Assessing nurses’ knowledge levels in the nutritional management of
diabetes
a b s t r a c t
Although nutrition education for diabetes patients is the responsibility of dieticians and/or nutritionist,
nurses have an important role to play. This study measured the knowledge level of nurses’ and associated
factors in the nutritional management of diabetes. In this cross-sectional study a sample of 200 nurses
completed a 21-item nutritional management of diabetes knowledge test developed based on the ADA
and WHO guidelines for the nutritional management of diabetes. Using Cronbach’s alpha, reliability
was 0.62. The nurses (n = 200) had almost a 1:1 male to female ratio (n = 99, 49.5% and n = 101, 50.5%)
and a mean age of 27.24 ± 3.66 years. Total mean score was 12.13 ± 3.17 (44.9% correct). Over 70% of
the nurses said diabetes patients could exclude any of the major nutrients from their meals. Almost
90% (n = 179) of the nurses did not know the recommended daily caloric intake of carbohydrates for dia-
betes patients. Higher mean scores were found in nurses who have ever had a refresher course in nutri-
tion, ever counseled a diabetes patient and took 2–3 nutrition courses during school. Nurses’
knowledge in the nutritional management of diabetes was poor.
1.
Introduction
Nurses play an important and critical role in educating the indi-
vidual with diabetes. Their role has become more pertinent in
these recent times of the rising prevalence of diabetes (especially
type 2) in every country. The sixth edition of the IDF Diabetes
Atlas reports that 382 million people have diabetes and will rise
to 592 million by the year 2035 (Aguiree et al., 2013). It reports
that 80% of people with diabetes live in low- and middle-income
countries (Aguiree et al., 2013). An estimated 522, 600 people in
Sub-Saharan Africa died from diabetes-related causes in 2013
(Aguiree et al., 2013).
With a clinical feature of high blood glucose, the major goal of
diabetes treatment and management is to maintain normal or near
normal blood glucose levels (Carney, 2010; Nelms, Sucher et al.,
2010) in affected individuals. It has been shown that maintaining
normal or near normal blood glucose levels in people with
diabetes reduces complications (Nelms, Sucher et al., 2010).
Diabetes care is largely self-care requiring the active participation
of the patient in
*
(Kaur & Walia, 2007). Effective self-management care is provided
by a multidisciplinary team of healthcare professionals including
nurses, dieticians, pharmacists, physicians, and diabetes educators.
An important component of the self-management care is nutri-
tion. Patients are usually educated on basic meal planning, carbo-
hydrate counting and exchanges as well as how to read food labels
with the goal of making them independent (Bantle, Wylie-Rosett
et al., 2008).
Although nutrition education is the responsibility of dieticians
and/or nutritionist, nurses have an important role to play. The role
of nurses in the multidisciplinary team is very crucial due to their
regular contact with the diabetes patient. In the hospital setting,
nurses are always available to patients 24 h per day, making them
more easily accessible to patients compared to other members of
the healthcare team. For instance, in the US, nurses are 40 times
more than dieticians and 100 times more than certified diabetes
educators to meet diabetes patients daily in the ward (Bureau of
Labor Statistics, 2011). Patients are more likely to trust them and
seek for advice from them regarding the treatment and manage-
ment of their condition. A study each from the US and Australia
have reported that 90% of nurses routinely receive request for
nutrition advice from patients (Lindseth, 1990; Schaller & James,
41
2005). This puts nurses in a critical position to ensure that
patients get the best of care.
Nurses must be adequately knowledgeable about nutrition
therapy for diabetes patients (Scheiderich et al., 1983; Evert
et al., 2013, 2014) in order to provide effective advice. The provi-
sion of inaccurate information to patients could lead to poor
adher- ence of the diabetes patient to dietary recommendations
resulting in diabetes complications and increased healthcare
cost (Carney et al., 2010).
