The Journal of School Nursing
2021, Vol. 37(4) 228-229
© The Author(s) 2021
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DOI: 10.1177/1059840519870314
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Adolescents with Type 1 diabetes (T1D) experience unique self-management challenges, which can lead to poor glycemic control and sequelae. School nurses may impact student self-efficacy behaviors for T1D management in adolescents. The purpose of this study was to determine the relationships among school nurse staffing patterns, measured by school nurse to student ratios, self-efficacy, and glycemic control in adolescents with T1D. The sample consisted of 89 parent–adolescent dyads. Adolescents aged 10–16 years old with T1D completed the Self-Efficacy for Diabetes Self-Management (SEDM) Scale. Parents completed a demographic questionnaire. Higher school nurse to student ratios correlated with better glycemic control and older age. Higher SEDM scores correlated with older age, and females scored significantly higher. Findings contribute new knowledge to the paucity of literature on school nursing and adolescents with T1D, with implications for nursing practice, education, research, and policy.
Type 1 diabetes, HbA1c, glycemic control, self-efficacy, adolescents, school nurse, teenagers, school nurse ratios
The prevalence of Type 1 diabetes (T1D), a chronic disease of childhood, has risen significantly over the past three decades (Mayer-Davis et al., 2017). The population-based SEARCH for Diabetes in Youth study noted a 21.1% increase in the prevalence of T1D in youth less than 20 years old from 2001 to 2009 across gender and most age subgroups, with the greatest increase noted in adolescents aged 15–19 years old (Dabelea et al., 2014). Using the 2009 SEARCH data, there were an estimated 166,984 youth less than 20 years old (Pettitt et al., 2014) and approximately 3 million individuals of all ages in the United States with T1D (Chiang, Kirkman, Laffel, & Peters, 2014).
Adolescence is a pivotal time in life, especially for adolescents diagnosed with T1D, which poses challenges for school nurses, particularly from a developmental perspective. Adolescents experience poor glycemic control (Datye, Moore, Russell, & Jaser, 2015; Demirel, Tepe, Kara, & Esen, 2013) and decreased treatment adherence (Datye et al., 2015; Rausch et al., 2012) and may develop microvascular complications within the first 2 years of diagnosis (Demirel et al., 2013). Complications of retinopathy, nephropathy, and neuropathy may appear after the onset of puberty or after just 5–10 years of diabetes duration (Chiang et al., 2014). Furthermore, 17% of youth with T1D had HbA1c levels greater than or equal to 9.5%, contributing to poorer outcomes related to cardiovascular risk factors, retinopathy, nephropathy, neuropathy, and arterial stiffness (Hamman et al., 2014). In addition to well-documented multi-organ effects, chronic hyperglycemia in children and adolescents also contributes adversely to brain development (American Diabetes Association [ADA], 2018) and decreased executive function and memory (Tonoli et al., 2014).
Puberty superimposes an additional challenge of shifting insulin sensitivity as adolescents grow and sexually mature, and reaching target blood glucose levels is more problematic for adolescents than adults (ADA, 2018). It is crucial for adolescents to reach current target HbA1c levels of less than 7.5% according to the ADA (Chiang et al., 2018). For those under 25 years of age, the International Society for Pediatric and Adolescent Diabetes (ISPAD) recommends a target HbA1c of less than 7.0% for those with access to comprehensive care and less than 7.5% in circumstances such as hypoglycemia unawareness and lack of access to advanced technologies (DiMeglio et al., 2018). Hypoglycemia unawareness occurs when blood glucose falls below 70 mg/dL without accompanying symptoms of hypoglycemia (ADA, 2019).
Although familial practices are largely influential in the development of health-promoting behaviors, the school nurse and the school setting are also important in the reinforcement of such behaviors (Bandura, 1997). Adolescents often have interactions with the school nurse that may be instrumental in helping them develop the knowledge, skills, and confidence for T1D management. Self-efficacy, or confidence, is the belief that one can carry out specific behaviors in specific situations and is the major determinant of intention (Bandura, 1997).
