
items were generally encouraging, they felt in-
service education could address misconceptions
concerning the seriousness of type 2 diabetes and
patient compliancy (Shute etal., 1997). This par-
ticular study involved urban based, ward nurses
and did not provide insight from the perspective
of rural PNs. Further, it was conducted prior to
the recent Medicare changes and the shift towards
greater involvement of health professionals in
DSME in the primary care setting. It was there-
fore timely to conduct a study to ascertain the
diabetes related knowledge of nurses, particularly
those in the rural Australian context.
Method
Study design and sample
This study used a non-experimental, cross-
sectional study design involving the distribu-
tion of a questionnaire to a convenience sample
of practice nurses employed by a regional/rural
eContent Management Pty Ltd
 Do practice nurses have the knowledge to provide diabetes education?
Division of General Practice in New South Wales.
All 52 PNs employed by the Division were invited
to participate in the study. The response rate was
57% (N=29); response rates between 50 and
70% are considered acceptable (Wolfer, 2007).
Permission to conduct this study was gained
from an associated university human research
ethics committee and the Chief Executive Officer
of the Division of General Practice. Throughout
the study ethical guidelines recommended by the
Australian National Health and Medical Research
Council were adhered to.
Data collection and analysis
Data was collected using a questionnaire including
demographical detail and the National Association
of Diabetes Centres knowledge test (National
Association of Diabetes Centres [NADC], 2004).
The test is used in the evaluation of the NADC
diabetes education programme for Australian
community nurses, so it was considered appropri-
ate to the study. It contains 14 multi-choice style
questions, addressing diabetes pathophysiology,
blood glucose levels and monitoring, dietary issues
and medication management.
Phase 1
Pilot testing of the instrument involved six diabe-
tes educators who worked in the same regional/
rural area as the Division of General Practice..
These educators were aware of the PNs roles
and responsibilities, and the diabetes knowledge
base required of practice nurses. The educators
reviewed the instrument for face and construct
validity (Berg & Latin, 2004). Feedback from the
educators resulted in only minimal changes being
made to the instrument. The internal consistency
of the NADC instrument was high (=0.94).
Phase 2
The questionnaire and study information sheet
was sent to PNs via the Divisions internal mail sys-
tem. The completed questionnaire was returned
in a reply paid envelope to the researcher.
Results
Most participants were RNs (N=26, 89.6%),
two (6.9%) were enrolled nurses and one (3.5%)
eContent Management Pty Ltd
CN
an assistant in nursing. Eight (28%) RNs had
completed a Bachelor of Nursing. Only one PN
had completed a postgraduate qualification in
diabetes, although another was currently studying
for the award. Most of the nurses had attended
one or more of three in-service, short courses in
diabetes offered at the Division in the 12months
preceding the study.
The majority of PNs were relatively new to
their position at their practice. Almost 80%
(N=23) had worked in the practice for <5years
and 58.6% (N=17) had been in their current
position <2years. Seven (24%) PNs worked full
time, the remainder worked part time. A large
group (41.4%) of PNs estimated they spent only
12hours each week in diabetes related work,
although two participants reported spending as
much as 910hours. The more experienced the
PN was the more likely they were to engage in
diabetes related care, although this linear associa-
tion peaked at 910years (Figure1).
A variety of diabetes related advice was pro-
vided by PNs; the leading topics were primarily
concerned with lifestyle behaviours (Figure2).
The diabetes skill of self-monitoring was com-
monly addressed (72%), although only 4% pro-
vided advice on insulin adjustment.
The overall score on the NADC knowledge
level was 77.1%. Practice nurses demonstrated
a sounder knowledge of diabetes pathophysiol-
ogy (88%), blood glucose monitoring (87%)
and diet requirements (79.5%) than medication
management (54%), Table1. The latter topic was
represented by three items, one item addressed
preferred site for insulin administration and
scored 93%, however knowledge concerning the
correct timing of insulin and its storage were less
well understand, scoring 38 and 31% respectively.
Apart from one dietary item concerning sources
of carbohydrates (58%), all other items scored
more than 75%.
Importantly, those PNs who had attended in-
service diabetes education provided by the Division
of General Practice scored higher (84%) than those
who had had not been to any of the three in-service
provided (64%). Likewise, PNs with more experi-
ence, 2years, scored higher (88.6%) than those
with <2years experience (71%).
Volume 46, Issue 2, February 2014 CN 237
CN Margaret Hollis, Karen Glaister and Jennifer Anne Lapsley

