Abstract
Aim
To understand the insulin injection knowledge, attitude and behaviour of nurses and their influencing factors in Guangdong Province.
Design
Cross‐sectional study.
Methods
A total of 19,853 nurses from 82 hospitals in 15 cities in Guangdong, China, participated in this study. The scores of the nurses' insulin injection knowledge, attitude and behaviour were determined through a questionnaire, and multivariate regression analysis was used to evaluate the influencing factors of insulin injection in different dimensions. STROBE.
Results
Among all nurses involved in this study, 22.3% of nurses had good knowledge, 75.9% of nurses had good attitude and 92.7% of nurses had good behaviour. Pearson's correlation analysis showed that knowledge, attitude scores and behaviour scores were significantly correlated. The influencing factors of knowledge, attitude and behaviour included gender, age, education, nurse level, work experience, type of ward, diabetes nursing certification, position held and most recent insulin administration.
Keywords: attitude, behaviour, insulin injection, knowledge, nurses
1. INTRODUCTION
The prevalence of diabetes is gradually increasing around the world (Li, et al., 2020). According to the data provided by the International Diabetes Federation in 2019 (Saeedi et al., 2019), nearly one billion people worldwide suffer from diabetes, and the number of people with diabetes is expected to increase by 25% by 2030. The number of people with diabetes in China is 116.4 million, the highest in the world. Diabetes can be divided into four categories: type 1 diabetes, type 2 diabetes, gestational diabetes and special type diabetes (American Diabetes Association, 2021). Type 2 diabetes is the most common type (Giugliano et al., 2021), which is characterized by insulin resistance and/or insufficient insulin secretion. If patients still have poor blood glucose control after lifestyle interventions combined with oral hypoglycemic drug therapy, insulin therapy should be used to control hyperglycemia (Moghissi & King, 2014).
1.1. Background
Insulin injection is an important part of insulin therapy. A previous study (Frid et al., 2016a) has investigated the insulin injection technology for people with diabetes. From February 2014 to June 2015, a total of 13,298 patients from 41 countries, including 3953 patients from China, were included in the study. The findings revealed that the non‐standard injection of insulin is widespread worldwide, and the injection status of people with diabetes with insulin in China is not optimal. Nurses play a crucial role in correctly administering insulin for people with diabetes, and the behaviour of insulin injection can directly affect the treatment effect and treatment compliance of patients (Frid et al., 2016b). However, at present, nurses have insufficient insulin injection knowledge in clinical practice and are not skilled in insulin injection (Grassi et al., 2014; Misnikova et al., 2017; Song et al., 2018). Inappropriate injection may lead to subcutaneous fat hyperplasia (Conwell et al., 2008; Pickup et al., 2014), fat atrophy (Breznik et al., 2013; Holstein et al., 2010; Yanachkova & Staynova, 2020) and pain (Hanberger et al., 2021), reducing insulin absorption and affecting blood glucose control. Wu et al. (2021) have conducted a cross‐sectional study on the insulin injection knowledge, attitude and behaviour of nurses in different medical institutions in various provinces and cities in China. However, the level of knowledge, attitude and behaviour of nurses vary across different regions. The medical level of Guangdong Province is among the top in China, and the level of nursing technology is relatively advanced. But the development of medical resources in hospitals in different cities is unbalanced, and the level of knowledge, attitude and behaviour of nurses are different. Most clinical nurses perform insulin injection in a standardized manner, but the knowledge and attitude of insulin injection need to be further improved. Guangdong Province is a high‐incidence area of diabetes in China. The prevalence is higher than the national average, and the total number of diabetics exceeds 1.5 million (Li, et al., 2020). Improving the level of knowledge, attitude and behaviour of insulin injection of clinical nurses can ensure the effect and safety of insulin treatment for diabetic patients, which is of great significance for improving the management of insulin injection, and also has reference significance for other regions. However, there is still a lack of comparative analysis of insulin knowledge, attitude and behaviour of clinical nurses in municipal hospitals in Guangdong Province. In view of this background, this study aimed to investigate the existing knowledge, attitude and behaviour of insulin injection of clinical nurses in regional hospitals at all levels in Guangdong Province and identify influencing factors. The findings could provide a reference for improving and standardizing the insulin training of clinical nurses in Guangdong Province.
2. METHODS
2.1. Study design and setting
This cross‐sectional multicentre study used stratified sampling to investigate insulin injection knowledge, attitudes and practices of nurses who had administered insulin injections in grassroot hospitals including community health service centers and township clinics, secondary and tertiary care hospitals in Guangdong Province, China, from July 28, 2019 to August 30, 2019. We randomly selected nurses working in 51 tertiary hospitals, 19 secondary hospitals and 12 grassroot hospitals for the survey. Inclusion criteria were: (a) had been hired in a medical institution as a Registered Nurse; (b) nurses who had performed at least one insulin injection in the previous year. Exclusion criteria were: (a) advanced nurses and interns; (b) unwilling to participate in the survey. The survey included 19,853 nurses from 82 hospitals in 15 municipalities. The study protocol was approved by the Ethics Committee of China‐Japan Friendship Hospital (No. 2019‐69‐K47), the main body supporting the study, and by the local ethics committee and institutional review committee of the participating institutions. All participants provided written informed consent prior to registration. The Strengthening the reporting of observational studies in epidemiology (STROBE) checklist (von Elm et al., 2008) was used in the reporting of this observational study (see Appendix S1).
