School Nurses’ Roles in Diabetes Education and Management for Students with Type 1 Diabetes in School Settings

Abstract

Background: Type 1 diabetes (T1D) is one of the most common pediatric chronic diseases in schools. Students with T1D experience challenges in schools related to disease management, development, and in-school support. School nurses, designated health care professionals, are responsible for helping and supporting students with T1D manage their disease and needs through continuous interactions with students, families and school personnel. Purpose: The overall purpose of this research is to gain a broad understanding of school nurses’ roles in diabetes education and management for children with T1D in school settings through examination of the following: 1) the interrelations between school nurses’ attitudes about diabetes and self-efficacy in diabetes management and education including diabetes care behaviors, 2) the nature of school nurses’ attitudes and support for transitional care for children with T1D in school settings, 3) the interrelations between the levels of school nurses’ educational preparation and their self-efficacy as well as attitudes related to delivering diabetes education and management to children with T1D, and 4) school nurses’ attitudes about their actual and potential activities related to diabetes education. Methods: A total of 114 school nurses who provided diabetes care in schools participated in a descriptive study. Participants completed online surveys about demographic information, school nurses’ roles, diabetes attitudes, self-efficacy in diabetes education, self-efficacy in diabetes management, and diabetes education/transitional care. From those who completed the surveys, 20 convenience sample participants participated in semi-structured interviews. Results: School nurses had positive attitudes toward diabetes related issues, a moderate level of confidence in diabetes education and diabetes management, and a moderate or higher level of implementation of recommended nursing practice for students with T1D. School nurses’ diabetes attitudes were not related to their self-efficacy in providing diabetes education, but nurses’ attitudes towards the psychosocial impact of diabetes were significantly related to their self-efficacy in providing diabetes management (managing insulin pumps, administering glucagon, and counting carbohydrates) and the number of diabetic students school nurses took care of was a significant contributor to this interrelation. Holding a higher nursing credential was associated with having positive diabetes attitudes, but not with having higher levels of self-efficacy in diabetes education and diabetes management. Having a national school nurse certification was positively related to school nurses’ self-efficacy in diabetes education and counting carbohydrates. Nurses’ work status and the type of school they worked in were significantly related to their self-efficacy in providing diabetes education. The interview data revealed the core construct of school nurses’ perceptions of transitional care to be “supporting students to gain autonomy in diabetes management based on continued care in school systems.” School nurses’ perceptions focused on care continuity of diabetes management in a new school along with increasing independence in diabetes management. Both the survey and interview data revealed that school nurses providing care for transitional care focused on preparation for upcoming changes involved with diabetic students’ transitions to a new school environment including attaining diabetes self-management. School nurses also suggested coordinating care, transferring health documents to the next school, and promoting students’ independent diabetes management for successful transitional care in schools. The core construct of the reasons for initiating diabetes education for students with T1D was “instantly responding to a diabetes-relevant situation” in schools. School nurses provided diabetes education to meet diabetic students’ immediate diabetes management needs. School nurses also suggested three possible formats for diabetes education in schools to ensure a proper approach with systemic preparation: short, one-on-one education enhancing diabetes management skills, group sessions for social-emotional support, and systemic readiness for diabetes education that includes a standardized curriculum and fulltime school nurses. Conclusions: School nurses having positive diabetes-related attitudes was related to having a higher level of self-efficacy in providing diabetes management not to having self-efficacy in diabetes education; however school nurses’ self-efficacy in diabetes management was highly correlated with their self-efficacy in diabetes education. Also, school nurses’ credentials were a significant contributor only to their diabetes-related attitudes. In contrast, holding a national certification of school nurse was associated with self-efficacy in providing diabetes education and diabetes management in carbohydrate counting. Attitudes of school nurses assisting students in diabetes management were significantly related to their experience of providing transitional care to students with T1D. Also, nurses’ self-efficacy in diabetes education was significantly associated with their experiences providing transitional care. School nurses perceived transitional care as support for enhancing students’ independence in diabetes management in schools and relevant care content focused on preparing students and families for new school environments and maintaining similar levels of diabetes care. School nurses’ diabetes education was mainly initiated based on the immediate needs of students in diabetic situations, not on the long-term goals of diabetes management. In addition, systemic approaches to diabetes education were identified as possible formats for diabetes education based on diabetic students’ levels of self-management and development. The new knowledge generated from the findings provides information about school nurses’ practices for caring of students with T1D and relationships between their diabetes-related attitudes and confidence in diabetes education and management, so current practices can be developed to more effectively support diabetic students in schools. In addition, the study findings help school nurses understand the importance of transitional care and necessary nursing care in school systems for students with T1D.