Research on youth with T1D has demonstrated that selfefficacy is influential in diabetes self-management (Chih, Jan, Shu, & Lue, 2010), blood glucose monitoring frequency (Helgeson, Honcharuk, Becker, Escobar, & Siminerio, 2011), glycemic control (Lansing et al., 2018), adherence to treatment (Lansing et al., 2018), and dietary practices (Eisenberg, Lipsky, Dempster, Liu, & Nansel, 2016). Given the importance of self-efficacy to the optimization of glycemic control and the subsequent reduction in complications, school nurses can facilitate more effective T1D management in adolescents, such as through interactions that include education and reinforcement of diabetes-related skills as well as the importance of good glycemic control to overall health.
Current recommendations are for at least one full-time school nurse in each school (American Academy of Pediatrics, 2016) and a school nurse workload that facilitates direct access for students to school nurses (National Association of School Nurses [NASN], 2015b). Although school nurse to student ratios are no longer used to ensure safe staffing levels, they represent school nurse presence and accessibility for student populations and therefore are used in this study.
Despite the rise in numbers of youth with T1D, research on school nursing and measurable diabetes outcomes in adolescents is scarce. Research on school nursing and students with T1D has focused on parental perspectives of safety and satisfaction in the school setting (Driscoll et al., 2015; Skelley et al., 2013), school nurse perspectives regarding diabetes management (Thorstensson, Fröden, Vikström, & Andersson, 2016; Wang & Volker, 2013), and case management (Engelke, Swanson, Guttu, Warren & Lovern, 2011; Peery, Engelke, & Swanson, 2012).
Adolescents with T1D are an at-risk group for poor glucose control. School nurses are well positioned to influence self-efficacy for T1D management in adolescents. Higher self-efficacy for T1D management in adolescents is associated with increased treatment adherence and increased glycemic control (Iannotti et al., 2006), which greatly reduces complications and morbidities associated with diabetes (Centers for Disease Control and Prevention, 2014, 2017).
A significant gap exists in the literature regarding the school nurse’s role in increasing adolescent self-efficacy for T1D management, which is crucial for the successful transition to independent self-management. To date, there is no research examining the relationships among school nurse to student ratios, self-efficacy for T1D management, and glycemic control in adolescents. The purpose of this study was to determine whether there are relationships among these variables. Age was explored as it has been shown to impact diabetes self-efficacy (Verchota & Sawin, 2016) and glycemic control in adolescents (Kristensen, Birkebaek, Mose, Berg Jensen, & Thastum, 2018; Lansing et al., 2018; Verchota & Sawin, 2016). Diabetes duration was also explored as it, too, has been shown to influence self-efficacy for T1D management (Chih et al., 2010) and glycemic control in adolescents (Hilliard, Wu, Rausch, Dolan, & Hood, 2013; Kristensen et al., 2018).
The theoretical framework used was Bandura’s self-efficacy theory, a major construct of social cognitive theory, which proposes that people can exercise influence over what they do and that they contribute to, but are not, the sole determinants of what happens to them (Bandura, 1997). Selfefficacy beliefs are based on individuals’ perceptions of their ability to execute specific tasks or behaviors rather than their ability to actually do so. Self-efficacy beliefs influence the course of action people choose to pursue, how much effort they expend, how long they persevere in the face of obstacles and failure, their resilience to adversity, whether their thought patterns are hindering or helpful, how much stress they experience in coping with challenging environmental demands, and the level of accomplishment they attain (Bandura, 1997). Therefore, adolescents with T1D who possess higher self-efficacy for T1D management are more likely to be persistent in management behaviors with thought patterns leading to success than those with lower self-efficacy, who anticipate failure and have negative thought processes (Bandura, 1997).