2.2. Questionnaire
The insulin injection knowledge, attitude and behaviour questionnaire was developed by Wu et al. (2021) according to the Guidelines for Drug Administration Techniques in Diabetes Patients in China 2016 Guidelines on Chinese Diabetes Medication Skills (Chinese Diabetes Society, 2017). It was a Chinese version of the questionnaire consisting of 45 items from three dimensions: knowledge (21 items) attitude (6 items) and behaviour (18 items). In this questionnaire, Cronbach's α of the insulin injection knowledge dimension was 0.686, Cronbach's α of the insulin injection attitude dimension was 0.785 and Cronbach's α of the insulin injection practice dimension was 0.886, indicating good internal consistency. The scores of each dimension were different. In the insulin injection knowledge dimension, there was 1 point for each question, with a total of 21 points. A total score of <13 indicated a poor knowledge of insulin injection, 13–17 was satisfactory, and >17 indicated a good knowledge of insulin injection. In the dimension of insulin injection attitude, 1–5 points were given for questions 1–4, and no point was given for questions 5 and 6. The total score was 20 points; a total score of <12 indicated poor insulin injection attitude, 12–16 indicated satisfactory insulin injection attitude, and >16 indicated good attitude towards insulin injection. In the dimension of insulin injection behaviour, questions 1–14 and 16–18 were given 1–5 points according to the choice order, and questions 15 were given 5–1 points according to the choice order, with a total score of 90 points. A score of <54 indicated poor insulin injection behaviour, 54–72 was satisfactory and >72 indicated good insulin injection behaviour.
2.3. Data collection
The questionnaire was distributed online (http://ww.wjx.cn) between July 28, 2019 and August 30, 2019. The QR code and web page were distributed through WeChat groups. Before the beginning of the survey, the researchers organized the heads of hospitals at all levels in Guangdong province to attend an online training session and introduced the study in detail, including the purpose of the survey, the qualifications of the participants and precautions for the online training meeting. The person in charge of each hospital was required to organize nurses to complete the questionnaire survey with high quality. After getting consent forms from the participants, respondents answered the questionnaire anonymously using electronic devices such as laptops and mobile phones. The participants were further informed of this voluntary survey by reading through the introduction section of the survey questionnaire, which adds an additional background of the survey, the purpose, data privacy protection and gratefulness for their participation. The participants can consult the researcher if they have questions when completing the questionnaire.
2.4. Statistical analysis
Statistical Package for Social Science (SPSS; IBM) 27.0 was used for data analysis. Descriptive statistics, including frequency, percentage, mean and standard deviation, were used to analyse general characteristics of the participants. In addition, t‐test and variance analysis were used to univariate analysis of each dimension. According to the results of one‐way analysis of variance, variables with statistically significant differences were selected as independent variables, and scores of insulin injection knowledge, attitude and behaviour were taken as dependent variables to conduct multiple linear regression analysis to explore the influencing factors of each dimension of insulin injection. Pearson correlation test was used to analyse the correlation between participants' knowledge, attitude and behaviour of insulin injection. p < 0.05 was statistically significant, and the test level α was 0.05.
3. RESULTS
3.1. Demographic and baseline characteristics of the participants
This study assessed 19,853 nurses from 82 medical institutions in 15 municipalities. After excluding 959 incomplete questionnaires, a total of 18,894 participants were included in the study. The demographic and baseline characteristics of the nurses in this study are shown in Table 1. The average age of the respondents was 29.6 ± 6.3 years. Most of them were female (96.5%) with a bachelor's degree (61.5%) and an average working period of 8.2 ± 6.8 years. Senior nurses accounted for the largest proportion (41.4%), followed by nurses (38.6%). Most of them were from non‐endocrinology departments (94.9%), and only 9.9% of them were certified as a diabetes nurse.
TABLE 1.
Demographic and baseline characteristics of the participants (N = 18,894).
