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Nurse-patient interactions related to diabetes foot care.

The Institute of Medicine's report, Priority Areas for National Action." Transforming Health Care Quality, identified diabetes as a health care area in need of improvement (Adams & Corrigan, 2003). Currently, about 24 million Americans or nearly 8% of the population have diabetes, and another 57 million are at risk for developing the disease (Centers for Disease Control and Prevention [CDC], 2008a). Patients with a primary or co-existing diagnosis of diabetes account for 20% of hospitalizations (Russo & Jiang, 2006), and 7.8% of the home health care population has a primary diagnosis of diabetes (National Center for Health Statistics, 2005). Future projections estimate a 198% increase in persons affected with diabetes by 2050 (Venkat Narayan, Boyle, Geiss, Saaddine, & Thompson, 2006).

However, "despite high quality evidence to aid providers in treating diabetes and screening for its complications, the quality of diabetes care remains less than optimal ..." (Agency for Healthcare Research and Quality, 2004, p. 1). Many patients with diabetes do not receive the established standards of care, especially related to eye and foot screenings. Approximately 12% of people with diabetes experience a foot ulcer, which is a risk factor for developing further foot problems including lower extremity amputations (CDC, 2003). Greater than 60% of nontraumatic lower limb amputations occur in persons with diabetes, which greatly impacts quality of life and contributes to increased health care and disability costs (CDC, 2008b). The CDC (2008b) estimated comprehensive foot care programs, which include annual exams and self-care strategies, can reduce foot ulcers and amputations by 45%-85%.

Because of the ongoing diabetes epidemic and the need for improved diabetes-related outcomes, nurses must be able to interact effectively with patients with diabetes. Because little is known about this phenomenon, the purpose of this study was to describe registered nurse-patient interactions related to diabetic foot care from the RNs' perspective and compare interactions across the two practice settings of acute care and home health.

Conceptual Framework

The Interaction Model of Client Health Behavior (IMCHB) (Cox, 1982a, 1982b) was used as a framework for this study because of its focus on identifying nurse factors and elements of nursing interactions with potential impact on client health outcomes. Cox (1982b) indicated the model's greatest use is for situations in which the "client's personal responsibility and control of a health problem or health promotion is paramount" (p. 47). The model's main concepts are client singularity, client-professional interaction, and health outcomes.

This study focused on client-professional interactions, which are viewed as a major influence on client health behavior and defined as "the therapeutic content and process that occurs between clinicians and patients" (Cox, 2003, p. E93). Clinician or nurse-patient interaction comprises the following four components: affective support, health information, decisional control, and professional or technical competencies. The relative importance of these interaction components will vary within each RN-patient interaction based on the patient's singularity and health needs (Cox, 1982a, 1982b).

Review of Nurse-Patient Interaction Literature

Upon reviewing the interaction literature, Shattell (2004) concluded research related to nurse-patient interactions contributed to the discipline's knowledge of how nurses communicate with patients, as well as how patients perceive these interactions, and that patients believe nurse-patient relationships are important to their care. However, Morse, DeLuca Havens, and Wilson (1997) argued that researchers who studied nurse-patient interactions and those studying nurse-patient relationships were actually exploring the same phenomenon from different perspectives; they proposed uniting the two concepts because nurse-patient interactions are presumed to be necessary for relationships to be established. Furthermore, Hagerty and Patusky (2003) claimed traditional nurse-patient relationships have changed to brief interactions due to current social, cultural, ethical, economic, legal, and technological trends impacting health care. They suggested nurses and patients can have positive outcomes from single or limited encounters often required during shortened hospital stays.

Nurse-patient interactions have been examined through various qualitative research methods and from different viewpoints (patient, nurse, or both) (Byrd, 2006; Cleary & Edwards, 1999; Fosbinder, 1994; Morse, 1991; Schoot, Proot, ter Meulen, & de Witt, 2005). Using a grounded theory approach, Byrd (2006) studied nurse-patient interactions during maternal-child home visits. The author found patients provided resources for the visit such as time, access to and space in their homes, attentiveness, and opportunities to observe infant behaviors. The nurses provided health information and referrals, status (offering reassurance, validating, and admiring comments), service (assessments and treatments), and goods (smoke detectors, infant formula, and clothes).