Several studies have assessed nurses’ knowledge in diabetes
but not their knowledge in the nutritional management of
diabetes. Our search of the literature yielded a few studies that
included nutrition as a component of the knowledge questionnaire
used in assessing the nurses’ knowledge. None have elaborately
covered nurses’ knowledge in the nutritional management of
diabetes.
The purpose of this study was to measure nurses’ knowledge in
the nutritional management of diabetes. In furtherance, factors
associated to the nurses’ knowledge were also measured.
2.
Methods
2.1.
Sample and setting
Using a cross-sectional study design, this study was conducted
in three randomly selected hospitals located in Tamale, Ghana
between January and July 2014. Lying between latitude 9°22 N and
longitude 0°500 W, Tamale is located about 500–600 km North of
Accra, Ghana’s capital city and has a population of 371, 351 inhabi-
tants and four hospitals. All of the hospitals had no designated dia-
betes educator or a team responsible for diabetes patient
education. However, all of them had a nutrition unit responsible
for providing general nutrition care for all forms of conditions. The
four hospitals were listed and three hospitals were selected for the
study through the process of lottery. The target population for this
study included all professional staff nurses working in the three hos-
pitals. Excluded from the study were student nurses; those who
were awaiting results from the Nurses and Midwives Licensure
examinations and head nurses. Age, years of experience or type of
employment (full or part-time) were not limitations for participa-
tion in the study. Permission to have access to the hospitals was
obtained from the administrators. Ethical approval was granted by
the Ethics Committee of the School of Medicine and Health
Sciences, Tamale, Ghana. A team of research assistants together with
the second and third authors visited the selected hospitals for pur-
poses of data collection. Nurses were approached at the unit in
which they worked. All nurses working in the unit were
approached
by a research assistant to participate in the study. The
purpose of the
study as well as the inclusion and exclusion criteria
was explained to
the nurses by the research assistant.
Questionnaires were given to all
nurses that consented, voluntarily
to participate in the study. Included in the questionnaire was a
cover letter that assured the nurses anonymity and confidentiality
of all data provided. Nurses were at liberty to take the
questionnaire home if need be. A total of 465 nurses were
approached to participate, 235 (participation rate = 50.5%)
consented and were given questionnaires. From all the three
hospitals, 200 questionnaires were returned yielding a response
rate of 85.1%.
2.2.
Questionnaire
The questionnaire consisted of two sections including demo-
graphic data and nutritional management of diabetes knowledge
test (NMDKT). A total of nine questions assessed the demographic
data of the nurses including their professional background. The
NMDKT consisted of questions that assessed nurses’ knowledge
levels in the nutritional management of diabetes. The content of
the NMDKT was developed based on the WHO and the American
Diabetes Association nutrition guidelines and published studies
that assessed diabetes and/or nutrition knowledge levels among
nurses (Crogan et al., 2000; Carney et al., 2010; Al-Shwaiyat
et al., 2013). The test was submitted to a panel of three experts
in nutrition and health for evaluation of content validity, test for-
mat and item construction. All items were revised based on the ini-
tial comments of the review panel and resubmitted for further
evaluation. All the items were approved by the panel as appropri-
ate assuring good content validity. Using Cronbach’s alpha to mea-
sure internal consistency, a reliability coefficient of 0.62 was
attained for the NMDKT. From a total of 21 items, six assessed gen-
eral concepts of diabetes; 13 tested knowledge in basic meal plan-
ning for diabetes patients and one on basic treatment for a
hypoglycemic patient. With regards to format, 12 items were mul-
tiple choice questions and the rest were statements that expected
nurses to indicate as true or false. An option of ‘‘I do not know’’
was included to all the items to cater for nurses who did not have
an idea at all about a test item. The questionnaire took
approximately 15–20 min to complete.
2.3.
Statistical analysis
Descriptive statistics of mean and standard deviation was used
to analyze achieved knowledge scores. All categorical data were
expressed as frequencies and proportions. Reliability and internal
consistency of the questionnaire were evaluated using
Cronbach’s alpha. Student t-test was used to compare means
among the study variables.