| Characteristics | Categories | Mean (SD) | Range | N (%) |
|---|---|---|---|---|
| Gender | Male | 655 (3.5) | ||
| Female | 18,239 (96.5) | |||
| Age (years) | ≤25 | 29.6 ± 6.3 | 18–59 | 5808 (30.7) |
| 26–30 | 6613 (35.0) | |||
| 31–35 | 3322 (17.6) | |||
| >35 | 3151 (16.7) | |||
| Education | Technical secondary school | 692 (3.7) | ||
| Junior college | 6520 (34.5) | |||
| Bachelor | 11,626 (61.5) | |||
| Master or above | 56 (6.3) | |||
| Nurse level | Nurse | 7291 (38.6) | ||
| Senior nurse | 7831 (41.4) | |||
| Nurse‐in‐charge | 3483 (18.4) | |||
| Associate chief nurse | 258 (1.4) | |||
| Chief nurse | 31 (0.2) | |||
| Work experience (years) | ≤3 | 8.2 ± 6.8 | 1–50 | 5446 (28.8) |
| 4–7 | 5491 (29.1) | |||
| 8–11 | 3629 19.2) | |||
| >11 | 4328 (22.9) | |||
| Type of ward | Endocrinology | 969 (5.1) | ||
| Non‐endocrinology | 17,925 (94.9) | |||
| Diabetes nursing certification | Yes | 1870 (9.9) | ||
| No | 17,024 (90.1) | |||
| Number of beds | ≤35 | 50.4 ± 22.8 | 0–200 | 4425 (23.4) |
| 36–45 | 3061 (16.2) | |||
| 46–55 | 4036 (21.4) | |||
| >55 | 7372 (39.0) | |||
| Department | Internal medicine | 5987 (31.7) | ||
| Surgery | 5256 (27.8) | |||
| Gynaecology and obstetrics | 1416 (7.5) | |||
| ICU | 1677 (8.9) | |||
| Endocrinology | 969 (5.1) | |||
| Paediatric | 328 (1.7) | |||
| Emergency | 688 (3.6) | |||
| Out‐patient | 36 (0.2) | |||
| Others | 2537 (13.4) | |||
| Position held | Clinical nurse | 18,842 (99.7) | ||
| Diabetes educator | 52 (0.3) | |||
| Most recent insulin administration | All the time | 12,616 (66.8) | ||
| In a year | 6278 (33.2) |
3.2. Insulin injection knowledge score
The average insulin injection knowledge score of the respondents was 14.2 ± 2.9; 22.3% of nurses had a good knowledge score, 50.7% of nurses had a satisfactory knowledge score and 27.0% of nurses had a poor knowledge score (Table 2). Knowledge score can be divided into three dimensions, that is, master basic knowledge (1, 2, 6, 16, 19–21), master insulin storage knowledge (3–5) and master insulin injection knowledge (7–15, 17, 18). The average accuracy rates of these three dimensions were 53.9%, 88.7% and 70.5%, respectively. Most nurses were able to correctly answer questions about insulin storage and injection; however, only around half of them (53.9%) were able to correctly answer basic knowledge questions. The five questions with the lowest accuracy in this field were: types of aspartic insulin(36.3%), short‐acting insulin injection time (38.0%), distance from the last injection point (53.2%), avoidance of an injection point for an extended period to reuse the same injection point (14.7%) and error of the insulin blending method (37.3%).
TABLE 2.
Insulin injection knowledge, attitude and behaviour scores of nurses (N = 18,894).
| Variables | Score categories, n (%) | Mean ± SD | Range | ||
|---|---|---|---|---|---|
| Good | Satisfactory | Poor | |||
| Knowledge | 22.3 | 50.7 | 27.0 | 14.2 ± 2.9 | 2–21 |
| Attitude | 75.9 | 21.1 | 3.0 | 17.1 ± 2.6 | 4–20 |
| Behaviour | 92.7 | 6.7 | 0.6 | 83.5 ± 7.4 | 22–90 |
3.3. Insulin injection attitude score
The attitude score of nurses ranged from 4 to 20, with an average of 17.1 ± 2.6 (Table 2). Most of them (75.9%) had a good attitude score. Only a few nurses (3.0%) had a poor attitude score, and 21.1% of them had a satisfactory score. More than 70% of nurses strongly believed that the insulin injection technology is highly important for blood glucose control, 34.8% and 36.3% of nurses believed that they could perform insulin injection according to specifications correctly and were very confident in guiding people with diabetes to administer insulin injection correctly, respectively. Moreover, 99.5% of nurses indicated that they would pay attention to the feelings of people with diabetes regarding insulin injection; however, the degree of concern was different. More than half of the nurses (53.7%) would pay attention to the reuse of needles by people with diabetes, and 35.2% of them thought that it is necessary to participate in training related to standardized insulin injection.
3.4. Insulin injection behaviour score
The average insulin injection behaviour score of nurses was 83.5 ± 7.4, which ranged from 22 to 90 (Table 2). More than half of them (97.2%) had a high behaviour score, and 6.7% of them had a satisfactory behaviour score. Only very few nurses (0.6%) had a poor insulin injection behaviour score. Around 74.6% of nurses would always wash their hands before injection and pay attention to the patients' blood sugar level. More than 80% of nurses would always check the name of the lead liquid, and shape, validity and margin, before insulin injection (80.8%), fully shake the liquid before injecting premixed insulin (81.8%), exhaust the air before using an insulin pen or syringe for insulin injection (82%), and check the blood glucose level of patients prior to injection (85.4%). In addition, 88.6% of nurses would always use a new needle when injecting insulin, and the needle stays under the skin for at least 10 seconds before pulling it out when injecting insulin with an insulin pen. Most nurses (90.8%) would always turn the dose knob of the insulin pen to the required scale before using the insulin pump for injection and always ask patients about food intake when injecting insulin with meals. However, 2.5% of nurses never took unopened bottles of insulin or insulin pen cartridges out of the refrigerator 30 minutes in advance to warm them up, 1.9% of nurses never exhaled before using insulin pens or syringes for insulin injection, and 16.9% of nurses injected insulin into the patients' skin lesions or lumps.
