Assessment of Nurses Knowledge Concerning Type 2 Diabetes Mellitus Management with Insulin Therapy in Intensive Care Units at Baghdad Hospitals

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INTRODUCTION:
Diabetes Mellitus (DM) has affected humans for millennia, and the descriptions of it are surprisingly ancient, which it's incidence is rising sharply worldwide (1) .Now days, the introduction of new insulin formulations and a new emphasis on tight blood glucose control make inpatient diabetes treatment has become more complicated (2) .Inpatient mortality and prolong hospital stay are significantly resulting from diabetes (3) .In addition, adverse patient outcomes may occur because the errors that results from insufficient knowledge of insulin using by medical staff (2) .Moreover, diabetes mellitus is a common health problem of a chronic nature that requires continuing care and education.For this reasons, health care providers especially nurses, irrespective of the discipline in which they work, need to have knowledge of inpatient diabetic with insulin therapy (3) .
Identifying the knowledge of the staff in using insulin therapy for patients in critical care units will allow for educational programs to be developed to bring the knowledge base of the staff nurse forward to achieve best practice.Keeping updated with the ongoing research is one of the challenges that the registered nurse faces in caring for patients with hyperglycemia (4) .The insulin therapy requires coordination and understanding of both the individual with diabetes and those responsible for diabetic care.There is no definite insulin dose that works well for every individual, the dosage of insulin changes based on patient's blood glucose levels and the type of insulin used (4) .
Therefore, insulin treatment must be individualized to fit the life style of the individual and metabolism of individual with diabetes.The changes and modifications are made as needed throughout the life of individual with diabetes (5) .The challenge that the registered nurse faces is how to keep the knowledge of the best practice at the forefront of patient care delivery.The role of insulin in managing patients with and without diabetes provides metabolic control to achieve homeostasis reducing the complication that can occur.Lack of knowledge has been identified as the greatest barrier to overcome when lowering the glycemic goals to improve outcomes.The treatment for Diabetic Mellitus (DM) includes administration of oral hypoglycemic agents and injectable insulin therapy along with life style modifications (6) .Objectives of the study: The study aimsto assess the knowledge of nurses concerning type 2 diabetes mellitus management with insulin therapy in intensive care units and to finding out the relationship between the nurse's knowledge and the demographic characteristics that includes (age, gender, level of education, years of experience, and training session).

METHODOLOGY:
Design of the study: Quantitative design (a descriptive study) was carried out to achieve the purpose of the study.Setting of the study:The study was conducted in ICU at Teaching Hospitals in specialized Cardiac Hospital Ibn-Albettar, Medical City, Al-khademia, Ibn-Alnafes and al-kharkh hospitals.These hospitals provide various nursing care for patients which suffering from diabetes with divergent management included treatment with insulin.

Sample of the study:
A non-probability (purposive) samples of (60) nurses' who was consisted of all nurses provided nursing care for patients who suffering from Diabetic Mellitus including management with insulin therapy and according to special criteriastarting from September 15 th 2013 up to the March 30 th 2014.Instrument construction: In order to assess nurses' knowledge, a constructed questionnaire was design and means of an interview technique with the nurses was constructed to measure the variables underlying study.A permission request was submitted to American Diabetic Association for using part of the questionnaire'Diabetes Basic Knowledge Test' and reproduce the article "Perceived and Actual Level of Knowledge of Diabetes Mellitus among Nurses".A questionnaire based on comprehensive review of relevant literature and previous studies was also used.These instruments consist of two parts namely; the demographic data of the nurse, and the nurses' knowledge about Diabetic Mellitus management especially, with insulin therapy.The questionnaire was constructed for the purpose of the study consisted of (22) multiple choice questions which include two parts: Part I: Demographic Date Sheet: Part one concerned with personal information include, the nurses (gender, age, educational level, numbers of experience years and whether if they participating in continuing course training inside or outside the country).

Part II:Nurses knowledge:
Part two contained multiple choice questions and included (22) items concerning nurses knowledge regarding Diabetic Mellitus management especially, with insulin therapy.The questionnaire were ordinal according to the right answers which were scored as (a, b, c, and d).
Validity of the instrument: Constant validity determined for questionnaire through the use of panel experts who are faculty members from College of Nursing.The experts were asked to review the questionnaire for content with clarity.Such changes were employed according to their suggestions and valuable comments.Reliability of the instrument:Pilot study was carried out between the October 10 th to November 10 th , 2013.On (10) nurses in ICU by the researcher and tested questionnaire was performed for determination of the instrument reliability level.The results indicated that the correlation coefficient was r = 0.74 at the percentage of variance (43.223) which was statistically acceptable.Data collection: The data collected with constructed questionnaire through an application of direct interview as mean of data collection.Statistical data analysis: Appropriate statistical approach was used that includes descriptive statistics (frequency, percentage, mean of score, Relative sufficiency) and inferential statistics significance, and correlation coefficient.