Cleary and Edwards (1999) used a qualitative approach to explore factors related to nurse-patient interactions in an acute psychiatric facility. Nurse participants indicated the need to maintain patient safety in the physical environment affected both the quality and quantity of interactions and how unplanned activities, such as admissions or critical incidents, interfered with planned patient interactions. Furthermore, nurses recognized patient acuity and nursing attributes, such as being nonjudgmental and understanding as well as having supportive colleagues, also affected their interactions. Instrumental support, such as staff orientation, education, and management attitudes, additionally impacted nurse-patient interactions. The patient participants identified many of the same nursing attributes, observed nurse roles went beyond physical tasks, recognized clinical interactions were prioritized based on patient acuity, and acknowledged nurses' time for interactions with patients was often limited.

Fosbinder (1994) conducted an ethnographic study to examine patient perceptions of nurse-patient interactions. Four interpersonal processes were identified: translating, getting to know you, establishing trust, and going the extra mile. In the translating process, the author found providing explanations, directions, and teaching occurred almost continuously during nurse-patient interactions. In the getting to know you process, Fosbinder noted nurses used personal sharing and humor. In the establishing trust process, patients felt more trust and confidence in nurses who took charge of situations, and who anticipated and promptly followed through with their care needs. Patients described nurses who used a personal touch to provide care beyond what was expected as going the extra mile.

Morse (1991) used a grounded theory approach to explore nurse-patient relationships, identifying four types of nurse-patient relationships as clinical, therapeutic, connected, and over-involved. The relationships that emerged were dependent upon the "duration of the contact between the nurse and the patient, the needs of the patient, the commitment of the nurse [to the patient], and the patient's willingness to trust the nurse" (p. 455). Morse described clinical relationships as having the attributes of an interaction, such as short duration, little personal involvement, and a lack of emotion.

Schoot and colleagues (2005) also used a grounded theory approach to explore nurse-patient interactions from the perspective of the chronically ill home care patient. Six patterns of nurse-patient interaction were identified: toeing the line, reluctance, consent, dialogue, consuming, and fighting. Authors recommended nurses promote patient-centered care by finding congruence between the patient's desire to participate and the allowed participation by the nurse evident in each pattern.

A review of the IMCHB literature located several studies that used the model to consider RN-patient interactions with persons with diabetes (Corbett, 1998, 2003; McDonald, Tilley, & Havstad, 1999; Molavi, 2001; Xaba & Dewar, 1991). Of these studies, only one explored staff nurses' perspectives of nurse-patient interactions related to diabetes care (McDonald et al., 1999), and only one specifically investigated RN-patient interactions related to diabetic foot care (Corbett, 2003). Furthermore, no studies in the literature were identified in which RN-patient interactions related to diabetic foot care were compared across practice settings.

McDonald and co-authors (1999) used the IMCHB to develop a questionnaire to explore staff nurses' perceptions of problems encountered during care of patients with diabetes and to identify potential patient problems.

Results indicated nurses perceived they needed more diabetes education to improve their diabetes care, and few nurses believed it was within their scope of practice to change prescribed diabetic treatment regimens. The nurses perceived the patients' main problems were knowledge deficits, noncompliance, and difficulty with the acceptance of long-term disease management.

Corbett (2003) examined one of the IMCBH interaction components (health information) with home care patients related to diabetic foot care knowledge, self-efficacy, and self-care skills. Her results indicated brief, individualized instruction provided by the home health nurses improved diabetic patients' foot care knowledge, foot care self-efficacy, and reported foot self-care practices.

Research questions. Based on the literature review, a knowledge gap exists regarding the effect RN-patient interactions have on diabetes-related outcomes, specifically foot care. To address this gap, the following research questions were explored: (a) Are nurse-patient interactions related to diabetic foot care occurring in acute care and home health settings? Co) Is there a difference in nurse-patient interactions related to diabetic foot care between practice settings? (c) Is there a relationship between nurse variables (age, gender, level of nursing education, and years of nursing experience) and reported nurse-patient interactions related to diabetic foot care?

