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Diabetes education in the inpatient setting: Who really needs the education?
Improving patient care starts with the medical staff.
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Diabetes educators work in a variety of settings and consequently face various challenges. For those of us who have responsibility for inpatients, we know providing education to patients who are sick is not an ideal situation.
Patients who are recently diagnosed with diabetes and need to take insulin often are so upset that they can’t hear or process what the educator is discussing with them. Unfortunately, this may be the only time a patient actually receives any diabetes education. As educators, we try to provide what is most important for the patient to go home and be safe living with diabetes. This may mean the only education the patient receives is about monitoring, insulin administration and the signs and symptoms of hypoglycemia, as well as how to treat it.
Processing all this new information at one time can be very overwhelming to a patient and difficult to remember once at home. Having only one opportunity to perform an injection when the diabetes educator is present is not enough to reinforce this task.
Reinforcement of education
 Nadine Uplinger |
As educators, we try to encourage the patient’s nurse to reinforce the diabetes teaching we provide, especially having patients inject their own insulin. This allows the patient to gain a small measure of confidence and skill in conducting their own injections while someone can assist them and make the necessary corrections. We know nurses are busy and are not always able to spend the extra time it takes to allow someone to give their own injection so it becomes important for them to realize the vital role they play in helping someone with diabetes provide their own self-care.
At the Albert Einstein Healthcare Network, we must rely on the floor nurses to reinforce the diabetes teaching that we provide patients. We also know that the nurses have varying levels of experience with diabetes and may not have a comfort level with current diabetes management. This realization came to us as a result of instituting various diabetes protocols to improve patient care. The nurse-driven hypoglycemia protocol was particularly challenging because everyone wanted to add his or her own “twist” to the recommended treatment. The protocol calls for 15 g of carbohydrate, but nurses might only provide 5 g, thinking this is sufficient. They also have trouble understanding the need to treat hypoglycemia when the meal trays are on the floor and ready to be delivered.
Patients often mimic what they see done in the hospital because they assume it is correct. We frequently have patients tell us they give their insulin in the arm because that is what the nurse did in the hospital. Other patients have had diabetes for years and are knowledgeable as to managing their disease. For them, it can be distressing when they realize they may know more about managing their diabetes than their nurse does.
Update in management
We wrote a proposal and obtained a small grant from our Albert Einstein Society to update interested nurses in current diabetes management. Nurses were represented from throughout the Albert Einstein Healthcare Network and were encouraged to serve as a resource person for their unit staff. We had about 70 nurses attend an eight-hour in-service on diabetes as well as another four hour session involving only the discussion of diabetes case studies.
Finally, they “shadowed” the diabetes educators to better understand the role of the diabetes educator and the process we follow to educate patients. We encouraged these nurses to participate in our Diabetes RN Resource group that meets monthly. We hold these meetings at lunchtime and encourage the staff to share any diabetes-related issues on their units with the group.
This program was a learning experience for both the diabetes educators and the nursing staff. Most of the nurses admitted that they had not received a diabetes update in years and were positive about the opportunity to improve their diabetes knowledge. As educators, we learned that our assumptions about what the nursing staff knew about diabetes were often incorrect. We were prepared to provide in-depth information about diabetes pathophysiology when we really needed to concentrate on providing case studies with concrete examples of how to handle various patient scenarios. This was especially true about handling insulin administration and not holding basal insulin because the patient was not eating. In general, most of the nurses had some degree of discomfort regarding the action times of insulin.
As educators, we need to do a better job of teaching nurses to “think like a pancreas.” Accomplishing this would solve the problems created by mismatched timing of glucose monitoring, insulin administration and meal delivery. Until we are successful in our attempts to educate the nursing and house staffs, our education efforts with patients are in jeopardy. Consistency in what we teach and practice is essential to improve the diabetes care of our patients.
Nadine Uplinger, MS, MHA, RD, CDE, BC-ADM, LDN, is the Director of the Gutman Diabetes Institute at Albert Einstein Healthcare Network in Philadelphia, PA.