Exploring why young people with Type 1 diabetes decline structured education with a view to overcoming barriers.

AIMS: To identify factors that influence lack of engagement of young adults with Type 1 diabetes (aged 13-21 years) with structured diabetes education (SDE) to inform and broaden the reach of future SDE. METHODS: A quantitative, cross-sectional survey was undertaken of 227 young people with Type 1 diabetes drawn from 11 health trusts across Northern Ireland and England, deemed to be representative of the wider population. Participants were asked to complete a questionnaire exploring non-attendance, along with the Diabetes Care Profile, the Diabetes Empowerment Scale (Short Form), the Diabetes Knowledge Test and the 12-item General Health Questionnaire. Demographic, health and diabetes-specific variables including HbA1c were also collected. RESULTS: The five most commonly cited reasons for non-attendance were 'Had other things to do' (68.3%), 'No time' (62.2%), 'Could not get time off school/college or work' (60.8%), 'Learnt about diabetes from other sources' (55.5%) and 'Feel able to cope on own' (52.9%). CONCLUSIONS: Greater emphasis is required on communication with young people about the benefits of SDE. In addition, efforts need to be directed to making diabetes education more accessible without losing the quality of structured programmes.

Comparing patient generated blood glucose diary records with meter memory in type 2 diabetes.

AIM: To assess agreement between meter and diary self monitoring of blood glucose (SMBG) records, over a year, in a sample of patients with type 2 diabetes. METHODS: Meter and diary records were available, for 95 individuals, who took part in the Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes study. Pearson's correlation coefficient was used to explore the relationships between the types of error. Maximum likelihood estimation was used to explore changes over time through a structural equation modelling approach. Paired samples t-tests were used to determine if the presence of errors led to a significant difference between the mean diary and meter SMBG concentrations or coefficients of variation. Multiple regression was used to explore possible predictors of the error indices. RESULTS: Mean over-reporting, under-reporting, concordance and overall reliability were 8.4%, 10.0%, 83.5% and 71.3%, respectively. The first week of monitoring had significantly more under-reporting, over-reporting and less concordance and overall reliability than subsequent weeks. The majority of concordance errors were not clinically significant. Those that were, tended to occur during the first three months of monitoring. Participants' at one trial site were significantly more likely to have recording errors than those at the largest site. CONCLUSIONS: Error levels were similar to those described previously in type 1 diabetes and there was a suggestion of an initial learning curve for record keeping. For some individuals diary records would not be considered acceptable if held to the same standards as blood glucose meters.

Hypoglycaemia risk among a hospitalised stroke patient cohort: a case for increased vigilance in glucose monitoring.

We conducted a retrospective cohort study involving a review of the records of 112 patients consecutively admitted with acute stroke or transient ischaemic attack (TIA) to all three district general hospitals in one Health and Social Care Trust in Northern Ireland from 1 January to 15 April 2008. Glucose results for each of the first 5 days of hospital admission were ascertained. We compared interventions and clinical outcome between patients who experienced hypoglycaemia (glucose<4.0 mmol/l) in the first 5 days, and patients with higher glucose results. Our results indicated that 11 (10%) patients experienced incidents of hypoglycaemia ranging from 1.8 to 3.9 mmol/l. None of the individuals affected had received intravenous or subcutaneous insulin. Only two of the hypoglycaemic episodes involved patients with a history of diabetes mellitus. Two patients experienced episodes of hypoglycaemia on 2 or more days. Six patients experienced hypoglycaemia at the lower threshold of glucose<3.5 mmol/l and this was not associated with a history of diabetes. A history of diabetes mellitus prompted near patient glucose testing, but among patients without diagnosed diabetes, glycaemia was under-monitored. The test that most frequently indicated hypoglycaemia was a routine electrolyte profile tested in the hospital laboratory. Patients in the first 5 days after stroke have a small risk of hypoglycaemia. There is a need for greater vigilance in the monitoring of glucose among patients admitted to hospital with stroke or TIA.

Comparing patient-generated blood glucose diary records with meter memory in diabetes: a systematic review.

