Evaluation of Online Education About Diabetes Management in the School Setting

INTRODUCTION

Diabetes is one of the more common chronic diseases in children. Of individuals younger than 20 years, 176,500 (0.22%) have diabetes (American Diabetes Association [ADA], 2006). About 1 in every 400 to 600 children and adolescents has type 1 diabetes. In addition, type 2 diabetes is a growing problem among children and adolescents, yet no national data are available to monitor this trend (ADA; Centers for Disease Control and Prevention, 2005). Along with an increase in the number of children with diabetes, technology and diabetes treatments have also changed (National Association of School Nurses [NASN], 2006). The new insulin pump technology requires that school nurses learn how to manage children with insulin pumps during school hours (Darby, 2006). It seems particularly important for school nurses to be updated on diabetes care, as the NASN membership survey found that more than half (58%) of the nurses responding were older than 50 years (Denehy, 2007).

In Missouri, a diabetes manual first issued in 1997 by the Missouri Department of Health and Senior Services (DHSS) Diabetes Prevention and Control Program and the Missouri Association of School Nurses (MASN) was updated by the Diabetes Management in the School Setting School Manual Committee. This group of experts convened to review current practices and new management tools and methods for the care of children with diabetes. The process included the following:

The committee identified resources from clinical experts within the state and across the country and redesigned the guide with new formatting, visual charts, and sections relating to specific areas of care.

To launch the newly revised manual, a statewide continuing education (CE) effort was made by the Missouri DHSS Diabetes Prevention and Control Program to educate approximately 900 school nurses in Missouri in face-to-face workshops about diabetes management using the school revised current practices manual. It became apparent that to reach school nurses who were unable to attend face-to-face workshops, the development of an online CE program was needed. To develop this online CE program, a partnership was established with the University of Missouri–St. Louis (UMSL), the Missouri DHSS Diabetes Prevention and Control Program, and MASN. This partnership brought together faculty with expertise in online delivery from UMSL and diabetes specialists from DHSS and MASN to develop an online CE course to educate school nurses in Missouri to establish a current practices diabetes management program in their school. The team determined it was important to have an evaluation strategy that included formative evaluation during the implementation of the online course to ensure the quality and relevance of the program. The purpose of this study was to develop and evaluate an online CE program to educate school nurses in how to manage care for children with diabetes in school using the current practice principles outlined in Diabetes Management in the School Setting: A Resource Guide for School Nurses.

REVIEW OF THE LITERATURE

Given the complexity of care for children with diabetes, continuing education is critical for the professional development of school nurses to ensure use of the latest information in the school setting (Vought-O’Sullivan, Meehan, Havice, & Pruitt, 2006). The goal of CE is to ensure quality health care and assist school nurses in their professional development by updating their knowledge, skills, and attitudes (NASN, 2003). Bullock, Libbus, Lewis, and Gayer (2002) studied the self-reported confidence of school nurses completing the Missouri Department of Health and Senior Services CE programs on suicide prevention, mental health, seizure disorders, diabetes, asthma, and clinical skills. They reported that school nurses (n = 120) who completed Missouri DHSS diabetes face-to-face CE had a statistically significant higher level of perceived confidence in caring for children with diabetes than did school nurses (n = 417) who had not completed the diabetes CE.

Fisher (2006) studied school nurses to determine their perceived self-efficacy in providing diabetes care. The Self-Efficacy Diabetes Education questionnaire was used to determine school nurses’ confidence with diabetes care. Scores on the instrument indicate complete, high, moderate, low, and no confidence. School nurses in this research study were moderately confident in providing diabetes care and education. A significant relationship between caring for children with diabetes and increased self-efficacy was found. Fisher noted that CE with current practice guidelines was important because it gives school nurses opportunities to learn new information, interact with peers, and share ideas and experiences. A concern noted by Fisher was that only 9 (5.5%) of 70 school nurses in the study had a diabetes curriculum (lesson plan) to provide diabetes education for students with diabetes.

