This is the first nationwide survey revealing what nurses experienced and perceived in their practice related to diabetes care in long-term care facility settings. The result revealed several difficulties that need to be addressed with priority.
The highest prevalence of perceived difficulty was recognizing signs/symptoms of acute metabolic failure due to hyperglycemia, and it was reported to be more difficult than being aware of the signs/symptoms of hypoglycemia. Hypoglycemia is a major safety concern for older adults with diabetes because it is often difficult to recognize it due to fewer and unspecific symptoms and can lead to negative consequences [5]. However, severe hyperglycemia causes dehydration and hyperosmolarity and can lead to the development of critical conditions [4], and previous studies have reported that nurses have insufficient knowledge of hyperglycemia as compared to hypoglycemia [16]. The increase in the clinical assessment skill and confidence in dealing with hyperglycemia is important.
Another difficulty perceived as being high was maintaining the blood glucose level in a healthy range while respecting residents’ needs and preferences. This might be a new insight because previous studies on nurses’ perception and knowledge have seldom focused on such a difficulty. This result may reflect nurses’ conflict between treatment goals of managing glycemic control and respecting their preferences. Previous studies report that nursing home residents were burdened by restricted diets and fingerstick monitoring and there is a need to be aware of how the setting of long-term care facilities might facilitate diabetes management while on the other hand, it can possibly hinder resident autonomy [17]. In order to promote residents’ quality of life, eliciting residents’ preference and empowering them may be an important step, but a description of a specific approach is needed [17,18].
People with diabetes need to receive special attention to foot and oral care, because they are at higher risk of poor oral health [19] or problems with lower extremities, which sometimes complicate their comorbidities [15]. The results show that oral problems are perceived as more difficult than foot problems. This may be because, for older adults in general, poor oral health is reported to be associated with other serious conditions, such as malnutrition [20] and infectious conditions, including aspiration pneumonia [21]. Although the Japanese government has adapted insurance benefits for improvement of oral health management in long-term health care facilities, there are more issues involved, including relatively low claim rates and challenges of nursing practice [22,23]. All these might be related to more perceived difficulty in oral care.
Discussing with physicians and obtaining the necessary orders was found to be less difficult probably because of the existence of a physician in each facility. Approximately half of the nurses perceived the development of shared understanding of the care plan with care workers as being difficult, while about 30% perceived sharing information regarding diabetes with care workers as being difficult. Care plans mostly include nursing assessment and the specific information of physical status, treatment, or medication, such that sharing care plans with care workers is sometimes difficult because of different levels of knowledge and confidence stemming from different occupational purposes [12]. Good collaboration between nurses and care workers will promote care quality and hence that attention needs to be paid to developing some tools or strategies.
Most difficulties did not associate with variables related to diabetes management. This result indicates that the level of difficulty may not be dependent on these variables. Probably other factors, such as knowledge, or resources, might be more effective at raising diabetes care confidence [24]. More participants recognized needs of educational opportunities and diabetes care guidelines and these were associated with diabetes management, such as the current number of residents with diabetes, those requiring insulin injection, and experiences of emergency transfers due to hypoglycemia. Most difficulties were also related to these needs. These results indicate that nurses who face challenges and are required to make decisions on a daily basis experienced such needs in higher levels. Additionally, the results showed that participants who had diabetes care guidelines in facilities more easily perceived their importance, indicating that the presence of any standard recommendation helps their daily diabetes care practice.
There were several limitations to this study. First, the response rate was 33.3%, which is comparable to other nationwide studies [23], though low. Participants may differ from nonparticipants in that respondents may be more interested in diabetes care; thus, some caution is needed to interpret and generalize the results. Second, we did not mention details or content and the focus of the supposed guidelines. Furthermore, other variables, such as nurse knowledge or ratio of residents with cognitive impairment may be related to perceptions of difficulties and needs. Future studies that investigate the role of such variables are warranted to further explore the needs in diabetes care in long-term care facilities.