8 PNs, especially in the rural

7 setting where access to dietetic
hours of diabetes related work

support is not always read-

6
ily available, must be able to
5 provide basic but sound nutri-
4 tional advice.
3
The knowledge of medica-
tion related aspects of diabetes
2
care was poor, despite pharma-
1 cotherapeutics being a main-
0
stay of diabetes management.
1-2 3-4 5-6 7-8 9-10 11-12 13-14 15-16
This finding is not unique; a
deficiency in nurses funda-
years in current position
mental drug knowledge was
also shown in several American
Figure1: Duration of current position and hours of
diabetes related work
and United Kingdom stud-
ies (Hearnshaw etal., 2001;
100 Leggett-Frazier, Turner, &
90 Vincent, 1994; Lipman &
80 Mahon, 1999; Schmidt, 1998;
70 Spollett, 2006).
percentages

60
50
The practice nurses
40 reported spending on average
30 3.9hours each week in diabe-
20 tes care. A large proportion
10
0
(41.4%) spent only 12hours
per week in diabetes related
s
g

se

t
en
he
ed

an
tin

in

rin

tio

work in the practice, despite

ci

ok

m
ot
ne
ea

uc

pl
ito
er

st
sm
ex

ed

re
on

ed
y

ju

over 7% of the adult pop-

th

ca
tr

ad
m
op

nt
al

gh
lf

tie
he

st

lin
se

ulation having diabetes.

ei

pa

su
w

in
ss

Although the Government

se
As

initiated several Medicare

Figure2: Areas of diabetes advice provided by PNs funded schemes to support
improved chronic disease
Discussion self-management, there remains limited finan-
Diabetes is in epidemic proportions and health cial incentive to support PNs dedicated time
professionals in the general practice setting have a for diabetes related care. If the practice nurse is
major role in DSME. The leading diabetes related a credentialed diabetes educator (CDE), they
topic PNs advised on was healthy eating (86%), can acquire a Medicare provider number and
yet PNs knowledge of some dietary aspects perti- assume a more extensive role in the Team care
nent to diabetes self-care were obviously lacking. Arrangement. However, nurses working in rural
Deficiencies in diabetes related dietary knowledge and remote settings may find it difficult to meet
was also evident in an British study of nurses the credentialling requirements of the ADEA
working in the community. Dietary advice is con- and thus the reality of increasing numbers of cre-
sidered a cornerstone of diabetes care and is para- dentialed PN educators is likely to remain low
mount for the well-being of clients with diabetes in these settings (Chabanuk, 2006). The CDE
and the stabilisation of glycaemic control (Harris, is specifically educated to support client self-
Mann, London, Phillips, & Webster, 2006). Thus management practices, and is better p ositioned