Reciprocal interactions between adolescents with T1D and the school nurse may have an effect on self-efficacy for T1D management. School nurses and students interact in each of Bandura’s (1997) four sources of efficacy information. Through verbal persuasion and encouragement, students acquire skills related to T1D management, directly influencing enactive mastery experience. Using vicarious experience, school nurses can facilitate meetings or support groups where students newly diagnosed with T1D can interact with students who have been effective in their own T1D management. Lastly, school nurses can influence the role of physiologic and affective efficacy information by using a calm and reassuring approach, reducing stress, and managing negative attitudes and behaviors.
Although there is little research on school nurse to student ratios, lower ratios have demonstrated favorable health outcomes for students, such as facilitating the school nurse’s ability to provide individualized care to students with diabetes and asthma (Maughan & Adams, 2011). Additionally, school districts with lower ratios were more apt to be involved in the care of students with chronic diseases, report more counseling services to children, and achieve higher numbers of vision referrals receiving follow-up care than districts with higher ratios (Guttu, Engelke, & Swanson, 2004). The researcher posited that lower school nurse to student ratios would be associated with higher selfefficacy for T1D management as well as lower HbA1c levels in adolescents.
A descriptive correlational design was used. Data were collected in a pediatric endocrinology practice associated with a large academic medical center in the Northeastern United States. Institutional review board approvals were obtained from both Seton Hall University and the medical center associated with the endocrinology practice.
A convenience sample of 89 parent–adolescent dyads was recruited for this study over a 4-month period. Parents were solicited in order to provide diabetes-related and schoolrelated demographic data. Adolescents are defined as young people between the ages of 10 and 19 years old (World Health Organization, n. d.). Adolescents with T1D between 10 and 16 years old, able to speak English, enrolled in public or private school, able to read and understand grade level material, and without comorbid disease or diagnoses that would result in an increased interaction with the school nurse were eligible. Based on an a priori power analysis (Faul, Erdfelder, Buchner, & Lang, 2009), a sample of 84 participants was needed for a two-tailed bivariate correlational analysis to achieve a power of .80, with a medium effect size of .30, and significance level of .05.
Researchers utilized two methods of participant recruitment. First, the participating endocrinology office sent a blind-copied e-mail to parents of adolescents aged 10–16 years old announcing the study with the researcher’s contact information. Of the 418 confirmed e-mail deliveries, 53 (12.7%) completed packets were returned through the postal mail. Additionally, participants were recruited from the waiting area of the endocrinology practice. Of the 44 parents who were approached, 36 (81.8%) completed study packets, yielding a total sample of 89 parent–adolescent dyads.
A letter of solicitation explaining the confidential and voluntary nature of the study was first distributed to all interested parent participants. If parents were interested, adolescents were then approached. Both written parental consent and adolescent assent were then obtained prior to participation. Parents and adolescents each received a US $10 target gift card as a token of appreciation at the completion of the study questionnaires.
Self-Efficacy for Diabetes Self-Management (SEDM). Based on Bandura’s self-efficacy theory, the SEDM (Iannotti et al., 2006) is a one-dimensional, 10-item Likert-style instrument reflecting present-day changes in diabetes treatment modalities and solicits adolescent information regarding selfefficacy. The instrument asks adolescents to rate themselves on each item with a scale of 1–10 (1 = not at all sure and 10 = completely sure) in commonly encountered situations (see Table 1). An overall mean score derived from each of the 10 items is calculated with possible scores ranging from 1 to 10.
Content validity of the SEDM was established by experts in developmental psychology, adolescent health behaviors, and pediatric endocrinology (Iannotti et al., 2006). Internal reliability of the SEDM in the norming sample (N = 168) was .90 (Iannotti et al., 2006). Widely used in research, the SEDM has demonstrated acceptable reliabilities: α >.80 (Berg et al., 2011, 2013; Kristensen et al., 2018; Lansing et al., 2018). Cronbach’s alpha in this study was .85.
