This study applied a descriptive cross-sectional design. Participants were recruited from 35 medical and surgical wards of two teaching tertiary referral hospitals in the Northwest of Iran using random sampling method. In the first step, all eligible nurses were identified from the 35 wards and their names were written on pieces of papers and folded and put in a box. The researchers then mixed the box before drawing out the required number of sample. To be eligible for the study, participants needed to have a minimum of a bachelor’s degree in nursing and be working as a fixed term registered nurse in a medical or surgical ward for at least one month. Information from a pilot study was used to calculate the sample size in this study. The required sample size increased to 156 participants when a possible dropout rate of 20% was considered. One hundred sixty participants were recruited to the study.
There is no diabetes educator position in Iran [17]. During data collection for this study, none of the participating hospitals had a designated diabetes educator or diabetes link nurse. However, both hospitals had a nutrition unit, which was responsible for providing general nutrition care for all forms of health conditions, including nutritional consultation to patients with diabetes.
Data collection tools
Data were collected using a self-report paper-based survey package containing four sections: The first section included questions about the socio-demographic and professional characteristics of nurses. The second section included the Nutritional Management of Diabetes Knowledge Test (NMDKT), designed and validated by Mogre et al. [5]. Its original version contains 21 questions; correct answers are scored 1, and others scored 0. Higher scores on the NMDKT represent higher level of knowledge about nutritional management of diabetes mellitus. A permission to modify and use the questionnaire for the current study was obtained from the designers (personal communication, November 3, 2019). The third section was the Nurses’ Attitudes about Nutritional Management of Diabetes Questionnaire, which developed by the researchers specifically for this study based on the WHO and the American Diabetes Association nutrition guidelines and the review of the relevant literature [2, 16, 18]. It contained 15 questions and used a five-point Likert scale, with responses ranging from strongly disagree (1) to strongly agree (5). Total scores could range from 15 to 75. The scores were then standardized between 0 to100 and categorized to three categories of high (66.6–100), moderate (33.3–66.6), and poor attitudes (0-33.3).
The final section included the Nurses’ Practice on Nutritional Management of Diabetes Questionnaire. This questionnaire was also developed by the researchers. It contained 15 questions and used a four-point Likert scale, with responses ranging from never (1) to always. Total practice scores could range from 15 to 60. The scores on practice about nutritional management of diabetes mellitus were then standardized between 0 to100 and categorized to three categories of good (66.6–100), moderate (33.3–66.6) and poor practice (0-33.3).
Validity and reliability
The survey package was submitted to a panel of 13 experts, 4 in nutrition and 9 in nursing, for evaluation of the face and content validity. The questionnaire was revised based on the comments of the review panel and resubmitted for further evaluation. For example, question 12 was removed for a cultural reason. The panel approved all the items as appropriate, assuring good content validity. In addition, the Content Validity Ratio (CVR) and content validity index (CVI) of all questionnaires were assessed and the results supported the content validity of the used tools. The CVR and CVI for were 0.99 and 0.98, respectively. The Nurses’ Attitudes about Nutritional Management of Diabetes Questionnaire had the CVR and the CVI of 0.99 and 1.00, respectively, and the Nurses’ Practice on Nutritional Management of Diabetes Questionnaire demonstrated the CVR and the CVI of 0.99 and 1.00, respectively. Using Cronbach’s alpha to measure internal consistency, a reliability coefficient of 0.65 was attained for the NMDKT, 0.83 for the Nurses’ Attitudes on Nutritional Management of Diabetes Questionnaire, and 0.90 for the Nurses’ Practice on Nutritional Management of Diabetes Questionnaire. The questionnaire took an average 17.88 ± 9.40 min to complete.
Thus, we used the NMDKT containing 20 questions in this study. Total row scores ranged from 0 to 20. The NMDKT scores were then standardized between 0 to100 and categorized to three categories of high (66.6–100), moderate (33.3–66.6) and poor knowledge (0-33.3).
Ethical considerations
The study received ethical approval from the Regional Research Ethics Committee of Tabriz University of Medical Sciences (Approval ID: IR.TBZMED.REC.1399.844), was carried out in accordance with the Declaration of Helsinki. Potential nurses were informed about the study and what participation would entail, and all provided informed consent before participating in the study. Permission to have access to the hospitals was obtained from hospital mangers. The survey was anonymous, and participants were ensured that the data could not be traced back to individual participants or hospitals.
Data analysis
Data were analyzed using descriptive statistics to characterize respondents’ profiles. This included reporting mean values and standard deviations for continuous variables and frequency and percentages for categorical and ordinal variables. Relationship between KAP concepts was assessed by Pearson’s correlation coefficient, and multiple linear regression analysis was used to identify the significant associates of KAP. Analyses were conducted using the IBM SPSS for Windows, Version 24.0 statistical software package. A p-value of < 0.05 was considered statistically significant.
