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Diabetes Nurse Educators and Preconception CounselingFrom Lincoln Land Community College, Nursing Department, Springfield, Illinois. Correspondence to Brenda Michel, Lincoln Land Community College, 5250 Shepherd Road, PO Box 19256, Springfield, IL 62794-9256 (brenda.michel{at}llcc.edu).
Purpose The purpose of this study was to examine the diabetes nurse educator's role, practice, and training in preconception counseling (PC) when caring for adolescents with diabetes. Methods A descriptive, correlational research design, using a cross-sectional survey technique, was used. Subjects were 2003 registered nurse members of the American Association of Diabetes Educators. A survey instrument was developed by the investigator and placed on the World Wide Web. Results Although most of the diabetes nurse educators were aware of PC, most reported not having received any training in PC and would benefit from this education. Thirty percent of the respondents did not routinely provide PC to their adult female clients, and 40% did not provide this to adolescents. Conclusions Results of this study suggest that the diabetes nurse educators in this sample would benefit from receiving instruction about PC. The diabetes nurse educators should be trained to provide PC to all female clients with diabetes of childbearing age starting at puberty.
The American Diabetes Association 2004 position statement, "Preconception Care of Women With Diabetes," states that all women of childbearing potential should receive counseling about the risk of birth defects and pregnancy-related complications that are associated with poor glucose control due to unplanned pregnancies, information on the use of an effective form of contraception to avoid an unplanned pregnancy, and the importance of planning each pregnancy.1 The American Association of Diabetes Educators (AADE) Task Force also developed guidelines for women with preexisting diabetes complicated by pregnancy. They state that preconception care should include counseling, education, and medical management and assessment for diabetes-related complications.2 The AADE task force stated that preconception teaching should be done for all women of childbearing age. In the 1970s, Jorgen Pedersen found that optimal glucose control during early pregnancy decreased the frequency of birth defects in the infants of women with diabetes.3 Many researchers have continued to study diabetes and pregnancy and agree with Pedersen's findings that there is an increased risk for birth defects and spontaneous abortions if the mother's glucose control is not adequate at the time of conception and during the first 8 weeks of gestation.3-12 The birth defects associated with pregnancy and diabetes are responsible for approximately 50% of all infant deaths.13 If glucose control is consistently optimal prior to and during pregnancy and the glycosylated hemoglobin is within the normal level, the rates of congenital birth defects and spontaneous abortions are similar to pregnancy without diabetes.14 Even though the outcomes have improved over the years, pregnancy in a woman with diabetes remains high risk.15 Several studies have been done to determine the benefits of preconception counseling (PC).11,16,17 In each, it was determined that a pregnancy program that includes PC improved pregnancy outcomes. These studies also found that there was a significant decrease in fetal birth defects in the women who attended PC programs for women with diabetes prior to their pregnancy. Several studies have looked at the female with diabetes and their practice of planning for their pregnancies. One study found that 59% of the women failed to plan their pregnancies.18 One of the factors for this was that the women had a perception of discouraging advice from health professionals concerning pregnancy and diabetes. Another study on unplanned pregnancies in young women with diabetes also found that the women believed they would have difficulty conceiving, so they did not consistently use birth control.19 Several studies indicated the need for more patient education about the risks of pregnancy and diabetes, proper use of and benefits of different contraceptive choices, and genetic counseling.20-23 One study identified characteristics and factors that determined why women with diabetes sought (or did not seek) preconception care.22 They found that women who sought preconception care prior to conceiving were more likely to have had discussed preconception care with a health care provider, were more knowledgeable about diabetes, understood the benefits of preconception care, and had received more support from their health care providers. Health care providers can significantly influence the outcomes of women with diabetes and their pregnancies. Starting at puberty, health care professionals should discuss with adolescent women with diabetes the effects of diabetes on sexual activity and pregnancy, preventing an unplanned pregnancy, and the positive effects of PC. They should become comfortable discussing sexual issues with adolescents and incorporate this into their routine diabetes education.24 Targeting adolescence (prior to sexual activity) is imperative in preventing unplanned pregnancies. Adolescence is labeled as the transitional stage of life from childhood to adulthood. Adolescents frequently feel conflict concerning their own sexuality. Instead of consciously thinking through the consequences of becoming sexually active, they will engage in sex without planning to do so. Sexual activity is regarded as an individual responsibility. Because of the immature emotional and social characteristics of adolescents, they may not have the decision-making skills and ego strength to go against the peer group to abstain from sexual activity.25 Adolescents also have a belief that they are omnipotent and feel that they will not be harmed by the risky behavior.26 Therefore, risky sexual activity is common among the adolescent population.27-30 Having a chronic illness does not preclude the adolescent from taking risk with sexual behavior.31-33 Diabetes during adolescence is a compounded risk factor. The chronic stressors of type 1 diabetes are