SCHOOL PERSONNEL’S KNOWLEDGE OF TYPE ONE DIABETES AND ITS EFFECT ON THEIR STUDENTS by Laura Stanford Tzunun A project submitted in partial fulfillment of the requirements for the degree of MASTER OF EDUCATION IN CURRICULUM AND INSTRUCTION WEBER STATE UNIVERSITY Ogden, Utah November 19, 2018 Approved Peggy J. Saunders, Ph.D. ____________________________________ Sheryl J. Rushton, Ph.D. ____________________________________ Ann L. Ellis, Ph.D. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 2 Acknowledgements I would like to thank all my professors who have taught me and helped me along the way of receiving my master’s degree. First, I want to thank Dr. Peggy Saunders, my first professor in the program, who radiates a love and enthusiasm for teaching and for the many hours she spent editing this paper, giving me direction, and making it possible for me to complete this project. Also, I would like to thank Dr. Richard Pontius for modeling such a great way of teaching, for getting me to think deeply and allowing us time to ponder. Finally, I would like to thank Dr. Vincent Bates who brought color to education. My mentor, Tammy Owens, who taught me so much in my student teaching. I feel so lucky that I was placed with her. She taught me how to organize a classroom and to manage it. The rigor she used in her lesson planning is something I will always try to model. Also, my teammate Danielle Lacefield who guided me through my first year of teaching. I would like to thank my dear friends Rosita and Astrid who became my first students and guided me towards working at my first school as a teacher. I would like to thank my wonderful mom who got me through all levels of my education, even now, and the many night she spent reading with me, helping me with my spelling, and for never giving up on me. For my dad who has always believed in me and my husband who has supported me all the way through this experience. My darling son Gabriel, who teaches me daily how to be a better person and allows me to continue my job as a teacher by teaching him. Finally, I would like to thank all of my wonderful students. I will never forget you! You have all changed me for the better and enriched my life! SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 3 Table of Contents NATURE OF THE PROBLEM...................................................................................................... 7 Literature Review................................................................................................................ 8 Type One Diabetes .................................................................................................. 8 Complications ............................................................................................. 9 Common Misconceptions ......................................................................... 11 Hypoglycemia’s Effect on Cognition ................................................................... 12 Managing Type One Diabetes in Children ........................................................... 13 Providing Reasonable Services at School ............................................................. 15 Section 504................................................................................................ 15 Problems of Proper Access ....................................................................... 16 Social Barriers for Students with T1D ...................................................... 17 School Personnel ................................................................................................... 18 Outcomes of Diabetes Interventions in Schools ................................................... 20 Summary ........................................................................................................................... 21 PURPOSE .................................................................................................................................... 22 METHOD .................................................................................................................................... 23 Participants ........................................................................................................................ 23 Instruments ........................................................................................................................ 24 Procedures ......................................................................................................................... 24 RESULTS .................................................................................................................................... 26 Spotting the Signs and Symptoms of Hypoglycemia ....................................................... 26 Treating Hypoglycemia .................................................................................................... 28 DISCUSSION ............................................................................................................................... 31 SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 4 Limitations ........................................................................................................................ 35 Recommendations ............................................................................................................. 37 Conclusions ....................................................................................................................... 