Parent Questionnaire (PQ). A PQ was constructed by the researcher to elicit demographic information including parental educational level, adolescent’s age, gender, most recent HbA1c level, age at diagnosis, and school of attendance. Parents were asked about the presence of comorbid conditions in adolescents and whether their presence increased interactions with the school nurse. Glycemic control was operationally defined by the most recent HbA1c level recorded by the parent on the PQ. Face validity of the PQ was established by pilot testing the instrument with three parents who evaluated the items for clarity and readability. The average time needed for adolescents and parents to complete the study instruments was approximately 10 min in total.
Data were examined using SPSS for Windows Version 22.0. Descriptive statistics were computed for all main study and demographic variables, including frequencies, percentages, means, and standard deviations (SDs). Means, median, mode, SDs, and reliability coefficients were computed for the SEDM overall mean score and each of the 10 scale items of the SEDM.
Data were analyzed using Pearson product–moment correlation coefficients for all continuous variables and Spearman’s rank order for pairs of continuous and categorical variables. An independent samples t test was performed to determine whether there were gender differences in HbA1c levels or in the SEDM overall mean score and individual scale items.
School nurse to student ratios were defined as the number of full-time equivalent (FTE) school nurses in the building available for the total student enrollment for one academic calendar year. For schools that employed one part-time school nurse, FTE status was calculated as the number of hours the school nurse was present each day divided by 7.0, reflecting the average number of hours that school nurses work per day. The average length of the public school day in New Jersey is 6.44 hr (U.S. Department of Education, n.d.) and the most recent national workforce data indicate that 39.3% of schools employ full-time school nurses more than 35 hr per week (Willgerodt, Brock, & Maughan, 2018). School nurses who were present for a combination of fulltime and part-time days during the week were assigned an FTE based on a 35-hr week. The same method was utilized to calculate FTE status for schools with more than one fulltime nurse.
School nurse to student ratio data were obtained in the following manner. Using the demographic data on the PQ, the researcher contacted the school nurses of the identified schools of attendance and requested the number of full-time and part-time school nurses employed. As some school nurses did not have access to current enrollment data or provided an approximation, the researcher utilized the enrollment data for one academic calendar year from the state department of education for all schools attended by participants as a means of obtaining the most accurate data. Level of school was identified and coded as either elementary/middle (grades K–8) or high school (Grades 9–12).
Table 2 presents a description of the adolescent and parent participants. The mean age of the adolescents was 13.43 years (SD = 1.79), and the sample consisted of predominantly males and older adolescents aged 13–16 years. There was no statistically significant difference (p = .798) between the ages of males (M = 13.39, SD = 1.85) and females (M = 13.49, SD = 1.75). Parent participants were predominantly female (n = 79, 88.8%) and well educated. Although the majority of parents held baccalaureate degrees or higher, no relationship was found between parental education and HbA1c levels (p = .128). Data were not collected regarding parents’ marital status or household structure; therefore, it is not known whether adolescents resided with one or both parents.
Mean diabetes duration was 5.23 years (range: 0–12 years), with the majority reporting a duration of 0–5 years (n = 49, 57%). Mean age at diagnosis was 8.07 years (range: 2–15 years). Parents reported mean HbA1c levels as 8.12%. There was no statistically significant difference in the HbA1c levels (p = .559) between males (M = 8.05, SD = 1.40) and females (M = 8.22, SD = 1.36), nor in the HbA1c levels (p = .462) between the age groupings of 10- to 12- year-olds (n = 25, M = 7.97, SD = 1.03) and 13- to 16-yearolds (n = 63, M = 8.18, SD = 1.50). Only 36 (40.4%) adolescents achieved ADA recommended target HbA1c levels of less than 7.5% and just 16.9% (n = 15) met the more stringent ISPAD recommended target HbA1c levels of less than 7.0%. Significantly, almost one fifth (n = 17, 19.1%)of the sample reported elevated HbA1c levels between 9.0% and 12.5%. No significant correlations were noted among glycemic control, age, or diabetes duration.
