Nurses' perception of diabetes care needs in long-term facilities in Japan: A cross-sectional survey

Abstract

Background: Diabetes is one of the common aging-related diseases, and older people with diabetes are likely to have significant health issues. In long-term care facilities, nurses often face challenges in providing appropriate diabetes care for residents. This study aimed to describe the experience and perception of nurses in diabetes care at long-term care facilities.

Methods: A nationwide cross-sectional survey was administered to 1371 nurses representing different facilities. A self-report questionnaire was used to collect data regarding demographic characteristics of participants, variables related to diabetes management, difficulties in diabetes care, and the recognition of educational opportunity needs in diabetes care as well as needs for diabetes care guidelines. Descriptive statistics and bivariate analyses were performed to examine the associations among variables.

Results: Among participants, 88.7% owned registered nurse license and had an average experience of 10.4 years in long-term care facilities. Approximately 61% perceived difficulties in recognizing signs/symptoms of acute metabolic failure due to hyperglycemia, while about 37% of participants did in being aware of the signs/symptoms of hypoglycemia. About 59% of participants perceived difficulties in managing blood glucose with respect to residents’ needs and preferences. Approximately 62% recognized educational opportunity needs and about 75% recognized the need for diabetes care guidelines suitable for long-term care facilities. These needs were related to the perception of difficulties, but not to variables related to diabetes management.

Conclusion: This study identified the specific areas in which nurses experienced difficulties in diabetes care for residents and revealed the areas in which an approach for improving confidence of nurses in diabetes care is needed as a priority. Moreover, educational opportunities and diabetes care guidelines are required to improve the quality of care for long-term care residents.

Background

Japan’s population shows the highest proportion of aging in the world. A recent report [1] showed that 27.7% of the population (35.2 million) is over 65, and 13.8% (17.5 million) is over 75. The level of functioning of the older population varies; ranging from well-functioning community dwelling adults to long-term care facility residents, the number of people requiring long-term care facility services is increasing [2].

Diabetes is a common aging related-disease. The report showed that the prevalence of diabetes increases with age; in Japan people with high risk of diabetes amount to 43% of people aged over 70, in contrast to 26% of those aged 50 to 59 and 35% of those aged 60 to 69 [3]. Diabetes can cause serious health consequences at any age, but older people with diabetes are more likely to develop significant health issues, comorbidities and negative health prognostics due to hypoglycemia and hyperglycemia [4–6]. The prevalence of diabetes in long-term care facilities in general range from 16 to 36% [7–10]. Further, older residents with diabetes have more complex problems. For example, previous studies showed that, as compared to residents without diabetes, residents with diabetes had higher chances of comorbidities, higher number of complications, infections and emergency room and hospital transfers [9,10].

Despite the growing evidence that older adults with diabetes are more likely to have complex health issues in long-term care facilities, there are few studies concerning nurse experience in diabetes care. Specifically, there is a lack of research on this issue in Japan. One study with 41 nurses revealed that they have insufficient knowledge of the diabetes care setting, especially signs and symptoms of hyperglycemia [11]. Another study with a healthcare staff including 36 nurses reported that nurses perceived themselves to be moderately to very knowledgeable and confident in diabetes care while also showing a high level of desire for further education about diabetes [12]. There is also a report on healthcare staff including 165 nurses of which the majority reported comfortable knowledge of the signs of hypoglycemia and hyperglycemia as well as techniques for administering insulin, even though there was a different level of comfort between registered nurses and registered practical nurses [13].