37 References .................................................................................................................................... 40 APPENDICES .............................................................................................................................. 43 Appendix A: Questionnaire .............................................................................................. 44 Appendix B: Cover Letter ................................................................................................. 48 Appendix C: Informed Consent Statement ....................................................................... 49 Appendix D: Permission Letters ....................................................................................... 51 SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 5 List of Tables Table 1. Spotting Signs and Symptoms of Hypoglycemia ........................................................... 27 Table 2. Confidence of Spotting Signs and Symptoms of Hypoglycemia ................................... 27 Table 3. Treating Hypoglycemia .................................................................................................. 28 Table 4. Confidence in Treating Hypoglycemia ........................................................................... 29 Table 5. Availability of School Nurses ......................................................................................... 29 SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 6 Abstract Type one diabetes (T1D) is one of the most prevalent chronic childhood illnesses effecting one in every 400-600 American children. Managing T1D in children can be complex and technical. School personnel may lack knowledge of T1D and how to care for students with T1D unique needs. The purpose of this study was to explore the knowledge of charter school personnel about T1D, specifically, if they can spot the signs and symptoms of hypoglycemia and if they know how to treat it. The participants were recruited from three charter schools with kindergarten through ninth grade in northern Utah. Participants were given a peer-reviewed questionnaire in order to analyze their knowledge of T1D. Descriptive statistics were used to analyze the data from the questionnaire. The results of this study showed that for the most part, school personnel can recognize the signs and symptoms of hypoglycemia, and they know how to treat it. However, other discoveries were made that the lack of proper access could be what is preventing students with T1D from receiving proper care. By ensuring that school personnel are well educated in diabetic care and that school policies are in place will help provide a safe learning environment for students with T1D. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 7 NATURE OF THE PROBLEM Maintaining one’s health after a type one diabetes (T1D) diagnoses is like trying to navigate through a labyrinth, which can only be solved by a team of expert maze runners, maps, and tools. “T1D is a complex, disease, requiring frequent self-monitoring of blood glucose levels and adjustment of insulin dose, diet and exercise” (Wang & Volker, 2012, p. 31). Trying to manage T1D is so complicated that one day diabetics may think they have solved the maze only to realize the next day the maze has completely changed with new traps and barriers added. Obstacles like stress, hormone changes, diet, exercise, sleep, sickness, and other unknown factors can affect a person with T1D blood glucose (BG) levels (Smith, Chen, Plake, & Nash, 2012). A team of doctors, nurses, parents or guardians, and school personnel should help children with T1D manage the complex disease (Wang & Volker, 2012). T1D is so complicated that many adults struggle to manage their own T1D even if they have had the disease their whole lives (American Diabetes Association [ADA], 2015). Managing diabetes is not something that becomes second nature for most adults. T1D is something that constantly needs to be cared for and adjusted (Lawrence, Cummings, Pacaud, Lynk, & Metzger, 2015). Children do not have the cognitive maturity to understand what diabetes is and how to take care of T1D (Kise, Hopskins, & Burke, 2017). They are often afraid to poke themselves to check BG or to inject themselves with insulin on their own; an adult must assist children with these procedures. Children often have a hard time noticing symptoms of hypoglycemia to the extent that they may become too confused to treat themselves (Kise et al., 2017). Children spend about one third of their day in school. School personal need to be trained how to manage students’ T1D. Unfortunately, school personnel may not know how to properly monitor T1D (Smith et al., 2012). School personnel who are uneducated or simply naïve have been known to not let students suffering from low BG (hypoglycemia) eat in class because of SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 8 class rules. These students have had to suffer through class not being able to understand what is going on until they get help. This problem has escalated to the point where students have had seizures in class because of their severely low BG (Pansier & Schulz, 2015). Some school personnel are too afraid to help students with high BG (hyperglycemia) because they fear the effects of hypoglycemia (Smith et al., 2012). These students with high average BG are enduring permanent damage to their body as well as reduced cognitive function (Warren & Frier, 2004). People with medical disabilities