due to living with an incurable condition that can result in many acute and long-term complications. Adolescents who have diabetes often experience feelings of depression, hopelessness, low self-esteem, and greater risk-taking behaviors.34 Diabetes control is a common problem with the adolescent. In puberty, insulin resistance is greater, leading to higher glucose levels.35 There is also an increase in growth hormones that can cause glucose levels to rise. The psychosocial milestones for adolescents with diabetes are the same as for all adolescents. They seek increased independence and tend to become rebellious toward their parents while seeking more peer advice and companionship. Not complying with their diabetes care regimen can be a means of expressing independence from parental authority.36 For all these above reasons, the female adolescent with diabetes has a high risk for an unplanned pregnancy and poor glucose control and therefore is very high risk for possible pregnancy-related complications. Most teens are not aware of these facts, nor are they aware of preconception care.23 Studies have found that women with diabetes have not been instructed on sexual issues or contraceptive options by primary health care professionals.20,22-24,37 Diabetes educators with adolescent clients have an ideal opportunity to provide fundamental PC and to prevent unplanned pregnancies. Yet most of them focus on the management of diabetes and rarely discuss sexual issues or contraception.38 Although many studies have shown the impact of PC in preventing complications, no studies have focused on the role of health care professionals delivering this information. Therefore, the purpose of this study was to examine the diabetes nurse educator's role, practice, and training in preconception counseling when caring for adolescents with diabetes.
The main objectives for this study were to determine the diabetes nurse educator's (1) awareness of PC for their female clients with diabetes, (2) their actual practice in providing PC, (3) what components (according to standards) of PC they provide, and (4) if and how they are trained in PC.
A descriptive, correlational study using a cross-sectional survey technique on the Web was conducted to determine the diabetes nurse educator's awareness of PC, their actual practice in providing PC, components they provide when implementing PC, and training received in PC for their female clients with diabetes (with a focus on adolescents). The 2003 registered nurse members of the AADE were systematically randomly sampled. Approval from the Institutional Review Board was obtained from Illinois State University. Approval was also obtained from the AADE to conduct a Web-based survey. With the increase in use of the Internet with professionals and the e-mail addresses of the participants published in the "AADE Member Resource Guide; 2003," the survey was conducted online. Online surveys are convenient for the participants due to the ability to complete the questionnaire and submit it immediately at completion. Cost of sending surveys in the United States Postal Service far exceeds the cost of the use of online surveys.
Data Collection
Participants
Evaluation Instrument The questionnaire used items modified from 2 validated instruments: "Reproductive Health Awareness for Teens With Diabetes" questionnaire by Denise Charron-Prochownik23 and the "Survey on Sexuality in Nursing Practice" questionnaire by Julie K. Waterhouse.39 Content validity was determined by the expert opinions from a panel of 6 content experts on diabetes and pregnancy. The questionnaire was revised according to their comments and recommendations. Face validity and usability of the questionnaire was determined by a pilot test with the Central Illinois Diabetes Educators, a subgroup of the AADE. A total of 10 nurses participated in the pilot study and were asked for feedback on the ease of use, errors in content, and problems with accessing and completing the questionnaire. No issues were found by this pilot group, and the questionnaire remained unchanged.
Internal consistency reliability of the current research instrument was
determined by Cronbach
Statistical Analysis
Sample Characteristics The sample of diabetes nurse educators consisted of 196 (97%) women. Most of the respondents (86 [42.6%]) were in the 40- to 49-year range and 78 (38.65%) were in the 50- to 59-year range with at least 6 years of experience. With regard to the current employment setting, 88 (43.6%) of the respondents worked in an outpatient diabetes clinic. (See Table 1 for age of the diabetes educator respondents, years of experience in diabetes education, and the current employment setting.) Of the sample, 174 (86.1%) were certified diabetes educators. (See Table 2 for the educational degree and certifications of the diabetes nurse educators.)
Diabetes Nurse Educator Awareness of PC
Diabetes Nurse Educator Actual Practice of Providing PC for the Adult and Adolescent Client With regard to the adolescent, 80 (39.6%) of the participants responded that they "do not routinely give PC to the adolescent." When asked about discussing PC, 84% agreed that it is important to discuss PC with the adolescent. Most, 112 (55.4%), of the diabetes nurse educators, felt PC should begin at age "11-14 years." The age of "15-17 years" was chosen by 77 (38.1%) of the respondents, while 11 (5.4%) did not feel that PC should begin until the ages "18-21 years." The diabetes nurse educators were asked to select the teaching methods that they use to provide PC to their patients with diabetes. Sixty-five (32.2%) selected "written materials." When the diabetes nurse educators were asked to determine the triggers to initiate PC to the patient with diabetes, 111 (55.0%) responded "I do." See Table 3 for all teaching methods and triggers to initiate PC. Those that chose "other" stated that they evaluated the need based on the interview of the clients and the questionnaires completed by the clients. One respondent asked his or her female clients about contraception use and plans for pregnancy and then provided information based on the client's response. Two respondents referred clients to psychologists or physicians for the information.