These findings focused on the perception and knowledge of nurses working with long-term care residents with diabetes, but these were restricted to limited samples, making evidence on this issue still scarce and inconclusive. A lack of a clear understanding on how nurses perceive and experience diabetes care may negatively affect care quality since nurses play a fundamental role in ensuring resident safety and comfort. Further investigating in a broader sample and involving broader areas of diabetes care practices will guide the development of adequate and necessary approaches for diabetes care in a long-term care facility setting. The purpose of this study is to investigate the experience and perception of diabetes care of nurses in long-term care facilities. Specifically, it focuses on perception of difficulties, needs of educational opportunities, of a diabetes care guideline, and related variables on a nationwide basis.

methods

Participants

A nationwide cross-sectional survey was conducted from February to March 2019 with nurses working at long-term care health facilities. In Japan, there are three types of facility services for older adults under the long-term care insurance system. Long-term care health facility is one of them and aims to provide rehabilitation and nursing care to older adults whose medical conditions are stable [2]. It has organizational standards for staffing: it is required to have a physician as well as other staff members such as nurse, care workers or therapists. We searched for long-term care health facilities in the official website of each prefecture in Japan and identified 4119 facilities. We then sent a letter explaining the goal of the study and the questionnaire to all if they agreed to participate. We asked them to select a nurse responsible for resident care in each facility to answer the questionnaire. The letter explained that we deemed consent to participate in the study when participants returned the questionnaire. Questionnaires were returned by 1371 nurses with a 33.3% response adherence. The study protocol was reviewed and approved by the institutional ethics review board.

Measurements

The questionnaire was developed based on the literature [11,14,15] and on interviews of seven nurses who work in long-term care health facilities. The questionnaire included demographic characteristic of participants: gender, age, license owned and duration of experience in long-term care facilities. Variables related to diabetes management, including the current number of residents with diabetes, those with insulin injection, frequency of checking HbA1c for residents, existence of guidelines related to diabetes care, experience with transferring residents with diabetes to an emergency room due to hypoglycemia/hyperglycemia. Difficulties of diabetes care were assessed with nine items, which focused on understanding of the condition of diabetes, the signs/symptoms of hypoglycemia and hyperglycemia, foot/oral problems, collaborating with physicians and care workers, and respecting resident need, as described in Table 3. We assessed the level of difficulty using a Likert scale from 1(not difficult at all) to 4 (very difficult).

Finally, we included an assessment of the recognition of needs of educational opportunities. Participants were asked whether they wished to have educational opportunities of diabetes care, answering in yes or no. They were also asked whether they recognized the necessity of diabetes care guideline suitable to older adults with diabetes in long-term care health facility settings and they had to answer from 1 (strongly disagree) to 5 (strongly agree).

Analysis

Descriptive statistics were used to characterize the data. The chi-square test was conducted to assess how each diabetes management variable was associated with difficulties, the need of educational opportunities and diabetes care guideline in practice. The need of diabetes care guideline was dichotomized into strongly agree and other responses because of the skewed distribution.

Results

Table 1 shows the nurses’ demographic data. About 94% were aged over 40 years and 88.7% owned registered nurse license. They had an average experience of 10.7 years in long-term care facilities. Variables related to diabetes management are described in Table 2. The number of residents with diabetes in facilities were 38.2% for less than 10 residents and 61.6% for 10 residents or more. Sixty-nine percent participants reported that there were any residents who required insulin injection. Any guideline related to diabetes care was available at 23.2%. Nurses who had experience transferring residents with diabetes to an emergency room due to hypoglycemia and hyperglycemia were 35.5% and 32.4%, respectively.

Difficulties of diabetes care experienced by nurses are shown in Table 3. Of the nurses, 60.9% responded “very difficult or “somewhat difficult” with regard to identifying the signs/symptoms of acute metabolic failure due to hyperglycemia, while 36.8% did so regarding identifying the signs/symptoms of hypoglycemia. Keeping blood glucose level in a healthy range while respecting residents’ needs and preferences was reported by 58.9% of participants. “Detecting and dealing with oral problems” and “developing the shared understanding of the care plan with care workers” were perceived as difficult by 43.6% and 47.8% respectively, while “detecting and dealing with foot problems” and “developing shared understanding of the care plan with care workers” were perceived as difficult by fewer nurses.