3.5. Correlation of the insulin injection knowledge, attitude and behaviour scores of nurses
Correlation analysis of the nurses' insulin injection knowledge, attitude and behaviour scores was performed. The results of Pearson's correlation analysis showed that there was a linear correlation between insulin injection knowledge and attitude (r = 0.23, p < 0.001), a correlation between insulin injection attitude and behaviour (r = 0.52, p < 0.001) and a correlation between insulin injection knowledge and behaviour (r = 0.22, p < 0.01). In addition, Spearman correlation analysis was performed to further confirm the correlation between insulin injection knowledge, attitude and behaviour (Table 3). The correlation between insulin injection attitude and behaviour was the highest (r = 0.52), followed by the correlation between insulin injection knowledge and attitude.
TABLE 3.
Correlation of the insulin injection knowledge, attitude and behaviour scores of nurses (N = 18,894).
| Pearson's correlation coefficient | Spearman's correlation coefficient | ||||||
|---|---|---|---|---|---|---|---|
| Variables | Correlation value | Knowledge score | Attitude score | Behaviour score | Knowledge score | Attitude score | Behaviour score |
| Knowledge score | R | 1 | 1 | ||||
| p | |||||||
| Attitude score | r | 0.23 | 1 | 0.20 | 1 | ||
| p | <0.001 | <0.001 | |||||
| Behaviour score | r | 0.22 | 0.52 | 1 | 0.18 | 0.49 | 1 |
| p | <0.001 | <0.001 | <0.001 | <0.001 | |||
3.6. Factors affecting the insulin injection knowledge, attitude and behaviour scores of nurses
The results of single factor analysis are shown in Table 4. The association of knowledge and attitude scores with all factors was statistically significant (p < 0.05). However, all factors except education, nursing certification and position held showed a statistically significant association with the behaviour score (p < 0.05). Women scored higher than men in insulin injection knowledge, attitude and behaviour (14.2 ± 2.9, 17.1 ± 2.6, 83.6 ± 7.2). Nurses aged 25 or below had the lowest scores in all three dimensions (14.0 ± 2.9, 16.7 ± 2.6, 82.8 ± 7.8), whereas nurses aged 35 or above had the highest scores (14.5 ± 2.9, 17.7 ± 2.4, 85.2 ± 6.0). The more educated the nurses, the higher the knowledge and attitude scores; however, the behaviour score of nurses with a master's degree was the lowest (p < 0.001). Nurse level and work experience were also factors that affected knowledge, attitude and behaviour scores (p < 0.001). In addition, the scores of nurses in the endocrinology department were significantly different from those in non‐endocrinology departments (p < 0.001). However, the knowledge score of certified diabetes nurses (13.8 ± 3.3) was lower than that of non‐certified nurses (14.2 ± 2.9). The attitude and behaviour scores of certified diabetes nurses were higher than those of non‐certified nurses (p < 0.001); however, there was no statistical significance in the behaviour score (p = 0.069). Moreover, nurses who had been working with insulin had higher scores in all three dimensions compared with the scores of nurses who had only been working in the last 12 months (p = 0.002, p < 0.001, p = 0.005). Notably, nurses working in a department with 36–45 beds had the highest knowledge, attitude and behaviour scores.
TABLE 4.
Association of specific factors with the knowledge, attitude and behaviour scores of nurses.
| Variables | Knowledge | Attitude | Behaviour | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Score (mean ± SD) | t/F | p | Score (mean ± SD) | t/F | p | Score (mean ± SD) | t/F | p | |
| Gender | |||||||||
| Male | 13.4 ± 3.3 | 6.7 | <0.001 | 16.5 ± 3.1 | 5.2 | <0.001 | 80.6 ± 11.0 | 6.9 | <0.001 |
| Female | 14.2 ± 2.9 | 17.1 ± 2.6 | 83.6 ± 7.2 | ||||||
| Age | |||||||||
| ≤25 | 14.0 ± 2.9 | 38.9 | <0.001 | 16.7 ± 2.6 | 144.9 | <0.001 | 82.8 ± 7.8 | 76.8 | <0.001 |
| 26–30 | 14.1 ± 2.9 | 17.0 ± 2.6 | 83.2 ± 7.7 | ||||||
| 31–35 | 14.5 ± 2.9 | 17.4 ± 2.5 | 83.9 ± 7.1 | ||||||
| >35 | 14.5 ± 2.9 | 17.7 ± 2.4 | 85.2 ± 6.0 | ||||||
| Education | |||||||||
| Technical secondary school | 13.8 ± 3.3 | 46.9 | <0.001 | 17.0 ± 2.7 | 4.8 | 0.002 | 83.5 ± 8.2 | 2.2 | 0.081 |
| Junior college | 13.9 ± 3.0 | 17.0 ± 2.6 | 83.6 ± 7.5 | ||||||