including diabetes are protected by law and must receive equal opportunities for education (ADA, 2015). Therefore, it is incumbent upon school personnel to understand how to monitor those students with T1D. Literature Review This literature review will first define type one diabetes (T1D), who it affects, the complications associated with it, including long-term and short-term complications. Next, the importance of properly caring for diabetes in children will be investigated. In addition, the complexity of the disease and children’s lack of understanding of how to care for themselves is discussed. Finally, a review of the lack of diabetic knowledge in the education community and how there is a need for it will be covered. Type One Diabetes Type one diabetes (T1D) is an autoimmune disease and a chronic condition of the pancreas in which it produces little to no insulin (Mayo Clinic, 2017). T1D attacks the pancreases making the body incapable to produce insulin (Bade-White & Obrzut, 2009). When people without diabetes eat starchy or sugary foods, their pancreases produce insulin, which reorganizes the food into glucose. However, people with T1D cannot convert food into glucose (energy). Insulin is a hormone that the body needs to transfer glucose from the bloodstream into SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 9 the cells of the body. Without insulin, the blood may become acidic causing the patient to fall into ketoacidosis or a diabetic coma. People with T1D must check blood glucose levels and inject insulin into their body every day to prevent short-term and long-term complications from the disease (Bade-White & Obrzut, 2009). T1D, was previously known as juvenile diabetes, because usually children and young adults are diagnosed with it. T1D is one of the most prevalent chronic childhood illnesses affecting one in every 400-600 American children (Bade-White & Obrzut, 2009; Herbert et al., 2014). In the past 20 years, the diagnosis of T1D in children has been rising throughout the world (Wang & Volker, 2012). Each year 70,000 children are diagnosed with T1D worldwide (International Diabetes Federation [IDF], 2005). Complications. People suffering from T1D are at risk of developing short-term and long-term side effects. Short-term side effects include hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). Long-term side effects include heart attack, stroke, amputation, kidney failure, blindness, and learning deficits (Lawrence et al., 2015). People with diabetes suffer from hypoglycemia and hyperglycemia. Hypoglycemia is caused by taking too much insulin, not eating enough food, exercising too vigorously, or by skipping a meal or snack (Bade-White & Obrzut, 2009). Symptoms of hypoglycemia include shaking, sweating, lightheadedness, severe hunger, irritability, confusion, and reduced cognitive functioning. People suffering from hypoglycemia should not drive, make important decisions, go places alone, do work or take a test, or engage in strenuous activities (ADA, 2015). Silverstein et al. (2015) and the ADA (2015) compiled research on diabetes care and created standards on diabetes care. They recommended that people suffering from hypoglycemia SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 10 should consume 15 grams of simple sugars such as juice or fruit snacks. It is wise to pair the simple sugar with a complex carbohydrate or protein. Fifteen minutes after treating the hypoglycemia blood glucose levels should be checked. Repeat until blood glucose is stable. Recovery from hypoglycemia can take to up an hour. If they are having a difficult time bringing their blood glucose up, it can take longer than an hour to recover (Silverstein et al., 2015). Hyperglycemia is caused by not taking enough insulin, overeating, stress, and illness. Symptoms of hyperglycemia include nausea, headaches, irritability, overall unwell feeling, and reduced cognitive function (Bade-White & Obrzut, 2009). If a person is in a hyperglycemic state over two to three days, they can fall into a ketoacidosis state or coma (Silverstein et al., 2015). Treatment of hyperglycemia includes taking a corrective inject of insulin to bring blood glucose down. Each individual uses a different ratio of insulin to blood glucose to calculate the amount of insulin to take. An example of a ratio is for every 50mg/dl above the person’s target blood glucose they would inject one unit of insulin. This calculation is not simple math for young children. If miscalculated they could fall into severe hypoglycemia (Silverstein et al., 2015). Patton, Dolan, Henry, and Powers (2007) studied the effects depression, fear of hypoglycemia, quality of life or rebellion, and how these issues can cause people with diabetes to choose to keep their blood glucose higher. Caregivers may also have a fear of hypoglycemia and decide to keep the individual's blood glucose level higher (Patton et al., 2007). Staying in a prolonged state of hypoglycemia is a very unhealthy habit and can lead to serious long-term health complications and even death (Kise et al., 2017). Long-term side effects of elevated blood sugar vary from person to person. Even having a slightly elevated blood sugar over a long-term period can cause heart diseases, stroke, kidney failure, nerve damage, skin complications, high blood pressure, gastroparesis, loss of limbs, and SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 11 blindness (Silverstein et al., 2015). Proper treatment of a person with diabetes is of