Table 4 displayed the needs of educational opportunities and for a diabetes care guideline. Approximately 62.7% desired to have educational opportunities for diabetes care, 30.8% responded “strongly agree”, and about 44.9% responded “agree” to the need of a guideline related to diabetes care in long-term facilities.

The associations between difficulties in diabetes care and variables related to diabetes management are displayed in Table 5. Most variables did not relate to difficulties except the number of residents with diabetes, that is, participants who responded that there were 10 or more residents with diabetes highly perceived difficulties in discussing with physicians and obtaining the necessary instructions regarding diabetes and keeping blood glucose level in a healthy range while respecting residents’ needs and preferences. Table 6 showed the results for the association with needs of educational opportunities and diabetes care guideline. For variables related to diabetes management, the following were associated with need of educational opportunities and diabetes care guideline: the number of residents with diabetes, residents with insulin injection, experience in transferring residents with diabetes to an emergency room due to hypoglycemia. Participants who had diabetes care guideline in their facilities highly perceived the need for such a guideline. For the items of difficulties, most variables, except detecting and dealing with the foot problems, were associated with needs of educational opportunities and diabetes care guideline.

discussion

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.

conclusions

This study examined the perception of difficulties in diabetes care among nurses in long-term care facilities and revealed the areas requiring some approaches for improving nurses’ confidence in diabetes care as a priority, e.g. recognizing signs/symptoms of acute metabolic failure due to hyperglycemia and managing blood glucose with respect to residents’ needs and preferences. Many nurses recognized the need for educational opportunities and diabetes care guidelines suitable for long-term care facilities and we found the association of perception of difficulties and these needs. Considering the high prevalence of older adults with diabetes, nurses are expected to be encouraged to avail the opportunities for increasing knowledge and confidence of diabetes care with their own effort, while there is a high need to provide environmental resources, such as access to standards, guidelines, or employer-supported educational opportunities.

declarations

Ethics approval and consent to participate

This study was conducted with the approval from the ethics review board of the Faculty of Health Sciences, Hokkaido University (18–57). The participants gave their informed consent by returning the written questionnaires, which were accompanied by a cover letter explaining the purpose of the study.

Consent for publication

Not applicable

Availability of data and materials

The data used during the current study are available from the corresponding author on request.

Competing interests

The authors declare that they have no competing interests

Funding

This study was conducted with research support from Grant-in-Aid for Scientific Research (C) from the Japan Society for the Promotion of Science.

Authors’ contributions

MS: Conceptualized and designed study, collected and analyzed the data and wrote the manuscript. MY: Conceptualized and designed study, checked the proposal. SO: Conceptualized and designed study, interpretation of data. All authors have read and approved the final manuscript.

Acknowledgements

The authors would like to express our appreciation to the participants who agreed to participate in this research.

Authors’ information

¹ Faculty of Health Sciences, Hokkaido University, Sapporo, Japan. ² El Qol Heiwa, Sapporo, Japan.

references

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tables

Table 1  Participants demographic characteristics　　　　　　　　　　　　　N=1371

Missing values excluded

Table 2 　Variables related to diabetes management                           N=1371

Table3  Difficulties of diabetes care                                          N=1371

Missing values excluded

Table4  Need regarding diabetes care practice            N=1371

Missing values excluded

Table 5  Association with perception of difficulty                                           N=1371

Other difficulties did not have any association with variable related to diabetes management.

Difficulty 6: Discussing with physicians and obtaining the necessary orders regarding diabetes.

Difficulty 9: Keeping blood glucose level in healthy range while respecting residents’ needs and preferences.

"Difficult" includes "very difficult" and "somewhat difficult"

"Not difficult" includes "not too difficult", "not difficult at all" and “not sure”

Table6  Association with needs of educational opportunity and diabetes care guideline             N=1371

"Difficult" includes "very difficult" and "somewhat difficult"

"Not difficult" includes "not too difficult", "not difficult at all" and “not sure”