*SD: Standard Deviation
Table (1) presented that most of the study participants were male nurses (n= 37; 61.7%), less than the half of them were in the (21-30 years-old) age group (n= 29; 48.3%), more than the half of them were graduates of nursing colleges (n= 31; 51.7%), less than the half of them have 1-5 years of working in nursing (n= 27; 45.0%), and less than the half of them reported that they sometimes participate in courses of continuous education (n= 29; 48.3%).The nurses responses about the insulin treatment knowledge was shows in table 2 which revealed that "the sites that require wiping with surgical gauze and disinfectant on insulin injection" and "the function of insulin is" (n= 53; 88.3%) (n= 52; 86.7%) respectively.While, participants incorrect answers were for the items of "In (DKA) Diabetes Mellitus when changing from the continuous insulin dose to subcutaneous insulin, this dose starts approximately within", " The mixed called 70/30 is", and "The mixed solution called 75/25 is" (n= 9; 15.0%) (n= 9; 15.0%) (n= 10; 16.7%) respectively.The findings of table 3 revealed that more than the half of participants have fair level of knowledge (n= 32; 53.3%).*df: Degree of Freedom **F: Frequency ***Sig: Significance Table 4 reveal that there was highly significant association between participation in courses of continuous education and level of knowledge (p= 0.000).

DISCUSSION:
Part I: Discussion of Intensive Care Unit Nurses Demographical Data's.Throughout the course of the present study, it has been noted that the majority of study sample (61.7%) were male.Concerning the nurses age, the highest proportion of nurses were young with (48.3%) at the age of (21-30).Related to the educational level, the highest percentages (51.7%) of the sample were academic nurses who graduated from Colleges of Nursing.On the other hands, the highest percentages (45.0%) of nurses were with (1-5) years of experiences in the ICUs while the lowest percentages (1.7%) of them were have more than 20 years of experiences in the ICU's.Finally, concerning the participating in continuous education , the results show that the highest percentages (48.3 %) were sometimes participating in continuous education about insulin therapy while (20.0%)only were not participating in such courses (table 1).
Nurses who are in continuous attendance with the diabetes patient, are in a prime position to ensure that the outcomes for the patient is optimizing when he/she treating them with insulin therapy.This not only requires accurate assessment and management skills, but also the need for educational initiatives regarding insulin formulations and inpatient management of diabetes for health care professionals; and acoordinated team approach would improve patient outcomes (2) .Part II: Discussion of Intensive Care Unit Nurses Knowledge Regarding to the DM Management with Insulin Therapy: The data analysis was conducted on 22 multiple choice questions that have assessed intensive care unit nurses knowledge regarding to the insulin therapy based on significantly of right answers, which had been reported and manifested out of the mean of scores of these answers.The results indicated that there was a high nurses knowledge grade in the question that demonstrate participants' correct answers were for the items of "the sites that require wiping with surgical gauze and disinfectant on insulin injection" and "the function of insulin is (table 2).While, participants incorrect answers and lower knowledge levels were for the items of "In (DKA) Diabetes Mellitus when changing from the continuous insulin dose to subcutaneous insulin, this dose starts approximately within", "The mixed called 70/30 is", and "The mixed solution called 75/25 is" respectively.Surprisingly, 20% of the participants have knowing what the insulin is, which is an interesting that most of ICU nurses do not have knowledge about what the "insulin" as a form.In conclusion, our study results indicates more than the half of participants who work in intensive care units have fair level of knowledge about insulin therapy.These results evoked our minds to mobilize the efforts for designing a framework to build nurses knowledge in the ICU setting for applying better patient's care and maximizing health outcomes.Otherwise, nurses with poor knowledge about insulin therapy in ICU resulting to occurring medical errors and thus to fateful results.Most of our participants have a high education level, which in this case "Bachelor Degree in Nursing", however, does not correlate with their knowledge regarding insulin therapy, which is similar to nurses with diploma.Intuition is a valuable source of knowledge that should be recognized in the provision of nursing care.Also, at times nurses knowledge has been perceived as a knowing, 'magic' knowing, and an amalgam of experiences and knowledge (7) .Commonly, medical staff adopts primary responsibility for applying diabetes therapy in teaching hospitals, and staff nurses are in the key position to administer insulin and recognize dangerous orders and impending hyper-and hypoglycaemia.However, they have been reported to be inadequately trained particularly in insulin treatment and generally, diabetes management (8) .Examining and exploring the knowledge ergo intuition of nurses is a necessary undertaking (9) .Diane et al. (2007) concluded that "nurses have to value empirical knowledge above all other forms of knowledge" (p.154) (9) .

CONCLUSION:
The study that the most of nurses whom work in intensive care unit have knowledge deficit about insulin therapy.However, the findings of the study indicated that there is a knowledge deficit of nurses in some aspects related to insulin therapy.

RECOMMENDATIONS:
1. Great emphasize should be direct toward the encouragement for participating in continuous educational programs and courses related to nursing care of patients with diabetic mellitus and insulin therapy.2. Hospital and health organisations should be applying flexible and responsible steps to facilitate passages for better educational level for junior nurses and those who need high graduated level.3. Nevertheless, further studies are necessary in order to assess nurses' knowledge toward DM management with insulin therapy in ICUs and demonstrate the errors that occur, which are lead to fatal complications.
Diabetes mellitus is a common health problem of a chronic nature that requires continuing care and education.For this reasons, health care providers especially nurses, irrespective of the discipline in which they work, need to have knowledge of inpatient type II diabetic with insulin therapy.