utmost importance to prevent these life threating complications. The good news is that improved diabetes control reduces the risk of short and long-term problems (Silverstein et al., 2015). Common misconceptions. In 2017 the Center for Disease Control [CDC] reported that 9.4 percent of Americans have been diagnosed with diabetes; however, of the population of people diagnosed with diabetes, only five percent of them have T1D (ADA, 2015). People often associate type two diabetes (T2D) with overweight individuals, unhealthy eating behaviors, sugar, and inactivity. In people with T2D, their body still produces insulin but becomes more resistant to it (Botero & Wolfsdorf, 2004). If not properly cared for, blood glucose may become, more and more difficult to manage. Treatment includes a strict diet, exercise, oral medication, and in more severe cases, insulin (Botero & Wolfsdorf, 2004). Because of the association with T2D, the general population has many misconceptions about T1D. Some of those misconceptions include the following: (a) people with diabetes cannot eat sugar; (b) T1D and T2D are the same disease; (c) diabetes is contagious; (d) T1D is caused by overeating sugar or by not exercising; or (e) people with T1D cannot participate in strenuous activities (Patil, Nasrin, Datta, Boratne, & Lokeshmaran, 2013). These misconceptions need to be clarified. Silverstein et al. (2015) explained the following: (a) People with T1D can eat sugar, as long as they chose too, and their doctor agrees with the plan. If they calculate the correct amount of insulin, the sugar should not cause a drastic spike in BG. At times of hypoglycemia sugar can be a lifesaving factor. (b) T1D and T2D diabetes are very different. T1D is an autoimmune disease where in the body is unable to produce insulin. T2D is usually brought on by unhealthy diet and activity choices. (c) Diabetes is not contagious. (d) T1D is an autoimmune disease and it does not discriminate based on race or SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 12 gender. There is currently no cure or preventive action for T1D. (e) People who manage healthy BG levels, take their insulin and track BG, can exercise. Exercise can cause a drop in BG, therefore people with T1D need to closely monitor their BG while exercising. People suffering from severely high BG (above 300mg/dl) should not participate in strenuous activities until their BG levels are brought down below 200mg/dl (Silverstein et al., 2015). Hypoglycemia’s Effect on Cognition Because glucose is the principal fuel of the brain, hypoglycemia may cause cognitive impairment (Bade-White & Obrzut, 2009). Experts’ findings vary on the amount of time it takes for full recovery of a hypoglycemic event. Recovery time also varied from person to person. The onset of cognitive impairment caused by hypoglycemia is immediate and, recovery may take up to an hour or longer. Research conducted by Warren and Frier (2004) found Hypoglycemia may cause cognitive impairment sufficient to interfere with an individual’s ability to perform everyday tasks, which in some contexts, may be dangerous. Cognitive impairment can be so severe that the individual may not be able to recognize or treat their hypoglycemia. (p. 493) In 2015 Lawrence et al. found that over time, hypoglycemia and hyperglycemia have been shown to have negative effects on learning. Hypoglycemia can develop rapidly and once blood glucose levels are lower than 90mg/dl it can begin to affect concentration, thought processing, and behavior. When hypoglycemia is recognized early by the school personnel, they can help students with diabetes avoid episodes by giving a fast-acting source of sugar. After treating the hypoglycemia, it can take “up to 45 minutes for its effects on intellectual functions to resolve” (Lawrence et al., 2015, p. 36). Students may need extra time or special accommodations SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 13 when a hypoglycemic event occurs at the time of an exam, lecture, or group work. Most students will want to lie down in the office or lie their heads down on their desks (ADA, 2015). Gonder-Frederick et al. (2009) conducted a study on the effects hyperglycemia has on cognition. They tracked 61 children with T1D for four to six weeks. The children were given arithmetic problems to solve; reaction times were measured immediately before checking blood glucose levels. They discovered that both hyperglycemic and hypoglycemic episodes were paired with slowed mental efficiency (i.e., the time necessary to complete arithmetic problems). During either type of incident, students took roughly 20% more time to solve the arithmetic tasks (Gonder-Frederick et al., 2009). Blasetti et al. (2011) studied the effect hypoglycemia has on children’s brains. They found recurrent severe hypoglycemic episodes in children T1D have a selective negative effect on the children’s cognition. Magnetic resonance imaging (MRI) was performed on children with T1D who have had one or more sever hypoglycemic episodes. After analyzing the MRIs, they found that the children had smaller gray matter volume at the left temporal-occipital junction. The side effect of the loss of gray matter showed memory dysfunction and learning disabilities. Children who have experienced severe hypoglycemia have also shown deficits in attention. The literature also reveals that children with earlier diabetes onset have greater cognition damage when compared to children with latter onset. These results suggest that