Darby (2006) interviewed 11 school nurses who reported that they were scared when caring for children with insulin pumps. Darby noted that school nurses were able to work through their fear by knowing their children with pumps and using resources from a regional children’s hospital to gain knowledge and hands-on experience with pumps. Darby stressed the importance of becoming knowledgeable about insulin pumps because of the increasing number of children with diabetes receiving insulin pump therapy.

With the increase in CE, strategies for active learning, feedback to the learner, attention to learning style, roles of students and teachers, program effectiveness, and outcome evaluation of CE effectiveness are all critical components to quality programs (Bell, Pestka, & Forsyth, 2007; Billings & Kowalski, 2007; Menix, 2007; Phillips, 2005). Vought-O’Sullivan and colleagues (2006) reviewed 15 articles related to the importance of and barriers to obtaining CE for school nurses. The importance of CE for school nurses included the wide scope of school nursing practice, the diverse student population, legal mandates, and the varied education backgrounds of school nurses. Barriers included time constraints, family responsibilities, limited finances, no back-up coverage at school, and difficulty in getting away during the school year.

In a review of online CE for school nurses in the late 1990s, the use of the Internet was recognized as an effective learning tool specific to school nursing by offering the opportunity for the learners to be in charge of their own learning (Bergren, 1999). Bergren reported that the Internet provided alternatives to classroom CE and, although limited, offered promise for school nurses to learn at their own pace in the setting of their choice. Phillips (2005) noted that online CE is on the rise in nursing because of the benefits of access, convenience, and quality learning.

There are a variety of state initiatives to provide education for health care professionals and school staff to improve the quality of care for children with diabetes while at school. For example, New York has established diabetes centers of excellence and provides health care professionals with information and resources aimed at improving diabetes prevention and treatment. New Hampshire offers school nurses and other health care professionals annual statewide training. In North Carolina, school nurses may compete for scholarships (tuition, materials, hotel) for a week-long multidisciplinary diabetes management CE program (offered annually) covering numerous topics from quality care to increasing cultural competency (Agency for Healthcare Research and Quality, 2004; North Carolina DHHS Diabetes Prevention and Control, 2007).

Studies suggest that diabetes CE is important for school nurses to stay up to date. However, little attention has been directed toward using online CE initiatives to provide diabetes education. Such studies will provide valuable data for providers of continuing education to sustain the need for such initiatives.

THEORETICAL FRAMEWORK

Rogers’s (2003) theory of the diffusion of innovations guided the development, implementation, and evaluation of an online CE program. Applying this theory, for online education of school nurses to manage care for children with diabetes to be successful, this innovative method must (a) be perceived as better than existing methods; (b) be compatible with existing values, past experiences, and needs; (c) be easy to use and understand; (d) be easily accessible for trial and error; and (e) have results that are easily observed. The degree to which a technology innovation is perceived as better than existing methods can be measured in terms of convenience, satisfaction, and advantage over existing methods.

Based on this theoretical framework, the challenge was to design the online education program so that (a) school nurses would find the diabetes management CE equal to or better than the CE methods they currently use, (b) the online CE would be relevant and meet their needs, (c) nurses would be able to learn the diabetes management information quickly and easily, (d) the online CE would be available for school nurses who were unable to attend the face-to-face workshop, and (e) nurses would perceive improved ability to implement current practices and new tools to manage children with diabetes in the school setting.

METHODS

The Missouri DHSS Diabetes Prevention and Control Program recruited 19 school nurses who were not able to attend the face-to-face workshops to participate in the online diabetes management CE program. There were two pilot courses: one in January and the other in June. To ensure quality, the team limited participants to 10 school nurses.

Access to Blackboard® Learning System, an interactive software application to deliver the course, was provided by UMSL. Course participants used the revised Diabetes Management in the School Setting: A Resource Guide for School Nurses, viewed online Power-Point® presentations (including written speaker notes), had access to external Internet links via Blackboard®, asked questions of faculty and other course participants via three discussion boards, and posted written answers to discussion questions on discussion boards.