Table 3 provides a description of the adolescent sample’s school of attendance characteristics. The majority of the adolescents attended elementary or middle school (n = 56, 62.9%) in public institutions (n = 77, 86.5%). Almost all participants attended schools with at least one FTE school nurse (n = 85, 95.4%). Four participants (4.5%) attending schools with less than one FTE school nurse attended nonpublic schools. The mean number of FTE school nurses was 1.33 (range: 0.5–4.0), and mean total school enrollment was 827 students (range: 84–2,953.5). The majority of adolescents attended schools with enrollments between 84 and 1,000 (n = 60, 67.4%). Almost two thirds (n = 65, 73.0%) attended schools with school nurse to student ratios of 1:750 or less, but more than one quarter (n = 24, 27%) attended schools with school nurse to student ratios of 1:751 or greater.
School nurse to student ratios were significantly, albeit weakly, inversely correlated with HbA1c level and strongly correlated with age, indicating that higher school nurse to student ratios are associated with lower HbA1c levels and older age of adolescents (see Table 4).
Table 1 presents a summary of the SEDM overall mean and scale item scores. SEDM overall mean scores ranged from 3 to 10 (M = 7.71), with higher mean scores indicating higher self-efficacy for T1D self-management. Adolescents reported the lowest mean score in choosing healthful foods when dining outside the home and the highest in adjusting insulin correctly when eating more or less than usual.
As seen in Table 5, there was a statistically significant difference in overall mean scores between males and females (p = .048). Females had higher SEDM overall mean scores (M = 8.06) than males (M = 7.42) and scored higher on 9 of the 10 scale items, 3 of which reached statistical significance. Higher scores were noted on Item 2, “Choose healthful foods when you go out to eat?†(p = .024); Item 7, “Manage your diabetes the way your health-care team wants you to?†(p = .008); and Item 10, “Identify things that could get in the way of managing your diabetes?†(p = .006).
Self-efficacy for T1D management was significantly correlated with age, indicating that older adolescents had higher levels of self-efficacy. Although not statistically significant (p = .146), there were small differences in SEDM overall scale means and SDs between the age groups of 10- to 12-year-olds (n = 25, M = 7.23, SD = 1.99) and 13- to 16-year-olds (n = 63, M = 7.87, SD = 1.24), consistent with the findings of a weak, positive correlation between age and self-efficacy.
This study sought to determine relationships among school nurse to student ratios, self-efficacy for T1D management, and glycemic control in adolescents. In this study, the mean HbA1c level was higher than ADA and ISPAD recommendations; however, adolescents in this sample had better glycemic control and lesser differences in mean HbA1c levels between younger and older age groupings than that reported from two recent large studies from the T1D Exchange Clinic Registry (Clements et al., 2016; Wood et al., 2013). Previously, the ADA (2014, p. S51) recommended a target HbA1c of less than 8% for children aged 6–12 years old and less than 7.5% for adolescents and young adults aged 13–19 years old, while ISPAD recommended a more stringent target HbA1c of less than 7.5% for children and adolescents 0–18 years old (Rewers et al., 2014). In this study, just 52% (n = 13) of adolescents aged 10–12 years old (n = 25) and 44.4% (n = 28) of adolescents aged 13–16 years old (n = 63) met the 2014 ADA’s recommendations for age-specific target HbA1c levels, although these percentages are higher than those reported in previous research (Hilliard et al., 2013; Wood et al., 2013). Using the aforementioned updated recommendations, even fewer adolescents (n = 8, 32%) in the younger age-group (n = 25) in this study would meet ADA target recommendations, which is significant, as early and intensive management has been associated with fewer and delayed diabetes-related complications (Chiang et al., 2014; Rewers et al., 2014). Importantly, although the mean HbA1c in this study was comparable to findings in the literature, 17 (19.1%) parents of adolescents reported values between 9.0% and 12.5%, the majority of whom were 13–16 years old (n = 15, 23.8%), approximating average blood glucose levels of 212–324 mg/dL (ADA, n.d.). Overall, in this study, just 36 (40.4%) adolescents met ADA and ISPAD HbA1c guidelines of less than 7.5%, which is noteworthy as the majority (n = 53, 59.6%) did not reach recommended target levels. Policies that enable school nurses to communicate not only with students and parents but also with the health-care provider may help to provide reciprocal feedback and clarify individual glycemic control goals.