| Bachelor | 14.4 ± 2.8 | 17.1 ± 2.5 | 83.5 ± 7.3 | ||||||
| Master or above | 14.8 ± 3.3 | 17.1 ± 2.7 | 81.0 ± 8.8 | ||||||
| Nurse level | |||||||||
| Nurse | 13.8 ± 3.0 | 56.0 | <0.001 | 16.8 ± 2.7 | 79.2 | <0.001 | 82.9 ± 8.0 | 31.2 | <0.001 |
| Senior nurse | 14.3 ± 2.9 | 17.1 ± 2.5 | 83.6 ± 7.2 | ||||||
| Nurse‐in‐charge | 14.7 ± 2.8 | 17.7 ± 2.4 | 84.5 ± 6.6 | ||||||
| Associate chief nurse | 14.6 ± 3.0 | 17.8 ± 2.4 | 85.3 ± 6.1 | ||||||
| Chief nurse | 14.1 ± 3.7 | 17.8 ± 2.0 | 83.8 ± 6.6 | ||||||
| Work experience (years) | |||||||||
| ≤3 | 14.1 ± 2.9 | 24.8 | <0.001 | 16.6 ± 2.6 | 166.1 | <0.001 | 82.4 ± 8.0 | 105.2 | <0.001 |
| 4–7 | 14.0 ± 2.9 | 17.0 ± 2.6 | 83.3 ± 7.6 | ||||||
| 8–11 | 14.3 ± 3.0 | 17.3 ± 2.6 | 83.7 ± 7.4 | ||||||
| >11 | 14.5 ± 2.9 | 17.7 ± 2.4 | 85.1 ± 6.1 | ||||||
| Type of ward | |||||||||
| Non‐endocrinology | 14.1 ± 2.9 | −17.4 | <0.001 | 17.0 ± 2.6 | −15.3 | <0.001 | 83.5 ± 7.5 | −7.1 | <0.001 |
| Endocrinology | 15.8 ± 2.9 | 18.2 ± 2.2 | 84.9 ± 6.3 | ||||||
| Diabetes nursing certification | |||||||||
| Yes | 13.8 ± 3.3 | −5.5 | <0.001 | 17.3 ± 2.6 | 4.0 | <0.001 | 83.9 ± 7.5 | 2.3 | 0.022 |
| No | 14.2 ± 2.9 | 17.1 ± 2.6 | 83.5 ± 7.4 | ||||||
| Number of beds | |||||||||
| ≤35 | 14.0 ± 3.0 | 20.5 | <0.001 | 16.8 ± 2.7 | 24.9 | <0.001 | 83.1 ± 8.2 | 14.9 | <0.001 |
| 36–45 | 14.5 ± 2.9 | 17.3 ± 2.5 | 84.1 ± 7.1 | ||||||
| 46–55 | 14.3 ± 2.9 | 17.2 ± 2.5 | 83.9 ± 6.9 | ||||||
| >55 | 14.1 ± 2.9 | 17.1 ± 2.6 | 83.4 ± 7.3 | ||||||
| Department | |||||||||
| Internal medicine | 14.3 ± 2.7 | 52.8 | <0.001 | 17.1 ± 2.5 | 44.0 | <0.001 | 83.2 ± 7.2 | 24.6 | <0.001 |
| Surgery | 14.0 ± 2.9 | 17.1 ± 2.5 | 83.8 ± 7.1 | ||||||
| Gynaecology and obstetrics | 14.5 ± 3.1 | 17.1 ± 2.7 | 84.7 ± 7.2 | ||||||
| ICU | 13.9 ± 3.1 | 16.5 ± 2.7 | 82.2 ± 8.8 | ||||||
| Endocrinology | 15.8 ± 2.9 | 18.2 ± 2.2 | 84.9 ± 6.3 | ||||||
| Paediatric | 14.2 ± 3.0 | 16.4 ± 2.8 | 84.4 ± 6.5 | ||||||
| Emergency | 13.2 ± 3.2 | 16.4 ± 3.0 | 81.6 ± 10.0 | ||||||
| Out‐patient | 14.8 ± 2.5 | 17.5 ± 2.4 | 85.8 ± 3.9 | ||||||
| Others | 14.1 ± 2.9 | 17.2 ± 2.5 | 83.9 ± 7.1 | ||||||
| Position held | |||||||||
| Clinical nurse | 14.2 ± 2.9 | −3.4 | 0.001 | 17.1 ± 2.6 | −5.7 | <0.001 | 83.5 ± 7.4 | −1.8 | 0.069 |
| Diabetes educator | 16.0 ± 3.9 | 18.5 ± 1.9 | 85.4 ± 6.6 | ||||||
| Most recent insulin administration | |||||||||
| All the time | 14.2 ± 2.9 | 3.1 | 0.002 | 17.3 ± 2.5 | 13.2 | <0.001 | 83.6 ± 7.3 | 2.8 | 0.005 |
| In a year | 14.1 ± 2.9 | 16.7 ± 2.6 | 83.3 ± 7.6 | ||||||
Further analysis of the degree of the effect of each variable on insulin injection knowledge, attitude and behaviour scores was conducted. According to the results of one‐way ANOVA, variables with a statistically significant difference (p < 0.05) were used as independent variables, and insulin injection knowledge, attitude and behaviour were used as dependent variables to perform multiple linear regression analysis. Regression models for predicting insulin injection knowledge, attitude and behaviour scores were statistically significant (F = 77.793, p < 0.05, F = 120.573, p < 0.05, F = 106.874, p < 0.05), explaining 3.5% of the variance of the knowledge score (adjusted R 2 = 0.035), 4.2% of the variance of the attitude score (adjusted R 2 = 0.042), and 2.2% of the variance of the behaviour score (adjusted R 2 = 0.022). The results showed that gender (β = −0.049, p < 0.001), age (β = 0.042, p < 0.05), education (β = 0.048, p < 0.001), nurse level (β = 0.107, p < 0.001), work experience (β = −0.079, p < 0.001), type of ward (β = 0.129, p < 0.001), diabetes nursing certification (β = 0.049, p < 0.001) and position held (β = 0.021, p < 0.05) were influencing factors of insulin injection knowledge (Table 5). Gender (β = 0.03, p < 0.001), age (β = 0.049, p < 0.05), type of ward, (β = 0.083, p < 0.001), diabetes nursing certification (β = −0.016, p < 0.05), most recent insulin administration (β = −0.081, p < 0.001) were independent influencing factors of insulin injection attitude (Table 6). The influencing factors of insulin injection behaviour were gender (β = −0.064, p < 0.001), nurse level (β = −0.031, p < 0.05), work experience (β = 0.144, p < 0.001) and type of ward (β = 0.040, p < 0.001) (Table 7).