238 CN Volume 46, Issue 2, February 2014 eContent Management Pty Ltd
 Do practice nurses have the knowledge to provide diabetes education? CN
Table1: Knowledge results on the NADC tests etal., 2007). Despite this, educational opportunities
Items Percent N-value may be lacking, with a Dutch study showing that
correct (%) nurses are aware they require improved counselling
skills and updated knowledge re diabetes (Jansink,
Pathophysiology 88
Braspenning, Weijden, Elwyn, & Grol, 2010).
Cause of diabetes 93 27
Effect of being overweight 83 24
This study was conducted in only one Australian
Long term complications 86 25
regional/rural Division of General Practice and
Treatment of hypoglycaemia 90 26
the sample size was small and thus findings may
Blood glucose monitoring 87
not be representative of other regional/rural or
Acceptable BGL range 76 22 metropolitan areas. A larger study involving PNs
BGL assessment 96 28 attached to a variety of Divisions across Australia
Testing times for BGL 89 26 is warranted.
Dietary 79.5
Effect of food nutrients on BGL 96 28 Conclusion
Snack containing most fat 82 24 The PN is often the first person to deal with
Good sources of carbohydrate 58 17 the newly diagnosed client (Rhodes, Nocon, &
Good sources of fibre 82 24 Wright, 2003). This study supports other empiri-
Medication 54 cal evidence to suggest that whilst this is the case,
Correct timing of medication 38 11 many PNs are not adequately prepared to provide
Preferred site for insulin 93 27 even generalist diabetes advice to patients in a pri-
administration mary health-care setting. The educational prepa-
Storage of insulin in use 31 9 ration of PNs is not comprehensive in DSME, and
thus a gap in-service provision may result, conse-
to provide more time for the education process quently adversely affecting the well-being of the
than the PN. Whilst this is the optimum, in individual living with diabetes. Action is required
many Divisions of General Practice, access to to facilitate role expansion of PNs to enable them
CDEs is not always possible. Thus PNs will ben- to be a pivotal force in assisting patients to self-
efit from generalised education in order to pro- manage diabetes. Identifying knowledge deficien-
vide clients with diabetes, basic DSME until the cies in diabetes care and management, as well as
client is able to access more specialised services. teaching and counselling skills, is the first step in
Despite this need, not all PNs have received spe- providing tailored continuing professionals devel-
cific education in the principles of DSME and opment opportunities so that local needs can be
although a New Zealand study indicated that in a better addressed.
little less than a decade, post registration diabetes
education rose from 14.8% in 1990 to 47.1% in Acknowledgements
1999, 88.2% still felt the need for more educa- Diabetes educator colleagues Leigh Spokes,
tion (Kenealy etal., 2004). Thus the opportunity Suzanne Leahy, Susan Unger. Colleagues, espe-
for continuing professional development of PNs cially Christine Cox, at North Coast Medicare
is vital to maintain currency of practice in this Local formerly Hastings Macleay Division of
field and to optimise patient health outcomes. General Practice. Practice nurses involved in the
The educational preparedness of the PN not research and my family.
unexpectedly influenced the scores attained on the
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Received 05 January 2012 Accepted 19 September 2013

N O W AVA I L A B L E
Substance Use and Mental Health
A special issue of Advances in Mental Health Volume 11 Issue 1 116 pages
ISBN 978-1-921729-78-2 October 2012
Guest Editors: Masood Zangeneh (Factor-Inwentash, Faculty of Social Work, University of Toronto, ON,
Canada) and Christine Wekerle (Department of Pediatrics, McMaster University, Hamilton, ON, Canada)
Editorial: On help-seeking Graham Martin OAM Measuring adolescent dating violence: Development of Conflict in
Foreword: Substance use and mental health Masood Zangeneh and Adolescent Dating Relationships Inventory Short Form Liria Fernndez
Christine Wekerle Gonzlez, Christine Wekerle and Abby LGoldstein
Substance use and mental health Differential and common correlates of non-suicidal self-injury and
Suicide attempts and suicidal ideation among street-alcohol use among community-based adolescents Tori Andrews,
involved youth in Toronto Tyler J Frederick, Maritt Kirst and Graham Martin OAM and Penelope Hasking
Patricia G Erickson Coping motives as moderators of the relationship b etween
Drug and alcohol use of the homeless within the Homeless Health emotional distress and alcohol problems in a sample of
Outreach Team: Is there an association between drug of choice adolescents involved with child welfare Abby L G oldstein, Natalie
argaret Campbell Vilhena-Churchill, SherryHStewart and Christine Wekerle
and mental health diagnosis? Chris Lloyd and M
The role of school connectedness in the link between family Responding to child maltreatment in Canada: Context for
involvement with child protective services and adoles- international comparisons Barbara Fallon, Nico Trocm, John

cent adjustment Hayley A Hamilton, Christine Wekerle, Fluke, Melissa Van Wert, Bruce MacLaurin, Vandna Sinha, Sonia
Angela Paglia-Boak and Robert E Mann Helie and Daniel Turcotte
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