Cronbach’s alpha analysis was performed using the IBM
Statistical Package for the Social Sciences (IBM SPSS) version
21.0. Student t-test analysis was computed using GraphPad Prism
version 5 (GraphPad software, San Diego, California, USA,
www.graphpad.com).
A p-value of <0.05 was considered significant.
3.
Results
Table 1 describes the general characteristics of the nurses. The
nurses had a mean age of 27.24 ± 3.66 years and have been
practic- ing nursing for a mean duration of 2.71 ± 1.80 years. One
hundred and fifty-five nurses (77.5%) were satisfied with the
nutrition edu- cation they received during training in school
and 185 (92.5%)
Table 1
General and professional background of the nurses (n = 200).
Variable Frequency (%)
Age
630 171(85.5%)
>30 29(14.5%)
Gender
Male 99(49.5%)
Female 101(50.5%)
No. of years in nursing
65 years 184(92.0%)
>5 years 16(8.0%)
No. of nutrition courses taken in school
0–1 148(74.0%)
2–3 52(26.0%)
Ever had a refresher course in diabetes management
Yes 6(3.0%)
No 194(97.0%)
Ever counseled a diabetes patient
Yes 141(70.5%)
No 59(29.5%)
42
reported that it is the responsibility of the nurse to provide basic
nutrition education to diabetes patients.
The nurses achieved a mean ± SD score of 12.13 ± 3.17
(44.9% correct) on the knowledge questionnaire. With a median
score of
12 (46.2% correct), the test frequency indicated a bell-shaped
curve. Table 2 shows the frequency of distribution of the scores.
Table 3
Basic knowledge on diabetes: percentage of correct responses among the nurses
(n-200).
Questionnaire item Frequency
(%)
Diabetes is indicated by an FPG of 6.1–6.9 mmol/dl 91(45.5%)
Included in the questionnaire were questions regarding basic
knowledge on diabetes (Table 3). A large proportion of the nurses
could recognize that diabetes is not caused by high sugar intake.
Exercise plays an important role in the prevention and
management of diabetes
Symptomatic hypoglycemia could be treated using 3–4 cubes of
sugar
177(88.5%)
124(62.0%)
However, 54.5% (n = 91) of the nurses could not correctly identify
the recommended fasting plasma glucose level for diabetes.
The questions answered correctly by the nurses relating to
knowledge in basic meal planning are presented in Table 4. Over
70% said diabetes patients could exclude any of the major
nutrients from their meals. Fifty one percent (n = 102), 17.5% (n =
35) and 54.0% (n = 108) of the nurses said carbohydrates,
protein and fat
Diabetes and obesity are closely related 171(85.5%)
Diabetes is related to hypertension 140(70.0%)
Diabetes is caused by high sugar intake 31(15.5%)
Table 4
Knowledge on basic meal planning for diabetes management: percentage of correct
responses among the nurses (n = 200).
respectively should be excluded from the meals of diabetes
patients. Almost 90% (n = 179) of the nurses were unable to iden-
tify the recommended daily caloric intake from carbohydrates for
Questionnaire item Frequency
(%)
diabetes patients.
Sixty-five percent (n = 130) of the nurses did not know the
effect of Trans fats on LDL cholesterol levels in the body and 29%
(n = 58) did not know that non-fat or low fat milk are lower in
calo- ries than whole milk.
Student t-test was used to measure the differences in mean
scores stratified by age, gender, duration of service, number of
Diabetes patients should not exclude any nutrient from their
diet
Use total carbohydrates on food labels to determine amount of
carbohydrates per serving
The total amount of carbohydrates is more important than the
type of carbohydrate
50–60% of the daily caloric intake of diabetics should come from
carbohydrates
50(25.0%)
23(11.5%)
84(42.0%)
40(20.0%)
nutrition courses taken in school, participation in refresher
courses
Diabetes patients should consume fruits
160(80.0%)
Diabetes patients should consume alcohol with meals 75(37.5%)
and experience in counseling diabetes patients and presented in
Table 5. Significantly (p = 0.003) males scored higher than females.