TABLE 5.
Factors affecting the insulin injection knowledge score.
| Variables | Knowledge score | |||||
|---|---|---|---|---|---|---|
| B | SE | β | t | p | 95% CI | |
| Constant | 8.855 | 0.842 | — | 10.516 | 0.000 | 7.204, 10.505 |
| Gender | −0.784 | 0.115 | −0.049 | −6.825 | 0.000 | −1.009, −0.559 |
| Age | 0.116 | 0.046 | 0.042 | 2.501 | 0.012 | 0.025, 0.206 |
| Education | 0.246 | 0.040 | 0.048 | 6.132 | 0.000 | 0.167, 0.324 |
| Nurse level | 0.402 | 0.045 | 0.107 | 8.982 | 0.000 | 0.314, 0.489 |
| Work experience | −0.205 | 0.042 | −0.079 | −4.937 | 0.000 | −0.287, −0.124 |
| Type of ward | 1.706 | 0.096 | 0.129 | 17.704 | 0.000 | 1.517, 1.894 |
| Diabetes nursing certification | 0.477 | 0.071 | 0.049 | 6.755 | 0.000 | 0.339, 0.616 |
| Position held | 1.192 | 0.403 | 0.021 | 2.958 | 0.003 | 0.402, 1.982 |
Note: Adjusted R 2 = 0.035, F = 77.793, p < 0.05.
TABLE 6.
Factors affecting the insulin injection attitude score.
| Variables | Attitude score | |||||
|---|---|---|---|---|---|---|
| B | SE | β | t | p | 95% CI | |
| Constant | 16.667 | 0.211 | — | 78.818 | 0.000 | 16.252, 17.081 |
| Gender | −0.431 | 0.101 | −0.030 | −4.267 | 0.000 | −0.629, −0.233 |
| Age | 0.120 | 0.039 | 0.049 | 3.102 | 0.002 | 0.044, 0.195 |
| Type of ward | 0.968 | 0.084 | 0.083 | 11.498 | 0.000 | 0.803, 1.133 |
| Diabetes nursing certification | −0.136 | 0.062 | −0.016 | −2.199 | 0.028 | −0.258, −0.015 |
| Most recent insulin administration | −0.447 | 0.039 | −0.081 | −11.334 | 0.000 | −0.524, −0.369 |
Note: Adjusted R 2 = 0.042, F = 120.573, p < 0.05.
TABLE 7.
Factors affecting the insulin injection behaviour score.
| Variables | Behaviour score | |||||
|---|---|---|---|---|---|---|
| B | SE | β | t | p | 95% CI | |
| Constant | 83.075 | 0.428 | — | 193.985 | 0.000 | 82.236, 83.914 |
| Gender | −2.582 | 0.293 | −0.064 | −8.815 | 0.000 | −3.156, −2.008 |
| Nurse level | −0.294 | 0.103 | −0.031 | −2.861 | 0.004 | −0.495, −0.092 |
| Type of ward | 1.358 | 0.242 | 0.040 | 5.607 | 0.000 | 0.883, 1.833 |
| Work experience | 0.948 | 0.072 | 0.144 | 13.260 | 0.000 | 0.808, 1.088 |
Note: Adjusted R 2 = 0.022, F = 106.874, p < 0.05.
4. DISCUSSION
The insulin injection practice of nurses can affect the safety of patients and the quality and effectiveness of patient care to a certain extent. This study used a questionnaire to evaluate the insulin injection knowledge, attitude and behaviour of nurses and their influencing factors by focusing on nurses in regional hospitals in Guangdong Province.
