Improving Pediatric Diabetes Management: New Research Investigates School Nurses Perspectives, Roles, and Interactions with Modern Devices

The incidence of type 1 diabetes (T1D) in children continues to increase. Intensive insulin therapy is standard of care, and during the last decade, much progress has been made in developing devices such as insulin pumps, continuous glucose monitors (CGM), and automated hybrid closed-loop systems to effectively administer insulin and monitor glucose levels. However, even with more innovative technologies available to patients and providers, children continue to struggle with and often do not reach glycemic control targets, increasing their risk for short and long-term complications. 

How do We Improve Glycemic Control?

For Christine A. March, MD, clinical instructor of pediatrics in the Division of Pediatric Endocrinology, Diabetes, and Metabolism at UPMC Children’s Hospital of Pittsburgh, the question is how we can improve overall diabetes management in patients with T1D, and who can we effectively partner with in the community to accomplish this?

“In addition to the family, I believe we can strengthen our partnership with schools, and school nurses in particular, as a means to fostering better management in children with T1D. Children spend nearly half of their weekday waking hours at school, and it is a place where they receive consistent care and support. Still, we don't know a lot about how that care has evolved and what circumstances arise in how school nurses interact with and understand the newer diabetes management devices. There also is a lack of data or consensus for providers on how they can best interact with the school nurse population to assist them with managing their students and families,” says Dr. March.

To better understand the experiences and practices of school nurses related to their interactions with new diabetes management devices and technology, Dr. March and colleagues designed a qualitative study targeting public school nurses across the Commonwealth of Pennsylvania in elementary and middle schools. They interviewed school nurses who have had experience in caring for students with T1D who use some form of device – CGM, insulin pumps, or hybrid closed-loop systems. 

This study was designed to understand the current practices, attitudes, challenges, and needs of school nurses in working with children with T1D and their new devices. The study also examined how school nurses interact with the broader health care system on behalf of their students. Dr. March and colleagues' study is the first qualitative approach documenting school nurse perceptions and experiences with the spectrum of modern diabetes devices and related questions.

Four Major Themes Emerged From the Study

Training and Experience With New Devices Is Greatly Needed by School Nurses

School nurses have, are, and expect to interact with children with T1D and the new diabetes devices they use, but there appear to be limited opportunities for school nurses to obtain the necessary training on the latest devices to become comfortable in their interactions.

“There is a perceived and real lack of uniformity in training available to school nurses. With how fast technology changes or advances, this poses significant challenges to school nurses to become adept at working with new devices. This is an area we need to address. If school nurses do not know about the new technologies and how they function, or when changes or new devices become available, they may initially have a harder time in helping their students,” says Dr. March.

Enthusiasm for New Technology Exists but Is Accompanied by Concerns

School nurses generally appreciate the ability of new diabetes management devices to help children more effectively control their diabetes with less interruption in their lives.

The devices are viewed by some as time savers when nurse/student interactions are required. They are considered a "safety net" because of their ability to warn about impending glucose issues. However, there can be a struggle with adapting to new changes. CGM in particular provides more information than in the past about glucose trends. Nurses and parents need to have a plan for how to manage the added glucose numbers and alarms without disrupting the child’s school day. Nurses also may be unfamiliar with how the device functions and may prefer to rely on trusted methods for glucose monitoring and insulin dosing.  

Barriers to Integrating Devices in the School

At both the classroom and institutional level, there are a number of challenges or limiting factors to wider integration of diabetes management technology.

Internet and Wi-Fi connectivity issues exist, and there are often policies in place at the institutional level limiting their use in the classroom.

Continuous glucose monitoring also is controversial in terms of whether or not it should fall into the school nurse's responsibilities because of liability and privacy factors.

“Firm guidelines do not yet exist from clinical organizations or at the state government level on whether CGM should be part of a nurse's personal responsibility. Because of this, tension can develop between parents who frequently feel that nurses should be handling monitoring and the nurses who may not have the capacity to monitor CGM consistently and are wary of liability issues,” says Dr. March.

Classroom-specific issues also were identified by study respondents. There is variability in classroom teacher support because of perceived disruption to the teaching environment if a student has constant CGM alarms or issues. Nurses raised issues related to training or advising teachers unfamiliar with T1D and the technologies used to manage them.

Limited or Lack of Collaboration Between Health Care Providers and School Nurses

In the study, school nurses described a wide variety of interactions with health care systems and what they would characterize as a good or collaborative relationship with health care providers. 

“Nurses experience a lot of variability in their relationship with health care providers. There can be communication challenges, and sometimes school nurses want or need more detailed information about their students and more engagement with the treating physicians. Not to mention, school nurses are a wealth of information about the student’s diabetes management; they make decisions with that child daily. School nurses want to be seen as part of the child's health care team. Identifying better ways for us to collaborate could be really helpful," says Dr. March.

Key Takeaways and Future Research Directions

For Dr. March, there are several overarching takeaways from this research that her team plans to address moving forward. First, there are opportunities to enhance school-based diabetes care so that families, youth, and school nurses are well-supported. Second, providers and health care systems can better partner with schools to help children with their diabetes management. 

These conclusions from the initial study form the basis for the next several steps in her research. In the short term, Dr. March and her team are launching studies in several key areas, including: evaluating CGM metrics to measure glycemic control during the school day and related factors; exploring provider perceptions of their role and ability to counsel patients and families about school-based diabetes care; and comprehensively assessing school nurse confidence and needs with diabetes devices. In the long-term, she plans to engage key stakeholders to build and rigorously test a collaborative care model which brings together various caregivers for children with diabetes – parents, school staff, and health care providers. 

"Our team has several immediate projects underway. Our future work in this space will explore important questions and gaps in our knowledge about leveraging diabetes care in the school setting to optimize outcomes,” says Dr. March. Dr. March is confident that a school-centered approach would lead to improved glycemic outcomes and psychosocial health for children with diabetes. 

Reference

March CA, Nanni M, Kazmerski TM, Siminerio LM, Miller E, Libman IM. Modern Diabetes Devices in the School Setting: Perspectives from School Nurses. Pediatr Diabetes. 2020 Aug; 21(5): 832-840.