younger children have a higher incidence of sever hypoglycemia and that damage is more severe during a developmental stage of the brain (Blasetti et al., 2011). Managing Type One Diabetes in Children A team of doctors, nurses, parents or guardians, and school personnel must help children with T1D manage their complex disease (Silverstein et al., 2015; Wodrich et al., 2011). SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 14 Individuals with diabetes are the most critical member of this team; they must comply with doctors’ orders and be diligent in their care (ADA, 2015). Diabetes educators and dietitians teach people with T1D how to do the following: count carbohydrates, calculate carbohydrate to insulin ratios, eat healthy foods, exercise, treat lows and highs of BG levels, take care of diabetes during illness, specific risk factors, and how to use the many supplies and devices (ADA, 2015). Checking blood glucose is a vital part of managing diabetes (Silverstein et al., 2005). People with T1D must know their blood glucose to treat themselves and administer insulin. To test blood glucose the individual uses a lancing device to draw a small drop of blood. Occasionally children are afraid to check their blood glucose because they must prick themselves. An adult usually does it for them. Children are also scared to inject themselves with insulin on their own. Most are too young to understand how much they should take. Children are susceptible to insulin. The smallest miscalculation of the amount of insulin required can create a life threating emergency. Therefore, administering insulin must be done by a trained adult. Children often have a hard time recognizing symptoms of hypoglycemia and hyperglycemia. Sometimes children will not treat hypoglycemia soon enough, causing them to become too confused to care for themselves. Adults who are responsible for the care of a diabetic child must be able to recognize early signs of hypoglycemia (Silverstein et al., 2005). Children with diabetes are at high risk for immediate diabetic emergencies (Bade-White & Obrzut, 2009). As children grow and develop, their frequent changes make managing T1D even more difficult. (Bade-White & Obrzut, 2009). Because their bodies are continually changing, the carbohydrate to insulin ratio needs to be frequently adjusted. Children’s activity levels vary day-to-day as well (Herbert et al., 2014). These changes play an important role in figuring the correct amount of insulin to administer to a child as well. (Herbert et al., 2014). SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 15 Silverstein et al. (2005) discussed the steps to care for diabetes and prevent diabetic emergencies. If the individual or the caretaker is aware of the signs and symptoms of hypoglycemia and hyperglycemia and check blood glucose levels often, they are likely to avoid an emergency from happening. If the persons responsible for caring for the individual with T1D are unaware of these symptoms, a diabetic crisis can occur. Hospitalization is common due to glycemic events (Silverstein et al., 2015). In a study conducted by Herbert et al. (2014), parents of students with T1D were surveyed to investigate how often their children were hospitalized. They found that 12% of 134 of the children in the study had experienced at least one T1D related hospitalization other than at the time of diagnosis. They also found that 8% of the children have suffered one T1D related seizure or a period of unconsciousness (Herbert et al., 2014). Providing Reasonable Services at School Reasonable services, such as trained staff, are necessary to prevent serious risks for those who have T1D (ADA, 2015). Because children with T1D are not able to care for themselves solely, nurses, teachers, and school staff need to aid in their care. Children spend much of their time in school with their teachers. Because children can have a difficult time recognizing symptoms of hypoglycemia, school personnel need to be aware of the signs, and they need to know what to do when a student is experiencing hypoglycemia. While experiencing hypoglycemia, students should not be expected to continue working because their cognitive ability has been severely affected (Kise et al., 2017). Section 504. A variety of laws protects people with disabilities. These regulations provide guidelines how to treat people with diabetes and the access to care that is necessary for each individual. Some examples of proper access include; access to diabetic supplies in class (blood glucose meter, insulin, glucose shots, and fast acting carbohydrates), being allowed to eat SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 16 in class to treat hypoglycemia, providing an area in class to check BG and providing trained staff in diabetic care (ADA, 2016). One such law is Section 504 of the Rehabilitation Act that protects children with diabetes in school. The ADA (2016) summarized the law: Section 504 of the Rehabilitation Act of 1973 (Section 504) provides important protections for students with diabetes attending public school or private and religious schools that receive federal financial assistance. Covered institutions are required to provide reasonable services and modifications and document them in a Section 504 Plan. (ADA, 2016, p. 3) Problems of proper access. Pansier and Schulz (2015) reviewed multiple studies and discovered that children were not receiving proper care and access at school to manage their T1D. Many students with T1D may face