The results of this study proved that clinical nurses in Guangdong Province had a basic understanding of insulin injection knowledge, their scores were above the middle level, and most of their attitudes and behaviours were satisfactory. However, this study demonstrated that the nurses' knowledge, attitude and behaviour of insulin injection still have room for improvement, which was consistent with the findings of other studies (Adhikari et al., 2018; Robb et al., 2017; Wu et al., 2021). According to the results, the knowledge, attitude and behaviour scores of nurses in the endocrinology department were better than those of nurses in the non‐endocrinology department (β = 0.129, β = 0.083, β = 0.040, p < 0.01). Nurses in the endocrinology department receive more training compared with nurses in the non‐endocrinology department; thus, endocrinology personnel are more familiar with the technical requirements of their specialty. In the future, insulin injection training should be strengthened in other departments to improve insulin injection practice in the hospital. On the one hand, we can give full play to the role of endocrinology nurses and diabetes contact nurses, establish the hospital diabetes management team, take non‐endocrinology clinical nurses as the key training objects, follow the relevant guidelines of insulin injection, and establish the awareness of standardized injection of clinical nurses (Wu et al., 2021). On the other hand, the insulin injection site rotation card and palm method can be used to standardize the injection behaviour of clinical nurses. Notably, although the attitude and behaviour scores of certified diabetes nurses were higher than those of non‐certified nurses, their knowledge score was lower than that of non‐certified nurses (β = 0.049, p < 0.01), which may be attributed to the absence of theoretical training or ineffective training. There is no unified institution and standard for the training of specialized diabetes nurses in China, and the standards recognized by different hospitals in each province are different, potentially resulting in the reduced training and quality of specialized nurses. In the future, theoretical training of diabetes specialist nurses should be strengthened, and theoretical and operational assessments should be carried out regularly. At the same time, training content should be formulated according to local conditions to overcome personality‐related barriers, which may improve the overall knowledge level of clinical nurses (Adhikari et al., 2018).
This study found a statistically significant correlation between the knowledge, attitude and behaviour scores of clinical nurses, suggesting that knowledge and attitude could influence insulin injection practice, highlighting the importance of the three dimensions. Overall, the findings suggest that improving the insulin injection knowledge and attitude of non‐endocrinology nurses, endocrinology nurses and people with diabetes may be beneficial for enhancing the safety and effectiveness of insulin therapy. Contact nurse groups can be set up between various departments to undertake diabetes specialist nursing and guidance, and supervise the nursing quality of other nurses. On the other hand, the groups can actively participate in the communication between diabetes specialist nursing and other departments (Cabre et al., 2021), so as to standardize insulin injection training so that the overall behaviour of nurses may be improved.
There is still room for improvement in the insulin injection knowledge of nurses in this study, and the deficiencies highlight the need for workplace‐based learning and development programs combined with real‐time guidelines and research, which can enhance the insulin knowledge and practice of district nurses. Overall, 72.3% of nurses were at a good and satisfactory level, which is higher than the reported value of 64.81% in a national study (Wu et al., 2021). The higher level of insulin knowledge in Guangdong Province compared with the national average may be attributed to the relatively high level of medical technology in hospitals in Guangdong Province and the relatively good knowledge of clinical nurses who have received more relevant training. With an increase in the age, education level and professional rank of nurses, the level of insulin injection knowledge is also higher. The working period may be related to knowledge of guidelines and related practices in the clinic. The longer the working hours, the less time for independent learning, which may result in reduced knowledge of insulin injection among non‐endocrinology nurses. However, with longer work hours, clinical experience is increased and insulin injection behaviour is improved when spending more time with patients. In the assessment of knowledge, only 36.3% of nurses could correctly identify the insulin aspart type, and 38.0% of nurses could correctly choose the injection time for short‐acting insulin (30 min before meals). If it is longer than 30 minutes or more, the patient may develop hypoglycemia because the food is not ingested in time (Frid et al., 2016a). Moreover, slightly more than half of the nurses knew that each injection point should be at least 1 cm away from the last injection point. If insulin is repeatedly injected into the same site, it could stimulate the growth of adipose tissue and lead to the development of fat hypertrophy (Chinese Diabetes Society, 2021), which in turn could affect the pharmacokinetics of insulin (Blanco et al., 2013; Hernar et al., 2017), thus affecting drug absorption. As insulin treatment and care options for diabetes continue to be updated, clinical nurses should learn the latest guidelines and requirements to qualify for clinical positions. The newly admitted nurses should carry out pre‐job training and strengthen their professional quality education. Department managers should also carry out in‐depth studies of injection methods, techniques, insulin treatment complications and other knowledge specified in the injection guidelines, and popularize specialized knowledge of insulin standardized injection (Robb et al., 2017). For individual practitioners or home care divisions, in the information age, you can use the network platform to improve their knowledge reserve, such as to participate in online courses or online video learning, etc., They can also participate in training classes for diabetes specialist nurses for further study, or attend academic lectures and conferences held by experts in the field of diabetes, to improve the level of knowledge, attitude and behaviour of insulin injection and broaden their knowledge horizon.
This study demonstrated that clinical nurses in Guangdong Province had a good attitude towards insulin injection. Only 3.0% of nurses had a poor attitude, which was less than 0.2% compared with national data (Wu et al., 2021). Among the nurses, 93.6% of them believed that the insulin injection technology is vital for blood glucose control, which is consistent with the findings of a study in Italy (Grassi et al., 2014). Proper insulin injection techniques can improve glycemic control in a relatively short period of time, improve treatment satisfaction, reduce daily insulin consumption and help improve treatment adherence. Only one‐third of nurses believe that they can fully implement the technical specifications of insulin injection correctly with the confidence to guide people with diabetes to inject insulin correctly. However, it is also necessary to receive training for standardized insulin injection. By providing continuing education and training, clinical nurses would be familiar with standardized insulin injection. They can hold insulin injection right lectures in the department, teach patients to use insulin correctly, can also improve autonomous learning motivation and the confidence of medical staff in guiding patients correctly could be improved (Greaves et al., 2003), which is of practical significance for the prevention and control of diabetes.