AIMS: To synthesize evidence relating to comparisons between patient-generated blood glucose records and meter memory in diabetes and to identify any predictors of agreement. METHODS: A systematic literature search was performed to identify articles comparing meter and diary records in those unaware of this assessment. RESULTS: Eleven observational studies, covering patients with Type 1, Type 2 and gestational diabetes were included spanning 1984-2009. Failure to record blood glucose measurements in the diary was the most extensive 'error', but addition of values, which were not measured, was a greater cause for concern. When present to a high degree, 'errors' lead to decreased variability in diary records compared with meter records. Allowing for a minimal amount of disagreement, just over 50% of adult diaries can be considered as 'accurate/reliable'. Disagreements were most extensive in teenagers and young adults, but the pregnant populations were only slightly better. Agreement was not related to sex, number of insulin injections or duration of monitoring. Those who were younger were more likely to have 'errors', while those who monitored more frequently had more 'accurate' diaries. CONCLUSIONS: The lack of meter-diary agreement suggests that the real reason for monitoring is not understood by many patients, raising issues about motivation, perceived need to impress healthcare providers and denial of poor control. Considering that diaries are used to inform decisions about therapy when HbA1c is raised or in pregnancy, when HbA1c is not suitable, there is significant cause for concern in relation to their clinical utility.

Hyperglycaemia monitoring and management in stroke care: policy vs. practice.

AIM: To evaluate the extent to which hyperglycaemia was monitored and managed among patients admitted to hospital with acute stroke and transient ischaemic attack. METHODS: We conducted a retrospective cohort study involving a review of the records of 112 patients consecutively admitted with acute stroke or transient ischaemic attack to all three district general hospitals in one Health and Social Care Trust in Northern Ireland from 1 January to 15 April 2008. Glucose results for each of the first 5 days of hospital admission were ascertained. We compared interventions, clinical outcome and discharge planning between patients who experienced glucose ≥ 7.8 mmol/l in the first 5 days, and patients with lower glucose results. RESULTS: The daily prevalence rate of hyperglycaemia > 7.8 mmol/l across the first 5 days ranged from 24 to 34%. A total of 41 (37%) patients experienced hyperglycaemia on at least one occasion during the first 5 days. A history of diabetes mellitus prompted near patient glucose testing, but, among patients without diagnosed diabetes, glycaemia was under-monitored. Hyperglycaemia was a persisting trend, was under-treated and under-reported to general practitioners. Elevated glucose results failed to influence higher rates of fasting plasma glucose tests and BMI assessment. CONCLUSIONS: There is a need for greater vigilance in the detection of hyperglycaemia and undiagnosed diabetes mellitus among patients admitted to hospital with stroke or transient ischaemic attack.

The health behaviours of Chinese people with chronic illness.

This study was undertaken to elucidate the type and range of health-promoting behaviours that Chinese people with chronic illness perform to enhance their health. Eight people with a diagnosed chronic illness were interviewed using a semi-structured interview schedule. From the perspectives of these subjects, health behaviour comprises three dimensions: physical, psychosocial and spiritual. The results of this study clarify health behaviours amongst Chinese people with a chronic illness and illustrate the important influence that culture has upon such activity. Additionally, exploring the health behaviours of these Chinese people can be used to inform and enable nurses to adjust their practices to relate more appropriately to patients' perspectives.

Adaptation of an instrument to measure the informational needs of men with prostate cancer.

AIM OF THE STUDY: The aim of this study is to adapt an instrument suitable for assessment of the informational needs of men with prostate cancer. BACKGROUND: In recent years prostate cancer has become an important public health problem world-wide with considerable social and economic consequences. It is reported that it is the most common cancer affecting British men, with an average lifetime risk of occurrence of one in twelve. DESIGN/METHODS: Methodological research was conducted to develop an instrument to assess the informational needs of men with prostate cancer on hormonal manipulation therapy (HMT) regarding their disease and treatment. The Toronto Informational Needs Questionnaire (TINQ-BC) (Galloway et al. 1997) was modified for use with this client group and was applied to a sample of 90 men generated from three urology centres in Northern Ireland. RESULTS/FINDINGS: Construct and content validity of the instrument was established. Internal consistency reliability using Cronbach's alpha was calculated and found to be satisfactory (0.92). Using confirmatory factor analysis, factor loadings ranging from 0.37 to 0.90 were obtained and considered satisfactory. The subsections of the TINQ-BC categorized as Disease, Investigative tests, Treatment, Psychosocial and Physical needs were confirmed as individual factors. These results indicate that this instrument can be validly applied to this client group. As the instrument was initially developed in Canada and successfully used in the United Kingdom (UK), it is suggested that this instrument also has the potential for cross-cultural application. It has the potential to be used as a clinical reference instrument to assess the informational needs of this patient group. Health care professionals must be aware of the domains of information that these men perceive important so that educational interventions can be accurately and appropriately planned.