School nurse to student ratios were not correlated with self-efficacy but were inversely, and unexpectedly, correlated with HbA1c levels, suggesting that adolescents with lower HbA1c levels attended schools with higher school nurse to student ratios. This may be explained by the finding that higher self-efficacy scores were associated with older sample participant age. As there was a nurse present in each school, there was little variability in ratio, which may also contribute to this finding. The positive correlation between school nurse to student ratios and age found in this study suggests that older adolescents attended schools with higher school nurse to student ratios, which is consistent with the strong positive correlation found between school nurse to student ratios and level of school (rs = .62, p < .01). In this study, school nurses practicing in high schools had higher school nurse to student ratios, and therefore, responsibility for more students than school nurses in elementary and middle schools. Despite the findings of an association of lower HbA1c levels with higher ratios, school nurses need to be mindful that adolescents differ in maturity and cognitive development and therefore may need more support from the school nurse than expected. Although students with established T1D may visit the school nurse infrequently or not at all, individualized health-care plans (IHPs) and/or emergency care plans must be developed by school nurses (NASN, 2015a), which can include provisions for contact with the school nurse.
This sample had higher SEDM overall mean scores than those reported in previous studies (6.59–7.19) conducted by Berg et al. (2009, 2011), Butler et al. (2009), Butner et al. (2009), Kristensen et al. (2018), and Lansing et al. (2018), although all but Kristensen et al. (2018) had younger participants (10–14) than in the current study. The younger age in previous studies may account for lower SEDM overall mean scores as SEDM was weakly correlated with age in this and other research (Verchota & Sawin, 2016; Winsett, Stender, Gower, & Burghen, 2010). This finding is not unexpected from a developmental perspective; as children enter puberty, they begin to develop more confidence in their ability to handle stressful situations (Bandura, 1997, p. 178). School district policies must provide the numbers of school nurses necessary to provide safe care (NASN, 2015b), which includes education and reinforcement of behaviors that lead to increased self-efficacy for T1D management in students of all ages, regardless of the length of diabetes duration.
Numerous studies have failed to demonstrate gender differences in self-efficacy for T1D management (Chih et al., 2010; Survonen, Salanterä, Näntö-Salonen, Sigurdardottir, & Suhonen, 2019; Winsett et al., 2010), yet, in the current study, higher SEDM overall mean and scale item scores were associated with females. The mean age for boys and girls in this sample did not differ statistically, suggesting that age was not a factor. Findings indicate that males had least confidence in choosing healthful foods when dining outside the home. Dietary adherence is one of the most problematic areas for adolescents with T1D (Eisenberg et al., 2016; Parker, Lee, & Reiboldt, 2013) and better dietary practices have been associated with higher levels of self-efficacy (Eisenberg et al., 2016). IHPs should address areas of nutritional education that can impact and reinforce students’ abilities to choose appropriate foods, particularly for males.
Findings among other variables, while not statistically significant, are still important for school nurses to consider. HbA1c levels have been correlated in previous research with parental education (Campbell et al., 2014; Haugstvedt, Wentzel-Larsen, Rokne, & Graue, 2011), age (Clements et al., 2016; Kristensen et al., 2018; Lansing et al., 2018), diabetes duration (Hilliard et al., 2013; Kristensen et al., 2018), and self-efficacy for T1D management (Chih et al., 2010; Kristensen et al., 2018; Lansing et al., 2018), yet this study found no such relationships. This may be partially explained by the higher levels of self-efficacy for T1D management, fewer years of diabetes duration, and older mean age found in this study than in the above studies. School nurses though, should not presume effective communication, but rather, ensure that parents have an understanding of what school nurses and other healthcare providers are communicating. For older adolescents and those with longer diabetes duration, it is vital that school nurses reinforce positive behaviors that may reduce future diabetes complications.