Components of PC Provided for the Adult and Adolescent Client by the Diabetes Nurse Educator The diabetes nurse educators were also asked to check the components of PC that they provide to the adolescent female with diabetes. Fifty-one percent stated that they provided information on "obtaining excellent glucose control prior to conception" routinely for the adolescent, 48.5% on "need to monitor for diabetes complications," 46% on "diabetes and pregnancy with the risks involved" and 44.6% chose information on the "importance of planning a pregnancy with diabetes." See Table 4 for all the results of the components of PC that were provided by the diabetes nurse educators to both their adult and adolescent female patients with diabetes.
Training of Diabetes Nurse Educators in PC When asked if they felt that they would benefit from further training in PC, 175 (87%) agreed. They were asked to rate whether they felt knowledgeable about sexuality regarding diabetes. One (0.5%) felt that she was not at all knowledgeable, 11 (5.4%) not very knowledgeable, 102 (50.5%) somewhat knowledgeable, 74 (36.6%) very knowledgeable, and 9 (4.5%) extremely knowledgeable.
There have been no previous studies that have examined the diabetes nurse educators' awareness of PC, actual practice of PC, the components they provide, and the training received. The results of this study revealed that most of this sample population was aware of PC and felt that it was important. However, 20% of the diabetes nurse educators were not aware of PC for the woman with diabetes and rated PC as not important in her care. Only a small percentage (32.2%) of this sample of diabetes nurse educators are routinely providing PC, thus supporting the study by Janz and colleagues22 that found that less than one half of the women with diabetes recalled being encouraged to seek preconception care. Regarding the practice of PC and the adolescent female, 39.6% of the diabetes nurse educators are not providing PC to this population of clients, with 15% of them stating that they do not feel PC should be discussed with the adolescent. These results confirm Betchart's statement24 that diabetes educators who counsel adolescents routinely focus on their diabetes care and do not frequently address sexual activity. In addition, studies on female adolescents with diabetes found that they do not consistently use contraception with each sexual intercourse, and they engage in unprotected sexual activity, which increases their risk for unplanned pregnancies.26,31,33 This current study provides evidence that adolescents are not given adequate information by most diabetes nurse educators on family planning to prevent unplanned pregnancies, even for those who are sexually active. Adolescents would benefit from being made aware of the effects of diabetes on pregnancy and reproductive health and the importance of seeking PC when planning a pregnancy to prevent complications. Teens must also be informed about preventing an unplanned pregnancy through abstinence and thoughtful family planning prior to becoming sexually active. Although most of the diabetes nurse educators (87%) felt that they were not trained in providing PC for their female clients with diabetes, this current study suggests that the diabetes nurse educators could benefit from receiving proper instruction in PC. They could further be made aware of the importance of PC for all female clients of childbearing age with diabetes. Therefore, continuing education for the diabetes nurse educators should emphasize the importance of PC.
Limitations Self-selection can lead to a potential threat to external validity. Diabetes nurse educators who provide PC to females with diabetes may be more likely to respond than those who do not. Also, the more educated and motivated diabetes nurse educators may have been more likely to return their questionnaires. The methodology of using e-mail can pose a location threat to the internal validity of this study. Many people may not open e-mail because of not recognizing the researcher's name. Many are overwhelmed with trash e-mail and delete it. This may result in failure to open the cover letter to determine whether they would want to participate with the research. The e-mail had "AADE research" in the "subject section" to encourage participation.
Implications for the Practice of Diabetes Education Diabetes nurse educators can provide education for the adolescent and must be comfortable and knowledgeable about preconception counseling. The diabetes nurse educator can be a resource and provide support and guidance for adolescents regarding these issues. Diabetes nurse educators can play a vital role in disseminating this information and decreasing the risk of pregnancy-related complications. Further research is also needed to provide a more in-depth representation of the actual practice of PC with the adult and adolescent female by the diabetes nurse educator. Future studies could assess the diabetes nurse educator's actual knowledge of PC and explore the barriers that the diabetes nurse educators have in providing PC to their female clients with diabetes, perceived threats to role relationships with their clients and peers, and personal concerns about PC. More intervention studies and cost-effectiveness analyses could be conducted.
The Diabetes Educator, Vol. 32, No. 1,
108-116 (2006)
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Abstract
Objectives
coefficients. This was generated by the SPSS
statistical package on the data provided by the participants. The standardized
item Cronbach