A paucity of data exists to examine nurses’ satisfaction with the use of insulin pens with safety needles in hospitalized patients with diabetes. We investigated major determinants of nurses’ preference of the method of insulin administration in the context of a General Hospital in Northern Italy.
Methods
Consecutive patients admitted to three hospital units of different care intensity requiring insulin received insulin therapy through either the vial/syringe method [October to December 2012] or pen/safety needles with dual-ended protection method [January to March 2013]. Before the implementation of insulin pens, floor nurses received a specific training program for proper insulin pen injection technique including individual testing of the devices [pen/safety needles]. At the end of the study, nurses completed the Nursing Satisfaction Survey Questionnaire. Cronbach’s alpha was used to determine the internal consistency and reliability of the questionnaire. Major determinants of satisfaction were investigated through an exploratory factor analysis. The association between each retained factor and time spent to teach patients how to self-inject insulin with pen devices was also investigated.
Results
Fifty-three out of 60 nurses [mean age ± SD 36.2 ± 8.5 years, 85 % women, 57 % with 10+ years of working experience] returned the questionnaire. Internal consistency of the questionnaire was satisfactory [Cronbach’s alpha > 0.9]. Three months after their introduction, about 92 % of nurses considered pen devices an “improvement” over the vial/syringe method. Two factors explained 85 % of nurses’ satisfaction, one related to convenience and ease of use, and the other to satisfaction/time spent for dose preparation and administration. The latter factor was inversely correlated with time spent on patients’ training tasks.
Conclusions
Nurses’ satisfaction with pen devices was higher than previously reported, possibly reinforced by safety needles with dual-ended protection. Perceived workload was a major determinant of nurse satisfaction using pen devices with safety needles. To facilitate the introduction of insulin pens in the hospital setting, it should be specifically addressed during training programs in the switch-over period.
Background
The prevalence of insulin pens worldwide has been recently estimated to be 60 % of insulin users; the figure being higher in Europe than in the US, and about 75 % in Italy []. Studies evaluating patient preference comparing self-administration of insulin using pen devices compared to traditional vial and syringe method found patients preferred insulin pens with respect to several items including ease of use, convenience, less injection pain, ease in handling, and ease of dosing []. Conversely, whether insulin pen devices should replace traditional vial and syringe in hospitalized patients is still a controversial subject []. Together with patients’ satisfaction [, ], economic evaluation [–] and safety issues related to the potential risk of biological contaminations for both nurses and patients [–], nurses’ satisfaction constitutes a key perspective for the management of hospitalized patients with diabetes requiring insulin injections. However, information on this topic is scarce, with the only data coming from the US, where 70 % of nurses considered insulin pens an “improvement” over conventional vial and syringe method 11 months after their introduction in two floors of one hospital []. The safety needles in this study differed from ours because they did not have a dual-ended protection. In addition, a limitation of this study was that nurses’ satisfaction was measured using a survey questionnaire developed by the authors that was not formally validated []. There are a variety of validated tools for patient’s satisfaction with self-administration of insulin [–], one of them specifically comparing pen devices with vial/syringe [], but to the best of our knowledge, no validated questionnaire exists to assess nurses’ satisfaction with insulin administration method to hospitalized patients. The existence of a validated tool is important to be able to compare findings from different populations using a standardized measure, to understand the determinants of nurses’ satisfaction and utilize survey findings to adequately promote and enhance implementation of insulin pens in the hospital setting. In this paper, we report on nurse satisfaction, as assessed in Davis et al. [], in the context of a pilot study aimed at implementing the use of insulin pens in hospitalized patients with diabetes at the Treviglio General Hospital in northern Italy. In addition, we performed an exploratory factor analysis, to investigate the latent structure behind nurses’ satisfaction.
Methods
Study setting
The SANITHY [SAfety Needles and Insulin pens at Treviglio Hospital – ItalY] study is a pilot study designed to implement the use of insulin pens in the hospital setting at the Treviglio General Hospital, northern Italy. From October to the end of December 2012, consecutive patients requiring multi-injection insulin therapy and admitted to three hospital units of different intensity of care [Cardiology and Coronary Care Unit; Neurology and Stroke Unit; Medicine and Urgency Unit] received the traditional vial and syringe method. Insulin pens and safety needles were adopted in the same hospital units the next successive three months from January to the end of March 2013 in consecutive patients requiring insulin therapy. The following insulin and prefilled insulin pens were utilized: Humalog© and Humalog Kwikpen© [Eli Lilly and Company, Indianapolis, USA] as rapid acting insulin; Lantus© and Lantus SoloSTAR© [Sanofi, Paris, France] as long-acting basal insulin. Together with pen devices, pen needles with a dual-ended protection safety system Autoshield Duo© [Becton, Dickinson and Company, Franklin Lakes, NJ, USA] were utilized. The dual-ended protection covers both the portion of the needle in contact with the patient, and the back-end which penetrates into the rubber tip of the pen. Prior to the study, nurses received a specific training program on insulin pens consisting of small-group sessions and hands-on training, with individual testing to insure competence in using the insulin pen devices and safety needles properly. Thereafter, study nurses administered prescribed insulin therapy with pens and safety needles to inpatients, under an expert’s supervision, to demonstrate the acquired technical skill. Moreover, slides and a short explicative movie were available on our hospital Local Area Network portal [e-learning] and a 24 h, 7 day a week, toll-free phone number was active during the study period to interact with expert consultants. The pilot study was approved by the Independent Ethical Committee of the Treviglio Hospital.
The nursing satisfaction survey questionnaire
The Nursing Satisfaction Survey Questionnaire [NSSQ] was proposed by Davis et al. to evaluate nurse satisfaction using pen devices as compared to vials/syringes in a sample of US nurses [], in a study setting very similar to ours. The first section of the NSSQ collects information on the number of years practiced as a nurse, as well as on the previous experience with insulin administration and with study pen devices. Nurses’ satisfaction with insulin pen devices as compared to vial/syringes is then investigated through 8 items, each on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree”, addressing different aspects such as insulin preparation and administration, convenience and ease of use, confidence and comfort in insulin administration, and time spent in dose preparation and administration. Items are reported in Table . Finally, the questionnaire attempts to quantify the time spent by the nurses to teach study patients how to self-inject insulin with each device, categorized as “