The online program consisted of three lessons. Lesson 1 was an overview of diabetes in children and an update on diabetes management in the school setting. Lesson 2 covered managing students with insulin pumps. Lesson 3 discussed the role of the school nurse in managing children with diabetes. Each lesson had a discussion board. Three faculty teams with expertise on each lesson guided discussions and answered questions. The purpose of the discussion questions was to help the school nurses consider how to manage children with diabetes in their school setting.

The Missouri DHHS (2006) current practices manual, Diabetes Management in the School Setting: A Resource Guide for School Nurses, includes (a) first steps in developing a diabetes program in the school; (b) an overview of diabetes; (c) nutrition guidelines for diabetes; (d) exercise and exercise safety tips with diabetes; (e) insulin, insulin therapy, insulin pumps, and troubleshooting insulin pumps; (f) monitoring glucose levels; (g) emergency action plans and sample tools needed to implement emergency action plans; (h) health management (eye, oral, foot, immunizations); (i) references with links to local and national resources; (j) a survey to elicit feedback about the manual; and (k) forms and handouts that can be adapted easily by the school nurse, printed out, and distributed as appropriate. The manual was used in conjunction with the National Institutes of Health and Centers for Disease Control and Prevention (2003) guide titled Helping the Student With Diabetes Succeed: A Guide for School Personnel.

A formative evaluation plan was developed to gather information that could be used to improve the online CE program. Three online evaluations were developed to determine if the course objectives were met. Upon completion of each lesson, the participants were asked to complete the online evaluation form. The Human Subjects Committee at UMSL and Missouri DHSS Institutional Review Boards granted permission to conduct the study.

RESULTS

Of the 10 school nurses who enrolled in the January online CE program, 9 (90%) completed the 3-week program. As a result of the formative evaluation, the team determined after the January session that the program could be accomplished in 2 weeks instead of 3. Therefore, the June program was reduced to 2 weeks. The team evaluation also determined that the order of the lessons should be changed. The role of the school nurse in managing children with diabetes should become Lesson 2 instead of Lesson 1. The team found that the school nurses needed the overview and update on diabetes and pump basics prior to the lesson on the role of school nurses in diabetes management. The two lessons gave the school nurses information needed to apply to their plans of care for children with diabetes in their schools.

Nine school nurses enrolled in the June CE, and six (67%) completed the 2-week program. Of the school nurses, 15 (79%) completed the CE, 12 (80%) completed the evaluation for Lessons 1 and 2, and 13 (87%) completed the evaluation for Lesson 3.

When evaluating each lesson, school nurses rated the extent to which the objectives were met for each lesson by checking “fully,” “partially,” “never,” or “don’t know/not sure.” For all but two objectives, the majority of respondents indicated that objectives of the lessons were fully met (Tables 1–3). Fifty percent of respondents indicated that the objectives “oral medications’ and over-the-counter medications’ effects on blood glucose” and the “process of developing a meal plan” were fully met (Table 1). Tables 1, 2, and 3 illustrate how respondents rated the lessons for organization and clarity of content, effectiveness of teaching method, handouts and resources provided, and questions and concerns adequately answered. Eleven (91%) respondents rated the value and usefulness of the online program as excellent and stated the information would improve their ability to manage students with diabetes. Four (33%) respondents indicated they preferred online education to face-to-face courses, two (17%) reported they did not prefer online education, and six (50%) stated they were not sure if they preferred online education to face-to-face education (Table 4).

Open-ended questions provided additional information. The participants were asked to rate the effectiveness of each lesson and make suggestions for change. Examples of effectiveness and suggestions for changes for each lesson are presented in Table 5.