The overall insulin injection behaviour of clinical nurses in Guangdong Province was good. More than half of the nurses were very concerned about the reuse of needles for people with diabetes and could properly handle the needles after use. The repeated use of insulin needles could affect the accuracy of the injection dose (Adhikari et al., 2018) and increase pain and inflammation risk. In clinical work, it is necessary to ensure that the needles are not reused, strengthen supervision and assessment, and improve the self‐restraint ability of nurses to prevent errors (Hassan & Wahsheh, 2011). To standardize the operation process, the insulin injection process and steps can be printed out and pasted in the department. The nursing team leader can check the operation process of insulin injection in each group every day, and correct the problems in time. For community nurses, it is more important to follow the injection method described in the guidelines and to perform insulin injections correctly in the community or at the patient's home. Community nurses can be trained to learn the commonly used names and doses of insulin, master the injection specifications of different types of insulin, and clarify the importance of strict implementation of insulin injection specifications (Theofanidis, 2017). A study (Li et al., 2022) found that 7.4% of participants experienced 620 needle injuries related to insulin injection in the past year, and the annual rate of infection caused by injury was 18.7 per 1000 nurses. Nurses should properly dispose of the needles after insulin injection to minimize the risk of needle injury caused by subcutaneous insulin injection (Friel et al., 2022; Yunihastuti et al., 2020; Zhao et al., 2019). More than three‐fifths of nurses always ask patients about the last injection site and whether there is pain at the injection site before injection, and more than 80% of nurses avoid injection at the induration site, otherwise drug absorption will be affected (Blanco et al., 2013). In this study, despite the high knowledge or education level of nurses, their insulin injection behaviour was poorer than that of other clinical nurses. This finding suggests that the practical skills of highly educated nurses should be enhanced. Some clinical competitions on insulin injection can be held to encourage postgraduates to actively participate and strengthen their practical ability, to help them better master insulin injection technology and improve their behaviour level (Theofanidis, 2017). Insulin injections in nursing work are a very common but very important part of, often overlooked. This study can help clinical nurses, community nurses or family nurse practitioners, and other nursing personnel pay more attention to insulin injections, by increasing their knowledge reserves to improve their attitude and to standardize their behaviour. It can also ensure the effect and safety of insulin therapy for diabetic patients (Zhou et al., 2018).
5. LIMITATION
This study was a cross‐sectional study on the insulin injection knowledge, attitude and behaviour of clinical nurses in hospitals of all levels in Guangdong Province; however, there were some limitations. The research participants may not fully represent all nurses in Guangdong Province. Although the sample size was large, there were fewer nurses from hospitals in villages and towns. In addition, the community health service centers in towns and townships often have a large number of chronic patients, including people with diabetes; thus, the nurses' level of experience with these patients may vary. Furthermore, the respondents completed the questionnaire on their own, and there was no evaluator to conduct a field study on the clinical nurses' knowledge and practice of insulin injection, and its results are not objective enough. In future studies, the ratio of the number of hospitals of different levels should be considered and adopt assessment as evaluation indicators to further explore the knowledge, attitude, behaviour level and influencing factors of insulin injection.
6. CONCLUSIONS
In summary, 73% of the nurses surveyed had a good or satisfactory knowledge score, and more than 95% of them had a good or satisfactory attitude or behaviour score. Standardized training and mentoring on insulin injection should be provided to nurses in hospitals in Guangdong Province with a focus on improving the knowledge of diabetes specialist nurses and the clinical practice of highly educated nurses, which may enhance the quality of clinical nursing care.
FUNDING INFORMATION
This study was funded by the Science and Technology Planning Project of Guangdong Province “Diabetes Intelligent Wearable Monitoring Device and Complication Prevention and Control Cloud Platform”. (Grant No. 2016B010108008).
CONFLICT OF INTEREST STATEMENT
There are no conflict of interest to declare.
ETHICAL STATEMENT
The study protocol was approved by the Ethics Committee of China‐Japan Friendship Hospital (No.2019‐69‐K47), the main body supporting the study, and by the local ethics committee and institutional review committee of the participating institutions. All participants provided written informed consent prior to registration.
Supporting information
Appendix S1.
ACKNOWLEDGEMENTS
We are grateful to all the participants for their valuable contribution. We thank all the members of the Diabetes Nursing Professional Committee of Chinese Nursing Association who participated in the survey for the great support of the current study.
Liao, Y. , Liu, X. , Huang, J. , Chen, Q. , Li, N. , & Zhou, P. (2023). Insulin injection knowledge, attitude and behaviour of nurses: A cross‐sectional study in Guangdong Province. Nursing Open, 10, 3754–3765. 10.1002/nop2.1633
Yangyang Liao and Xueyan Liu: Co‐first authors.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Appendix S1.
Data Availability Statement
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.