problems such as having reduced opportunities to monitor and treat blood glucose levels, increased risks of diabetes complications, and even a denial of access to school and extracurricular activities. Many schools created rules and policies to create a safe and orderly environment for their students; however, many of these regulations conflict with the needs of students with T1D (Pansier & Schulz, 2015). Some schools do not allow their students to carry backpacks or medicines to their classes. Because of this rule, students with T1D do not have ready access to their diabetic supplies such as insulin, blood glucose meter, and fast-acting sugar to treat hypoglycemia (Pansier & Schulz, 2015). Research revealed that close access to these supplies improves BG levels (Kise et al., 2017). When students are required to keep their diabetic supplies in their locker or office, there is an increased risk of the student passing out while traveling to treat or monitor their blood glucose levels (Kise et al., 2017). SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 17 Some schools prohibit students eating or drinking in class. The best and least invasive treatment for hypoglycemia is consuming food containing sugar or simple carbohydrates (Silverstein et al., 2005). If not treated immediately, hypoglycemia can continue to worsen and become more debilitating; however, if addressed right away, the students can usually avoid severe hypoglycemia. School lunches can pose other issues; however, many schools do not provide nutritional information to the parents and students (Kise et al., 2017; Tolbert, 2009). With the nutritional information, a calculation of the amount of carbohydrates consumed can be used to determine the exact amount of insulin to inject (Silverstein et al., 2005). Parents noted that their schools only gave nutritional data occasionally or not at all. Other parents complained that schools do not provide healthier options with lower carbohydrates (Kise et al., 2017). Parents have also reported that their child is not given enough time to finish their lunch because of the extra time they need to check BG and administer insulin (Freeborn, Loucks, Dyches, Roper, & Mandleco, 2013). Social barriers for students with T1D. Students with T1D also face social barriers in their school life. Students have reported that they feel a lack of support, stigma, and discrimination because of their condition (Pansier & Schulz, 2015). These added stress factors on students with T1D can lead to “absenteeism, depression, stress, poor academic performance and poor quality of life” (Pansier & Schulz, 2015, p. 65). Some students will purposefully keep their blood glucose levels high to prevent hypoglycemic episodes while they are at school. One of the reasons they give is to avoid an embarrassing situation of needed emergency care. Staying in a hyperglycemic state, of course, is not healthy for the individual's future health. The need for T1D interventions is critical to provide a safe environment for students with T1D (Pansier & Schulz, 2015). SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 18 Some students feel self-conscious when managing diabetes alone at school. Some are so unsure that they do not perform treatment at all to avoid unwanted attention and feeling different (Wodrich, Hasan, & Parent, 2011). Embarrassment from a diabetic episode, negative attention received, becoming ill from a diabetic episode, doctors’ appointments or fear of not receiving proper care at school can result in absentness. His study suggested that students with T1D miss twice as much school as their healthy peers and siblings (Wodrich et al., 2011). School Personnel The National Association of School Nurses [NASN] (2012) provided position statements for school nurses to follow to treat students with T1D. They stated that school personnel are required to aid in the care of students with managing their T1D at school to insure students are given a safe environment. School personnel need training in spotting the signs and symptoms of hypoglycemia to provide a safe environment for the students (IDF, 2005). School personnel record all accommodations in a diabetes care plan for each student with T1D. Individualized education plan (IEP) or a 504 plan should be recorded for each student with T1D (Smith et al., 2012). Diabetes organizations have set guidelines, which include “the right to manage their diabetes without being excluded or discriminated against in school and the right to participate fully and safely in all school activities” (Pansier & Schulz, 2015, p. 65). Even though laws protecting people with T1D are in the books, school personnel may not be entirely prepared to assist students in their T1D care. The main obstacles to students receiving reasonable services are a small number of informed and trained staff, inadequate knowledge of and misconceptions about diabetes, the inability for a school nurse to be at school each day, and an insufficient amount of diabetes management policies (Pansier & Schulz, 2015). Smith et al. (2012) researched this problem and discovered that parents are anxious for their students’ with SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 19 T1D wellbeing while they are at school and are often concerned with diabetes-related care. Many parents are unaware whether their child’s school has a written diabetes care plan. Wodrich et al. (2011) investigated if school personnel knew how to recognize the signs and symptoms of hypoglycemia. They studied