Methods

Sample and setting. A descriptive correlational design was used to survey the registered nurses from one health care system in a rural Midwestern state. Participants were employed full-time, part-time, or contingent on a medical-oncology unit or a surgical unit, or in two home health care agencies. Exclusion criteria included employment as nurse managers, advanced practice nurses, or educational coordinators.

Procedure. Prior to initiating the study, human subject approval for the study was obtained from both the Oakland University Institutional Review Board and the health care system where the study was conducted. Nurses were contacted by the author during scheduled monthly staff meetings after approvals were given by respective nurse managers. Registered nurses who met the inclusion criteria were given essential information about the study by the author and were asked to provide informed consent. Nurse managers or their assistants distributed study materials to registered nurses who did not attend the meetings. The author posted flyers on the units to remind staff nurses to return the surveys. A small incentive of a beverage coupon for an in-house or a drive-through coffee shop was included in each recruitment packet. Completed study forms were returned to a locked box kept in a secure location on each unit. Participant confidentiality was maintained by use of coded numbers instead of names and unit titles.

Instrumentation. A demographic data form was used to collect information from the participants related to age, gender, practice setting, years of nursing experience, level of nursing education, and number of persons with diabetes cared for each week. However, few tools specific to the IMCHB interaction element were found in the literature, with the notable exceptions being the Client Encounter Form (CEF) (Bear & Holcomb, 1999) and three instruments developed by Ervin, Chen, and Upshaw (2006). Therefore, the author developed a new instrument specific to the IMCHB interaction concept for use with patients related to diabetic foot care. To develop the Nurse-Patient Interaction Questionnaire (NPIQ), the definitions used in the CEF (Bear & Holcomb, 1999) and described in the literature (Bear & Bowers, 1998; Brown, 1992; Cox, 2003) were adapted. Permission to adapt the CEF was obtained from its author (M. Bear, personal communication, May 11, 2007). A panel of six experts (advanced practice nurses and certified diabetes educators) reviewed items on the NPIQ to ensure they were representative of expected nurse-patient foot care interactions with adult patients with diabetes and were consistent with the IMCHB.

For this study, the operational definition of nurse-patient interaction was a RN's summative score on the NPIQ. The NPIQ consists of 18 questions with responses on a Likert scale ranging from 1 (never) to 5 (always). The range of possible scores on the NPIQ is 18-90, with higher scores equating to more frequent interactions related to the model's interaction components. An open-ended question at the end of the NPIQ allowed participants to provide comments.

Results

Data were analyzed with the Statistical Package for Social Sciences (version 15.0) using descriptive statistics, chi-square, t-tests, and Pearson's product moment correlations. Cronbach's alpha coefficients also were used to examine instrument reliability. Prior to analysis, one item (#18) was reverse coded as it was negatively worded.

Description of the sample. The sample comprised 42 registered nurses out of a possible 89 (47.2% participation rate). The acute care group (n=22) included nurses who worked on either a combined medical-oncology unit or a surgical unit within one health care system. The home care group (n=20) included nurses from two agencies operated by the same health care system's home health network.

Subjects' ages were 25-68, with a mean age of 44.1 (SD=10.0). Age did not differ significantly between the acute care and home health nurses. All but one of the subjects were female (98%). The majority of nurses (57%, n=24) had baccalaureate degrees in nursing; 36% (n=15) held associate degrees in nursing; and 7% (n=3) had diploma preparation. None of the subjects reported having an advanced nursing degree (see Table 1).

To determine whether a difference existed in level of education between the two groups, the nurse subjects with diploma preparation were combined with the nurse subjects who had associate degrees to create two education levels (ADN/ diploma and BSN). Level of education was significantly different between the two practice settings ([chi square] =4.6, df=1, p=0.032), with the acute care nurses more likely to be BSN-prepared (73%, n=16) than the home health nurses (40%, n=8).

Years of RN experience ranged from 1 year to 36 years, with the mean being 16.1 years (SD=10.1) (see Table 1). The mean number of hours worked per week was 31.9 (range 16-52), and the number of patients with diabetes cared for per week ranged from 1.5 to 20 (M=7.3, SD=4.7). No statistically significant differences existed between the acute care and home health groups' means scores for these variables.