School nurses were also asked an open-ended question regarding their preference for online versus face-to-face education. For those who preferred online education, convenience was the main theme: “Online is so nice a person can fit the course into their personal schedule,” “I can fit it into my schedule,” “It’s easier than driving and missing work for education,” “Better than taking time off,” “I was able to build on my previous knowledge at my convenience and speed,” and “I don’t have to travel to access it.” For those who preferred the face-to-face learning style, difficulty with the online format was evident: “I do prefer face-to-face over online,” “I learn better in a classroom setting,” “Self discipline to get myself online and read is difficult for me,” and “I had difficulty getting into the site every time I tried to do a lesson.”

DISCUSSION

A majority of school nurses responded that the objectives for the course were met. A majority rated the class as excellent for value and usefulness and stated that the information would improve their ability to manage students with diabetes. This finding supports Rogers’s (2003) diffusions of innovations theory in that it was apparent that the school nurses in this study found the online education to be relevant and that it enhanced their ability to manage students with diabetes in their schools.

Rogers’s (2003) premise that an innovation should be equal to or better that existing methods was inconclusive in this study. Only 4 (33%) preferred the online CE program, 6 (50%) were not sure, and 2 (17%) did not prefer online CE. Responses to the open-ended questions were mixed. Some of the school nurses appreciated the convenience of the online education, whereas others stated it did not fit their learning style and they learned better in a classroom setting. This finding is consistent with the work of Fisher (2006), who noted that school nurses reported that the opportunity to interact with peers to share ideas and experiences was a valuable part of face-to-face diabetes workshops. In this present study, of the five objectives for Lesson 2, Managing Students With Insulin Pumps, four were in the lower range (67%). This is consistent with Darby (2006), who reported that caring for children with insulin pumps is challenging for school nurses. This finding also indicates that more time for questions and answers and/or information is needed about managing children with insulin pumps.

The team thought the summer would be a better time for an online CE program because school nurses would not be busy with school activities and would have more time to complete the program. However, the summer session was not as successful, as three (33%) participants did not complete the summer program. Only one (10%) school nurse did not complete the January program.

IMPLICATIONS FOR SCHOOL NURSING PRACTICE

With the increasing prevalence of children with diabetes in schools, an important finding of this study is that online CE with current practices on care and pump technology may enhance school nurses’ ability to manage children with diabetes in their schools. This method allows for CE for school nurses who find it difficult to attend face-to-face workshops. The online method saves travel time and expenses; however, computer skills and access to computers are needed. With almost half of the nurses responding to the NASN membership survey being older than 50 years (Denehy, 2007), the need to learn computer skills is especially important. The online CE program links school nurses to diabetes experts and peers with similar questions via the online discussion board. This enables school nurses to get advice about children with diabetes in their schools. The manual Diabetes Management in the School Setting: A Resource Guide for School Nurses is a valuable resource available online at the Missouri DHSS (2006) Website.

An important finding is that online CE is not for everyone. The results of this study found that some school nurses prefer face-to-face contact, learn better in a class setting, and have difficulty using computer technology. Another implication is that current practices related to insulin pumps continue to be a need for school nurses. In addition, more specific information on types of insulin as well as meal-planning guides is needed. The Missouri DHSS (2006) online diabetes manual continues to provide resources related to insulin pumps not only for Missouri school nurses but also school nurses across the country.

CONCLUSION

The purpose of this study was to evaluate an online CE program to educate school nurses about managing care for children with diabetes using current principles of practice. Two online CE sessions were implemented. Each session included an overview of diabetes in children with updates, managing students with insulin pumps, and the role of the school nurse in the management of children with diabetes. School nurses responded that the objectives of the course were met and that the CE would enhance their ability to manage the care of children with diabetes. Findings suggest that online CE is not for everyone. The majority of school nurses were not sure if they preferred online CE or face-to-face CE. Because of the increasing prevalence of diabetes in children, it is important that school nurses have access to CE that provides current information for diabetes management for children. Whether this CE is face-to-face or online will depend on the learning preferences of each individual school nurse.