the existing literature on the subject in which they found that the majority of school personnel said that “they know relatively little about T1D and their gloomy self-appraisal may be accurate” (p. 66). Wang and Volker (2012) reviewed a study completed twenty years ago to analyze if teachers could identify the signs and symptoms of hypoglycemia. They found that about one-half of teachers currently teaching a student with T1D were not able to recognize the signs of hypoglycemia or identify the proper treatment. They also reviewed a study from 2002 that found that only 12% of teachers could correctly recognize the symptoms of hypoglycemia when presented to them in a multiple-choice test. Wodrich et al. (2011) found that 42% of parents said their child’s school staff lacked knowledge in routine diabetic care. They also found that 22.8% of students reported issues with school staff, such as crediting all their school problems to diabetes, calling attention to their diabetes in class, and giving false diabetes information to classmates (Wodrich et al., 2011). Kise et al. (2017) surveyed a group of adolescents with T1D, the parents of a child with T1D, and school personnel where the student with T1D attended school. Almost half of the interviewed believed that school personnel were inadequately trained. The majority of the parents and adolescents in the study stated that they “wanted teachers to have a better understanding of what to do during acute hypoglycemic/hyperglycemic episodes” (Kise et al., 2017, p. 365). Parents want “teachers to empathize and interact holistically with the child and avoid value judgments or stereotypes” (Kise et al., 2017, p. 365). SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 20 Outcomes of diabetes interventions in schools. Pansier and Schulz (2015) investigated school-based diabetes interventions and their outcomes. Their objective in reviewing the literature was to improve programs and improve policies. The interventions intended to “address the lack of informed and trained staff, limited knowledge, and misconceptions about diabetes, and to increase knowledge and confidence of school personnel” (Pansier & Schulz, 2015, p. 69). The majority of the studies reviewed reported “overall satisfaction with the training provided, gains of knowledge and confidence” (Pansier & Schulz, 2015, p. 69). Smith et al. (2012) evaluated the impact of a diabetes education curriculum for school personnel on disease knowledge and confidence in caring for students. They tested their curriculum on 81 participants from 15 schools. They pointed out the importance of confidence of assisting students with T1D by referring to Bandura’s social cognitive theory. According to Bandura’s theory, the self-efficacy (confidence) influences their “willingness to perform a behavior” (Smith et al., 2012, p. 450). They found that their program resulted in “improved knowledge of diabetes and confidences in caring for students with diabetes” (Smith et al., 2012, p. 454). Educating school personnel is extremely important because it has been discovered that students who attend a school where school personnel is trained in T1D care to have improved blood glucose control and glycated hemoglobin test (Hba1c) levels. A Hba1c shows the average blood glucose levels over the past three months. This can be used to measure overall diabetes health (Silverstein et al., 2015). Kise et al. (2017) investigated different ways to improve school experiences for adolescents with T1D. They searched 27 articles in their integrative literature review. In their review, they found that when school personnel had training in T1D management strategies, they could provide a safer environment. Additionally, they discovered that positive diabetes SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 21 management at school correlates with improved blood glucose control and increased quality of life (Kise et al., 2017). To create a safe school environment and care plan, doctors, parents, school nurses, and other school personnel must work together as a team. Participants in Wang and Volker’s (2012) study reported that diabetes management at school was more effective when doctors, parents, school nurses, and personnel worked together. Everyone agreed on the importance of collaboration and involvement to better support students with T1D and to create a safe and healthy environment at school. Summary Type one diabetes is one of the most common childhood diseases. Complications associated with T1D can be life threating or debilitating making it hard for children to do normal every day activities when they fall ill due to the effects of diabetes (ADA, 2015). With proper training and management students with T1D can live relatively normal lives and avoid serious life threating situations (ADA, 2015). T1D is a complex disease to manage. It requires a team of specialty doctors, nurses, nutritionists, diabetes educators, guardians, school nurses, teachers, and staff (Wang & Volker, 2012). Students spend about one third of their day at school; therefore, teachers and staff need to be aware of a diabetes management plan for each student (Smith et al., 2012). One of the most important skills teachers and staff need is how to recognize the signs and symptoms of hypoglycemia. This skill can help them prevent a serious emergency occurring, it can help their students perform better in class, and not miss out on any activities (Smith et al., 2012). SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 