Regarding the type of diabetes, 66% (n=27) of the nurses reported caring primarily for patients with type 2 diabetes, whereas another 13 nurses (32%) indicated patients with type 1 and type 2 diabetes were seen equally. One nurse reported being not sure (2%) regarding the types of diabetes in the patients for whom he or she provided care. None of the nurses in either practice setting reported caring primarily for patients with type 1 diabetes (see Table 1).

NPIQ scale analysis. The scores on the NPIQ ranged from 34 to 84 (out of a possible 18-90), with a mean score of 65.76 (SD=13.28). The 18 individual NPIQ items were analyzed using descriptive statistics; mean item scores ranged from 2.8 (item 18) to 4.3 (item 9) out of a possible range of 1-5. Higher item scores indicated higher levels of nurse-patient interactions related to the variable(s) addressed in each item (see Table 2).

To examine the internal consistency of the NPIQ, Cronbach's alpha coefficient was used; the total NPIQ scale had strong reliability ([alpha]=0.84). Cronbach's alpha coefficients also were calculated for each subscale: affective support ([alpha]=0.92), health teaching ([alpha]=0.93), decisional control ([alpha]=0.93), and professional/technical competencies ([alpha]=0.87).

Analysis of research questions. To assess whether nurse-patient interactions related to diabetic foot care were occurring in acute care and home health settings, the author analyzed descriptive statistics. Nurse-patient interactions were occurring as determined by the total NPIQ mean score of 65.76 (SD=13.3). The data also revealed nurse-patient interactions were occurring within the specific domains measured by the NPIQ's four subscales: affective support, decisional control, health information, and professional/technical competencies (see Table 3).

To detect if difference occurred in nurse-patient interactions related to diabetic foot care between two practice settings, the author used a t-test to compare the acute care and home health nurses' mean NPIQ total and subscale scores Results indicated the two groups' mean total NPIQ scores differed significantly (t= -2.98, df=33.6, p=0.005). The home health nurses' mean NPIQ score was 71.5 (SD=8.4), whereas the acute care nurses mean score was 60.5 (SD=14.9). Significant differences were found between the two groups for three of the subscales: affective support (p=0.007), decisional control (p=0.018), and health teaching (p=0.001). The home health nurses' mean subscale scores were significantly higher than those of the acute care nurses for these three subscales. However, statistically significant differences were not found between the two groups for the professional/technical competency subscale (see Table 4).

A Pearson product moment correlation was used to examine the relationship among NPIQ total score, nurses' age, and years of nursing experience. The results indicated nurse-patient interactions were not related to age or years of nursing experience. Because there was only one male subject, gender differences in nurse-patient interactions could not be assessed; this inability represents a limitation of this study.

A t-test was used to compare the mean NPIQ total and subscale scores with level of nursing education to determine if level of nursing education was related to nurse-patient interactions. A significant difference was found in mean total NPIQ scores based on nursing education (t=2.06, df=40, p=0.046), with the ADN/diploma nurses scoring higher (M=70.4, SD=9.6) than the BSN-prepared nurses (M=62.2, SD=14.7). The health information subscale scores also differed significantly (t=2.67, df=40, p=0.011), with ADN/diploma nurses scoring higher (M=24.2, SD=3.5) than the BSN-prepared nurses (M=20.4, SD=5.1). No significant differences were found on the remaining subscale scores (affective support, decisional control, and professional/technical competency) based on type of nursing education. When NPIQ mean scores and subscale scores within practice settings were compared, no significant differences were found based on level of nursing education.

Qualitative analysis. Nine subjects (21.4%) wrote comments related to nurse-patient foot care interactions in the space provided at the end of the NPIQ. The emergent theme was barriers to interactions, which included unreceptive patients or those not following treatment recommendations, lack of time, high patient loads, and working on the night shift.

Discussion

Findings suggested nurse-patient interactions related to diabetic foot care were occurring but significant differences existed regarding the extent and nature of interactions between practice settings. The home health nurses reported significantly greater numbers of interactions with patients with diabetes, as well as more affective support, health teaching, and decisional control than the acute care nurses. Level of education was related significantly to increased interactions, with ADN/diploma-prepared nurses reporting more interactions than BSN nurses.