Non-fat or low fat milk contains less fat and low calories than
142(71.0%)
whole milk
Trans-fats increases LDL cholesterol levels
40(20.0%)
Animal fat should be restricted for diabetes patients
97(48.5%)
4.
Discussion
Scoring a mean knowledge score of 12.13 (44% correct), our
10–15% of the daily caloric intake of diabetics should come from
protein
Cholesterol should be restricted to 300 mg daily for diabetes
patients
20(10.0%)
71(35.5%)
nurses knowledge on the nutritional management of diabetes
was poor. Direct comparison to other studies may be difficult
due to limited studies assessing nurses’ knowledge in the nutri-
tional management of diabetes as most reported studies either
assessed nurses’ general knowledge in diabetes and/or its
manage- ment, with a few including nutrition as a component of
the ques- tionnaire. However, comparing our findings with the few
ones available, the mean score achieved by the nurses in this
study was lower than 58.8% reported by Al-Shwaiyat et al. (2013)
in a sample of Jordan nurses using a 31-item questionnaire that
assessed their nutritional therapeutic knowledge. Another study
that assessed the knowledge of nurses and student nurses on the
nutritional management of diabetes found a mean knowledge
score of 53% and 50% for nurses and students respectively using
a 20-item questionnaire (Carney et al., 2010). Comparing our find-
ings with other studies that had nutritional component as part of
the general diabetes knowledge questionnaire, the mean score
achieved by the nurses in this study is higher. These studies have
reported a mean diabetes-related nutrition knowledge score of
0.7–22.3% (Feustel, 1976), 14% (Knight et al., 1984) and 20%
Diabetes patients should eat balanced diets 80(40.0%)
Table 5
A comparison of nurses’ knowledge on the nutritional management of diabetes with
some general and professional background of the nurses.
Variable
Mean
95% CI
p value
Age
630 years
12.28 ± 3.29 11.78, 12.78 0.091
>30 years 11.21 ± 2.10 10.38, 12.04
Gender
Male
12.93 ± 3.10 12.31, 13.55 0.003
Female 11.34 ± 3.05 10.73, 11.94
Duration of service
65 years
12.17 ± 3.19 11.71, 12.64 0.460
>5 years 11.56 ± 2.96 9.98, 13.14
No. of courses in school
0–1
11.99 ± 3.39 11.44, 12.54 0.322
2–3 12.50 ± 2.42 11.83, 13.17
Ever had a refresher course
<5 <20
4(2.0%)
No 11.88 ± 3.59 10.95, 12.82
5–7
20–29
10(5.0%)
8–10 30–39
41(20.5%)
11–13 40–49
81(40.5%)
14–16 50–59
53(26.5%)
(Modic et al., 2009). The inconsistency in the mean knowledge
17–19
20–22
60–69
70–79
6(3.0%)
5(2.5%)
scores between the studies could be due to the use of variable
questionnaires to assess knowledge. It could also be related to cur-
Maximum score = 27.
ricular differences and focus.
Table 2
Frequency of distribution of the knowledge scores.
Raw scores
% correct
Frequency (%)
Generally, nurses’ knowledge on basic meal planning for
diabetes patients was found to be deficient. Contrary to the ADA
and the WHO guidelines for the management of diabetes, over
three-quarters of the nurses would recommend that diabetes
patients should exclude one or more macronutrients (carbohy-
drates, protein and lipids) from meals. More evidently about 60%
of the nurses did not know that it is important for diabetes
patients
to eat balanced diets as 51% (n = 102), 17.5% (n = 35) and
54.0%
(n = 108) of them indicated that carbohydrates, protein and
fats respectively should be excluded from the meals of diabetes
patients. The ADA and the WHO guidelines recommend that the
meals of diabetes patients should be adequately balanced contain-
ing all the nutrients.