School nurses engage in frequent interactions with adolescents with T1D and can thereby influence mastery of T1D management skills. School nurses provide vicarious experiences through the facilitation of interactions where students can support and learn from each other. Verbal persuasion by school nurses builds the confidence necessary for adolescents to successfully participate in T1D management. Finally, the school nurse manages physiologic and affective states through a calm and reassuring approach. School nurses caring for lesser numbers of students are more likely to have time to facilitate Bandura’s four sources of efficacy information in adolescents with T1D than school nurses with more students, validating the importance of optimal school nurse to student ratios for improved health outcomes.
Increasing knowledge and self-efficacy for T1D management in adolescents is essential in the achievement of recommended target levels of glycemic control, particularly in the newly diagnosed. School nurses can support adolescents through the development and enhancement of self-efficacy for T1D management and glycemic control.
This study recruited a homogeneous convenience sample from one large pediatric endocrinology practice; therefore, findings are limited in generalizability. Although the homogeneity of the sample does not lessen the importance of the findings, it would be beneficial to include and collect data from diverse socioeconomic and ethnic and racial groups. The use of two recruitment methods, while expediting the process, may have diminished the rigor of the study. Participants who were recruited electronically to receive the study materials by mail may have been reluctant to ask for clarification regarding the questionnaires and thus may explain the low response rate. Conversely, the in-person data collection afforded participants the opportunity to ask the researcher questions as they progressed through the study materials and may explain the higher response rate of nearly 82%, substantially reducing response bias. However, future studies should aim to be consistent in one data collection method.
Self-report methods for both adolescents and parents may be subject to response bias (Polit & Beck, 2012, pp. 312–313). Nonresponse bias could not be evaluated; characteristics of nonresponders receiving the recruitment e-mail were unknown. Adolescents in this study had higher SEDM overall mean scores and slightly lower HbA1c levels than reported in previous research, and parents were well educated. It is unclear whether the sample in the present study is representative of the endocrinology practice population, as data for the practice were unavailable.
Findings from the current study provide new information relevant to school nursing practice about adolescents with T1D in the school setting. Although higher self-efficacy scores were associated with female gender and older age of adolescents, school nurses need to be mindful that expectations of self-efficacy for T1D management must be tailored to each adolescent’s unique needs. While older adolescents may appear to be more independent and capable of self-management, school nurses need to develop and maintain strategies to enhance communication, as adolescents are at risk for diminished treatment adherence (Hilliard et al., 2013; Rausch et al., 2012), which is especially important with a new diagnosis of T1D, regardless of the age of the adolescent.
The implications of gender differences in self-efficacy for T1D management found in this study are notable in that males may require more support from the school nurse, especially those with a new diagnosis. Although males had statistically significant lower scores on choosing healthful foods when dining outside the home, school nurses should target dietary education to all adolescents with T1D. These findings present an opportunity for school nurses to enhance self-efficacy for T1D management through the reinforcement of self-efficacy sources of enactive mastery experience, vicarious experience, and verbal persuasion. Success in meeting the developmental challenges facing adolescents depends largely on their sense of personal efficacy, gained primarily through prior mastery experiences (Bandura, 1997), and school nurses are well suited for the facilitation of these mastery experiences as they relate to diabetes selfmanagement.