These findings may be explained partially by the IMCHB as Cox predicted: as patients' need for professional/technical skills decreased (e.g. vital-sign monitoring), their need for health care decision making would increase (Cox, 1982a, 1982b). Cox also theorized a patient's need for health information would vary based on changing health status and ability to process information. Hospitalized patients may not be receptive to diabetes teaching due to their altered health status and may have decreased ability to process health teaching because of the stress associated with illness or surgery, lack of sleep, and environmental distractions (Clement et al., 2004). Thus it might be expected that nurses who interact with patients with diabetes in the home setting may have more foot care related interactions, along with additional opportunities for foot care teaching, than nurses who interact with acutely ill hospitalized patients.

Acute care nurses also may perceive diabetic foot care for patients with diabetes who are hospitalized for non-diabetic problems as not a high priority or their responsibility. "The management of diabetes in the hospital is generally considered secondary in importance compared with the condition that prompted admission" (Clement et al., 2004, p. 553). When diabetes education in the hospital setting is provided, often it is intended to give basic information rather than comprehensive diabetes knowledge, and patients are expected to receive appropriate outpatient referrals and resources (Clement et al., 2004). Similarly, hospitalized patients who are not admitted for an acute diabetes-related condition may not expect the focus of their nursing care to be related to their diabetes and may be hesitant to initiate encounters with nurses related to diabetic foot care.

Further explanation for the interaction differences found in nurse-patient interactions between practice settings may be evident in the remarks reported by the acute care nurses. The comments identified primarily barriers to effective interactions, specifically unreceptive patients or those not following treatment recommendations, lack of time, high patient loads, and working on the night shift. These barriers are similar to those documented by Cleary and Edwards (1999), Leichter (2003), and West, Barron, and Reeves (2005). Cleary and Edwards noted staff nurses perceived unplanned unit activities and high levels of patient acuity interfered with patient interactions. Barriers identified by West and colleagues included lack of time, training, and tools, such as materials, equipment, space, and privacy. Specifically, they described how a lack of time limited hospital nurses' abilities to address patients' emotional concerns and teaching needs. Leichter contended that due to decreased lengths of stays, the time available for nurses "to teach and provide support services to diabetic patients in the hospital is much shorter than it used to be and often nonexistent" (p. 6).

Another important finding from this study was the differences reported by the ADN/diploma and BSN graduates regarding their foot care-related interactions Although the ADN/diploma-prepared nurses in this study were more likely than the BSN-prepared nurses to report greater numbers of interactions, as well as report more health teaching interactions, this difference may be related more to the practice setting than level of nursing education. Significantly more ADN/diploma-prepared nurses than BSN-prepared nurses worked in home health, and home health nurses had significantly more nurse-patient interactions related to diabetes foot care than acute care nurses. When ADN/diploma-prepared nurses were compared to BSN-prepared nurses within their respective practice settings, no differences in nurse-patient interactions scores were found.

In addition, it is important to note this study's sample of RNs differed from the national average regarding level of nursing educational preparation. The acute care RNs in this study were mostly BSN-prepared nurses (73%, n=16,) with fewer ADN (18%, n=4) and diploma-prepared nurses (9%, n=2) (see Table 1). At the national level, however, 37.6% of hospital-based nurses are prepared at the BSN level, 41.9% ADN, and 16.4% at the diploma level (U.S. Health Resources and Services Administration, 2006). This study's predominance of BSN-prepared nurses may be explained in part by the study hospital's location near a state-supported university with a BSN program. However, when compared to the national averages, the home health nurses' level of education in this study was similar. The percentage of BSN-prepared home health nurses in this study (40%, n=8) equates to the national figures (33.7%). Home health ADN/diploma prepared (60%, n=12) also reflected national employment figures for RNs employed in community or public health settings (58.6%).