The paediatric diabetes specialist nurse and diabetes education in childhood.

AIMS OF THE STUDY: The aim of this study was to identify the job title, work setting, qualifications and training of the paediatric diabetes specialist nurse (PDSN) as well as to examine the composition of the multidisciplinary diabetes team. It also aimed to determine who is involved in diabetes education and to explore the teaching methods, approaches, tools and materials that the PDSN uses in the educational process. DESIGN AND METHODS: A survey design was used. Questionnaires, which combined quantitative and qualitative approaches, were sent to 80 participants from eight opportunistically selected regions of the United Kingdom (UK). Access to names and addresses was gained through the directory of diabetes specialist nurses (DSNs). The selection criteria were nurses working full-time with children with diabetes or having children with diabetes on their caseloads. The overall response rate was 66 (82.5%). FINDINGS: The study findings showed that the majority of the respondents were based in both hospital and community, held paediatric qualifications and had undertaken further training to prepare as diabetes specialists. Respondents used a wide range of teaching methods and materials in the educational process. A substantial number of individuals and voluntary organizations were also involved in diabetes education. CONCLUSIONS: The findings of this study support the belief that the PDSN, as a member of the multidisciplinary paediatric diabetes team, has a key role in the education of children with diabetes and their parents/carers. However, the importance of the team approach as a whole should not be underestimated.

The evolving concept of health in nursing research: 1988-1998.

This article concerns the evolution of the concept of health, as reported in selected nursing journals, over the last 10 years. It builds on an analysis reported by Reynolds [Reynolds CL. The measurement of health in nursing research. Adv Nurs Sci 1988;10(4):23-31.] who initially investigated the concept of health and the means by which it was measured during the period 1977-1987. Using the same journals as Reynolds, the methodology of systematic review is used to analyse the way in which health is defined, the frequency with which it is investigated and the means by which it is measured, and these data are compared with Reynolds findings. The results indicate that; three times as many studies have been conducted in the last 10 years, a more holistic concept of health has emerged, and the instruments used are becoming more sophisticated. These findings are discussed and the implications for patient education and health care professionals considered.

A study of the effectiveness of different measuring times and counting methods of human radial pulse rates.

The purpose of this study was to determine the reliability and validity of measuring resting radial pulse rates by the use of three measuring times: 15, 30 and 60 s; and two counting methods: one beginning with zero (0) and the other with one (1). A two-factor within-subjects experimental design was used to determine the mean difference between pulse rates obtained from the radial artery, and the heart rates recorded by simultaneous electrocardiographic (ECG) recordings. The sample comprised 206 students. Mean difference was used to calculate the extent of any differences between radial pulse rates and the rate shown by the ECG. The interaction between measuring time and counting methods was confirmed using a two-factor within-subjects analysis of variance. For all types of measuring time, the counting from zero method produced a greater mean difference than the counting from one method. For all measuring times, the mean difference between radial pulse rates and rates shown by the ECG were non-significant in the counting from one method. In other words, when the pulse rate is counted from one, the rates obtained at 15 or 30 s could be used to predict the one-minute resting pulse rates. The results of this study can contribute to the evidence base for this commonly used aspect of patient care.

Care study: providing effective care in palliative nursing.

Currently, nurses are under great pressure to demonstrate effective, evidence-based patient care. In this article a single case study will be used to demonstrate that care can be based on recent research within a palliative care setting to produce effective outcomes. Research-based interventions, which were used to provide care for a patient who will be referred to as Maria, will be discussed and evaluated to illustrate the contribution that evidence-based practice made to her nursing care. Although it is a single case study and the findings cannot be generalized, it is suggested that this article can be used to demonstrate the need for accurate interpretation of assessment data, illustrate the use of research to support nursing interventions in pain management, constipation and skin pressure damage, and show that empirical evidence alone may not be a sufficient basis for care and that moral issues must be taken into account.

The influence of psychological factors on the self-management of insulin-dependent diabetes mellitus.

This study investigated the influence of a number of psychological factors upon the practice and outcome of diabetic self-management among young adults with insulin-dependent diabetes mellitus. Health beliefs, perception of control and knowledge were assessed by scales and questionnaires and glycosylated haemoglobin results and clinic attendance records obtained for 263 patients. The results demonstrated that the sample members perceived that they were responsible for the control of their diabetes, that the benefits of following treatment were greater than any barriers and that they were knowledgeable about their diabetes. However, these factors were not predictive of the outcome variables of metabolic control or clinic attendance according to multiple regression analysis. Implications of these results for nursing practice and for future research are discussed.