While glycemic control in adolescents in this study was better than that reported in several multisite national studies (Clements et al., 2016; Wood et al., 2013), less than half of study participants (n = 36, 40.4%) met ISPAD age-specific target HbA1c levels and almost 20% (n = 17) reported HbA1c levels between 9.0% and 12.5%. These elevated levels are alarming and should be a call for action from school nurses as well as other health professionals to investigate initiatives to lower HbA1c levels to mitigate sequelae. It is not uncommon for high school-age students with T1D to see the school nurse infrequently unless newly diagnosed. It is imperative that school nurses at all levels check in with their students with T1D, if only as a beginning conversation to assess general well-being during a period rife with physiological, emotional, and social changes. School nurses have a valuable opportunity and a moral duty to support and educate adolescents with T1D on glycemic control through Bandura’s sources of self-efficacy.
While school nurse to student ratios are not determined by school nurses, it is imperative that sufficient numbers of school nurses are employed to advocate for this vulnerable population at a pivotal time in an adolescent’s life. In an effort to promote health and alleviate the devastating complications of T1D, school nurses must continue to engage the stakeholders such as parents, school administrators, and boards of education with the best evidence to facilitate optimal T1D management. The school nurse is an essential and highly accessible community resource to impact care to ensure best outcomes during adolescence and into adulthood.
Recommendations for future research include utilizing a more heterogeneous sample, as recent literature has demonstrated disparities in access to care and treatment outcomes in diverse populations (Chalew et al., 2018; O’Connor, Carlin, Coker, Zierler, & Pihoker, 2019; Rose et al., 2018). Varied geographic locations and expanding the research question to include targeted school nursing interventions aimed at increasing self-efficacy for T1D management in the adolescent population are warranted. Moreover, it’s imperative that school nurses investigate interventions aimed at reducing HbA1c levels to recommended ADA and ISPAD target levels. Although the target sample age was 10–16 years old, the majority of the sample (n = 63, 70.8%) was 13–16 years old. It would be beneficial to solicit a quota sample, so that all ages are represented equally (Polit & Beck, 2012, pp. 277–278). It is particularly important to continue this line of inquiry nationwide where school nurses are charged with the care of many more students than in the current study. It is essential to ensure accurate reporting of the number of children with diabetes and other chronic illnesses in order to aid advocacy efforts of school nurses and their professional organizations in promoting the health and self-efficacy for T1D management of adolescents with T1D. Given that dietary adherence is problematic for adolescents with T1D, experimental designs with structured educational interventional programs on nutrition in diabetes by school nurses may have a measurable impact on self-efficacy for T1D management.
This was the first study to examine the relationships among school nurse to student ratios, self-efficacy for T1D management, and glycemic control in adolescents. To the author’s knowledge, this was also the first study to report statistically significant gender differences on SEDM individual scale items, which is important for school nurses to understand for the purpose of targeting educational initiatives for adolescents with T1D. Females had statistically significant higher scores on both the SEDM overall mean score and 3 of the 10 individual scale items. Findings of the current study add to the small body of knowledge regarding school nursing and adolescents with T1D. As the prevalence rate of diabetes is increasing, particularly in the 15- to 19-year-old age-group (Dabelea et al., 2014), it is crucial that school nurses acquire and maintain the ability to increase self-efficacy for T1D management in adolescents. Furthermore, education of adolescents with T1D remains a vital role for school nurses to reinforce healthy diabetes management strategies in the prevention of diabetesrelated complications.
The author acknowledges her dissertation committee members, Drs. Marie Foley, Pamela Galehouse, and Donna Mesler for their contributions to this study, as well as Dr. Kathleen Neville for her assistance in the editing of this manuscript.
The author was responsible for the conception and design of the study, acquisition and analysis of data, writing the original and revised drafts, and agrees to be accountable for all aspects of the work, ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Lori Wilt, PhD, RN, NJ-CSN, NCSN https://orcid.org/0000-0001-7436-2918
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1 Seton Hall University, South Orange, NJ, USA
Corresponding Author:
Lori Wilt, PhD, RN, NJ-CSN, NCSN, Seton Hall University, South Orange, NJ 07079, USA.
Email: lori.wilt01@gmail.com