Clinical Implications

Nurses in both practice settings must have current, evidenced-based diabetes knowledge and follow the recommended clinical practice standards for diabetic foot care (American Diabetes Association [ADA], 2007). Research indicates registered nurses may lack essential diabetes knowledge (El-Deirawi & Zuraikat, 2001; Findlow & McDowell, 2002; O'Brien, Michaels, & Hardy, 2003; Uding, Jackson, & Hart, 2002) and desire more diabetes knowledge and training (McDonald et al., 1999; Siminerio, Funnell, Peyrot, & Rubin, 2007; Xaba & Dewar, 1991). Although current inpatient trends include the use of multidisciplinary diabetes management teams (Clement et al., 2004; Greene et al., 2002), the use of such teams without ongoing staff nurse education also has raised concerns that staff nurses' diabetes expertise may decline or fail to develop due to reliance on these diabetes teams (Greene et al., 2002). Periodic in-service training related to diabetes foot care for acute care and home health RNs could address these concerns. Because home nurses may have more opportunities to interact with persons with diabetes, home nurses and managers should seek diabetes education opportunities and ensure patient education resources related to diabetes foot care are readily available (Corbett, 2003).

Practice setting barriers that interfere with nurse-patient interactions about diabetes management also should be explored. The acute care nurses in this study indicated unreceptive or noncompliant patients, limited time, and high patient loads interfered with nurse-patient interactions, as well as working on the night shift. These interaction barriers may contribute to poor foot outcomes such as ulcers, which can lead to infections and lower extremity amputations. Rubin, Peyrot, and Siminerio (2006) examined data from the Diabetes Attitudes, Wishes, and Needs (DAWN) study (Alberti, 2002) and determined better provider-patient collaboration was associated with more favorable patient-reported outcomes. For nurses to have positive impact on diabetic foot outcomes, they first need to have purposeful interactions with patients with diabetes.

In addition, the identification of practice settings where nurse-patient interactions occur with patients at high risk for diabetic foot problems could be important for future studies. For example, Neil, Knuckey, and Tanenberg (2003) found patients with end-stage renal disease receiving outpatient dialysis were at high risk for developing foot ulcers due to insensate feet, not wearing appropriate footwear, and not practicing self-care protective behaviors. Berry and Hunt Raleigh (2004) examined the charts of patients with diabetes in a long-term care facility and concluded poor documentation, along with failure to meet ADA foot care standards, increased their risk of diabetic foot problems.

Conclusions

Replication beyond one health care system and one geographical location is recommended for further examination of RN interactions with persons with diabetes and comparisons across various practice settings. Future studies also should explore the relationships between the IMCHB interaction components (as measured by the NPIQ) and singularity and foot health outcomes for patients with diabetes.

Although this study found the NPIQ to be reliable and initial content validity was established, construct validity for the tool was not determined. Evaluation of the NPIQ with a larger sample of RNs is recommended to establish construct validity and establish further reliability. In addition, based on item analysis and feedback from participants, one item (#18) may need to be revised as it was confusing to several participants.

Results of this study suggest nurse-patient interactions may be occurring differently across practice settings. Nurses employed in demanding clinical settings often face challenges related to interacting with patients in need of diabetic foot care. However, nurse-patient interactions are necessary so prevention, early detection, referrals, and interventions to manage diabetes-related foot complications can be initiated. By keeping nurse-patient interactions the center of nursing practice (Shattell, 2004), nurses may be able to have a positive impact on foot health of patients with diabetes.

Acknowledgement: The author acknowledges the guidance of Research Committee Chairperson Sarah Newton, PhD, RN, and the diabetes expertise provided by Committee Member Ann Constance, MA, RD, CDE, during the original research study, which was completed as part of a Doctorate in Nursing Practice degree through Oakland University in Rochester, MI.

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U.S. Health Resources and Services Administration. (2006). The registered nurse population: Findings from the March 2004 national sample survey of registered nurses. Retrieved December 5, 2007, from ftp://ftp.hrsa.gov/bhpr/workforce/0306rnss.pdf

Venkat Narayan, K.M., Boyle, J.R, Geiss, L.S., Saaddine, J.B., & Thompson, T.J. (2006). Impact of recent increase in incidence on future diabetes burden: United States 2005-2050. Diabetes Care, 29(9), 2114-2116.

West, E., Barron, D.N., & Reeves, R. (2005). Overcoming the barriers to patient-centered care: Time, tools and training. Journal of Clinical Nursing, 14(4), 435-443.