Learning the practice of nursing: views about preceptorship.

The provision of clinically based education for nursing students is an essential part of their learning needs. In this article, the opportunity to enhance clinically based learning by means of preceptors is discussed and investigated. A case study was conducted of one college of nursing after the introduction of the Preregistration Diploma of Higher Education in Nursing (Project 2000) course. The study involved preceptors (62), nursing students (15), ward managers (4), senior nurse managers (2) and nurse teachers (8). The investigation involved quantitative and qualitative approaches, data being gathered through questionnaires and interviews. The results indicate that preceptors included functions such as being a role model and supervision of learners' skills but not assessment as part of their role. These views were supported by students, teachers and managers. Knowledge of the clinical area and experience were reported to be preceptors' greatest assets for the role but lack of time to work with students was cited as the greatest barrier. Extra resources required were reported to be protected time for the student and preceptor to work together and further in-service education. The implications of these results for clinically based learning opportunities in the future are discussed.

Knowledge and diabetes self-management.

This paper discusses the role of knowledge in the self-management of diabetes mellitus and addresses limitations in the measurement of knowledge in studies which have been undertaken. In addition, the findings of a recent investigation related to knowledge of diabetes in young adults with the condition are reported. The results showed high levels of knowledge and glycosylated haemoglobin values which were acceptable when length of time with diabetes was considered. However, no relationship between knowledge and level of glycaemic control was demonstrated. In the light of recent research confirming the need for tighter metabolic control, the implications of these findings in relation to future research and the education of health care professionals are considered. Although this paper related to diabetes mellitus many of the issues raised are equally applicable to the wider forum of chronic illness management.

Self-management of chronic illness: implications for nursing.

Health problems and disease have changed during the last century with an increase in the numbers of people with chronic illness. Literature reveals the role of patients changing from passive to active participation in care management. A study of factors influencing self-management using both quantitative and qualitative methods was carried out. Selected results, with the major focus on the qualitative data, are presented to support discussion of a number of issues related to self-management of diabetes. However, many of the implications of the results also apply to those with chronic illness.

Measuring constructs accurately: a prerequisite to theory testing.

Accurate identification and measurement of constructs is particularly relevant to mental health nurses, who often have to work with clients that have intangible needs and problems. In this paper, the measurement of constructs, the relevance of construct validity to nursing research and, in particular, to theory testing will be discussed. Constructs within the health belief model are used to illustrate the discussion and procedure of factor analysis. Analysis of data based on a survey of health beliefs of 276 adults with the chronic condition of insulin-dependent diabetes is presented, interpreted and discussed. Whilst the paper focuses upon specific constructs and study population in order to provide a worked example, the issues raised and principles outlined relate to an analytical model that can be applied to other research problems and settings.

Monitoring diabetic control.

Recent research from America has confirmed that the quality of metabolic control achieved by people with insulin-dependent diabetes does influence the onset and progression of diabetic complications. More than ever before diabetic individuals now have good reasons for striving to attain as good a standard of diabetic control as is possible. Regular monitoring of diabetic status is essential if good control is to be achieved. This article will focus upon the concept of control and consider aspects of diabetic monitoring which may be undertaken either by patients or through professional services. Both direct and indirect monitoring methods will be discussed and strengths and weaknesses considered.

Evaluation of tools to assess clinical competence.

Assessment of student nurses' clinical skills is an important issue in nurse education. However suitable instruments are difficult to locate, and also to design. In the course of this article the need for scientifically designed and tested assessment instruments is discussed. The thoroughness with which 11 clinical assessment documents were developed was evaluated using specific criteria. It was found that in the majority of cases use of a systematic research process to guide development was not evident. However it must be noted that the assessment documents were only evaluated via their presentation in journal articles. Full details of the entire project had perhaps not been published. The implications of the results, some of the difficulties inherent in instrument design and the limitations of this small review are considered.

Developing a system of student nurse profiling through action research.

This article concerns the early stages of a research study which attempted to improve the assessment of student nurses' clinical competence by means of profiling. During the course of the paper the reasons for undertaking assessment will be considered, the existing assessment approach will be briefly reviewed, the use of action research as the method of inquiry will be addressed, and the initial findings from the study described.