Furthermore, nurses’ knowledge on the daily macronutrient
requirements of diabetes patients was found to be one of the
weak- est. Respectively, 20%, 10% and 14% of the nurses were
able to cor- rectly indicate the average amount of calories
expected from carbohydrates, protein and lipids daily. While
about 60% selected wrong options, over 40% of them indicated
that they did not have an idea at all as to the daily
macronutrient requirements of dia- betes patients. Furthermore,
over 50% of the nurses did not know that the total amount of
carbohydrates consumed per meal is gen- erally more important
than the type of carbohydrate consumed. With over 70% of the
nurses ever providing dietary advice to dia- betics; these findings
makes one to worry about the quality of advice provided to the
diabetes patients. Nurses’ knowledge in this regard requires
improvement probably through refresher courses. The
coexistence of high cholesterol and LDL levels in diabetes patients
puts them at a higher risk of developing the metabolic syn- drome.
As such advising diabetes patients to reduce their intake of fat
especially animal fat is very important. However, the nurses’
knowledge in this regard was found to be weak. Even though over
70% of the nurses were able to correctly identify that non-fat or
low-fat milk was lower in fat and calories than whole milk, 80% of
them did not know that trans-fats increases plasma LDL
cholesterol
levels. In fact over 70% of them did not know trans-fats
and their food
sources. In furtherance, over 50% did not know
that animal fat should be restricted for diabetes patients. Also,
over 60% did not know the recommended daily intake of
cholesterol for diabetes patients. The lack of knowledge among
the nurses in the dietary management of fats may pose risks to
the adherence of the diabetes
patients to dietary recommendations.
Another important finding of this study was that, 62.0% of the
nurses were able to correctly identify the appropriate initial treat-
ment for hypoglycemia. This is higher than the 6.5% reported by
Drass et al. (1989); consistent with the 62.9% reported by Carney
(Carney et al., 2010) but lower than the 73% reported by Ahmed
et al., (Ahmed et al., 2012). Notably, in this study as between 4%
and 7% of the nurses said they will recommend either a piece of
cake with icing, 1 cup of milk or a slice of bread for the initial treat-
ment of hypoglycemia, 23.5% did not know what to do with a
patient experiencing hypoglycemia. Even though about 62.0% of
nurses could treat hypoglycemia, it is of concern that over one-
third of them did not know the appropriate treatment for
hypoglycemia.
Commendably, nurses’ knowledge in the general concepts of
diabetes was found to be good. Over 70% of them were able to rec-
ognize the relationship between diabetes and hypertension, and
obesity. Furthermore, they correctly overcame the general miscon-
ception that diabetes is caused by the excessive consumption of
sugar.
Even though the differences were not significant we found that
higher knowledge scores were associated with nurses aged 30
years or younger; and those having worked for 5 years or lower.
Furthermore nurses who took 2–3 nutrition courses in school;
ever had a refresher course in nutrition; and ever counseled a
diabetes patient; had higher knowledge scores than their
counterparts, even though the differences were not significant.
This demonstrates that improving the curricula of nursing
programmes with regards to nutrition could help improve the
nutrition knowledge of nurses during training. These findings also
indicate that making refresher courses available to nurses may
help improve their knowledge in the nutritional management of
diabetes.
5.
Conclusion
Nurses’ knowledge in the nutritional management of diabetes
was poor. It raises concerns about the adequacy of nurses’
knowledge in the nutritional management and the quality of
dietary information provided to patients. The curricula of nurses
training could revised to improve nurses’ knowledge in nutrition
during training. Continuing education through workshops and
refresher courses could be organized for nurses already in service
to improve their knowledge in nutrition.
Conflict of interest
We have no conflict of interest to declare.
Acknowledgements
Authors wish to thank the administrators of the selected hospi-
tals for granting them permission and access to the participants.
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