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Lisa Sue Flood, DNP, RN, CNE, is a Professor of Nursing, Northern Michigan University, Marquette, MI.
Table 1.
Demographic Variables of the Registered Nurses by Practice Setting

                        Acute Care    Home Health      Total
Demographic Variable      (n=22)        (n=20)        (N=42)

Age (in years)
  Mean                     43.4          44.9          44.1
  SD                       12.6           6.5          10.0
  Range                    25-68         31-57         25-68
Years RN Experience
  Mean                     16.6          15.6          16.1
  SD                       12.4           7.1          10.1
  Range                    1-36          2-30          1-36
Hours Worked per Week
  Mean                     30.4          33.4          31.9
  SD                        4.5           7.6           6.3
  Range                    20-36         16-52         16-52
Persons with Diabetes Seen per Week
  Mean                      6.6           8.0           7.3
  SD                        4.0           5.4           4.7
  Range                   1.5-16         2-20         1.5-20
  Missing                    1             1             2
Level of Education
  BSN                   72.7% (16)      40% (8)     57.1% (24)
  ADN                    18.2% (4)     55% (11)     35.7% (15)
  Diploma                9.1% (2)       5% (1)       7.1% (3)
Type of Diabetes
  Type 1                     0             0             0
  Type 2                68.2% (15)    63.2% (12)    65.9% (27)
  Both types             27.3% (6)     36.8% (7)    31.7% (13)
  Unsure                 4.5% (1)          0         2.4% (1)
  Missing                    0             1             1

Table 2.
NPIQ Questions and Descriptive Statistics
                                                 Actual
Item                                             Range     M      SD

 1. Foot inspection                               1-5     3.9    0.87
 2. Health teaching on footwear                   1-5     3.1    1.05
 3. Lower limb assessment                         1-5     4.1    0.98
 4. Encouragement of health promotion goals       1-5     3.4    1.11
 5. Discussion risk factors and strategies        1-5     3.4    1.04
 6. Offer reassurance for concerns/fears          1-5     3.9    1.08
 7. Encouragement to promote daily foot           1-5     3.6    1.14
    self-care
 8. Assessment of knowledge and self-care         1-5     3.6    1.17
 9. Adjustment of teaching based on               2-5     4.3    0.84
    assessments
10. Offer reinforcement for correct self-care     1-5     3.9    1.14
11. Provide information on smoking cessation      2-5     3.7    1.09
12. Monitor blood glucose and hemoglobin A1C      1-5     4.1    0.87
13. Instruct patients to have yearly foot         1-5     3.2    1.36
    exams
14. Assess for loss of sensation                  1-5     3.6    1.16
15. Assist patients in decisions related to       1-5     3.0    1.16
    foot referrals
16. Spend time listening to concerns/feelings     1-5     3.8    1.12
17. Provide teaching to control blood glucose     2-5     4.2    0.78
18. Provide foot care interventions only when     1-5     2.8    1.40
    ordered

Table 3.
NPIQ Total and Subscale Descriptive Statistics

                                                Actual    Possible
Scale                          Mean      SD      Range     Range

Total Scale                    65.76   13.28     34-84     18-90

Affective Support              11.57    2.93     3-15       3-15
(Items: 6, 10, 16)

Decisional Control             10.02    3.00     3-15       3-15
(Items: 4, 7, 15)

Health Information             22.02    4.83     11-29      6-30
(Items: 2, 5, 9, 11, 13, 17)

Professional Competencies      22.14    3.78     13-29      6-30
(Items: 1, 3, 8, 12, 14, 18)

Table 4.
Comparison of NPIQ Scores by Practice Setting

          NPIQ                M      SD       t      df        p

Total Scale
  Acute care                 60.5    14.9   -2.98   33.62   0.005 *
  Home health                71.5     8.4

Affective Support
  Acute care                 10.4     3.4   -2.88   32.06   0.007 *
  Home health                12.8     1.7

Decisional Control
  Acute care                  9.0     3.2   -2.46   40.00   0.018 *
  Home health                11.2     2.4

Health Information
  Acute care                 19.8     5.2    -3.7   32.90   0.001 *
  Home health                24.5     2.8

Professional Competencies
  Acute care                 21.3     4.4   -1.53   36.31     0.134
  Home health                23.0     2.8

* p<0.05
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Title Annotation:Research for Practice
Author:Flood, Lisa Sue
Publication:MedSurg Nursing
Geographic Code:1USA
Date:Nov 1, 2009
Words:6207
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