22 PURPOSE T1D is one of the most prevalent chronic childhood illnesses, effecting one in every 400-600 American children (Herbert et al., 2014). Serious short-term and long-term conditions can develop if the condition is not properly cared for, such as hypoglycemia which can lead to seizures, and loss of consciousness. The disease can also cause hyperglycemia which can lead to a diabetic coma, heart disease, neuropathy, loss of limbs, kidney failure, and retinopathy (Smith, et al., 2012). Children with diabetes manage their condition by visiting a doctor on a regular basis, taking medication, closely monitoring their diet and exercise, and checking blood glucose. Children lack the ability to effectively manage their diabetes on their own. It is difficult for them to recognize the symptoms of hypoglycemia, which puts them at high risk for seizures and loss of consciousness. Unfortunately, most school personnel are not properly trained in diabetes management (Smith et al., 2012). The purpose of this study was to explore the T1D knowledge of northern Utah charter school personnel (administrators, staff, and teachers) who work with students in grades kindergarten to ninth. Specifically, the research answered the following questions: 1. Do school personnel know how to spot the signs and symptoms of hypoglycemia? 2. Do school personnel know how to treat someone suffering from hypoglycemia? SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 23 METHOD This investigative study was conducted to explore what charter school administrators, staff, and teachers in kindergarten to ninth grade (school personnel) know about type one diabetes (T1D) and how it effects their students. The information collected was used to assess participants’ confidence, their current ability to help students manage their T1D, and to identify signs and symptoms of hypoglycemia and its effects on cognition. Participants The participants were recruited from three charter schools: charter school A; charter school B; and charter school C working with children in kindergarten to ninth grade in northern Utah. Approximately 321 school personnel were asked to complete the questionnaire, of those 321, 38 or 11.8% participants took the survey. School A had 21 participants take the survey; school B had 10, school C had three, and the last four participants did not report their school. Participants were volunteers. People who have T1D or who have a close family member with T1D were not included in the study. Seven (18%) participants reported having close relations with a family member with type one diabetes. These seven participants did not complete the questionnaire after filling out their demographical information; therefore, only the data from 31 participants was used for analysis. Demographical information was obtained from participants. Job position held by the participants was collected. Of the 31 participants, 15 (48.39%) were teachers, 6 (19.35%) were teachers’ assistants, 5 (16.13%) were administrators, four (12.90%) were office staff and 1 (3.23%) was undeclared. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 24 Instrument A questionnaire was developed by the researcher in order to answer research questions of the schools’ personnel’s current knowledge of T1D (see Appendix A). The questionnaire contained multiple choice questions, yes or no statements and Likert type questions. Questions 1-4 addressed demographic information. Questions 5-12 inquired about the test takers knowledge of hypoglycemia and hyperglycemia and how to treat them. Questions 13 and 14 asked about the test taker’s knowledge of diabetes effects on cognition. Questions 15-17 dealt with issues with access for students with T1D. Questions 18 and 19 requested information about common misconceptions. Items 20-23 included confidence questions designed by the researcher to measure individual school personnel’s confidence in caring for students with T1D. Participants were asked to respond to their level of confidence on a 5- point Likert-type scale (1 = Strongly Disagree to 5 = Strongly Agree). Procedures Approval of WSU’s Education IRB and school administrators from the target schools involved in the study was obtained before the research was conducted. A mass email was sent to all school personnel at the chosen three schools. All information and testing material were distributed using Google forms. Participants were emailed an informed consent form, the questionnaire, and cover letter. All data collected were kept on a password protected personal computer. At the end of the questionnaire, participants were given links to specific YouTube videos to learn more about T1D (http://www.diabetes.org/living-with-diabetes/parents-and-kids/diabetes-care-at-school/school-staff-trainings/tips-for-teachers.html and https://www.beaumont.org/services/childrens/pediatric-endocrinology/managing-type-1-diabetes-in-school). However, the videos were not required, nor any data were recorded about SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 25 what they learned from the videos, or if they even watched them. The focus of the study was to analyze current knowledge. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 26 RESULTS Previous studies analyzed school personnel’s knowledge of type one diabetes (T1D) in grades K-12 in public traditional schools (Freeborn et al., 2013; Kise et al., 2017; Pansier & Schulz, 2015; Smith et al., 2012; Wang & Volker, 2012; Wodrich et al., 2011). Charter schools in the northern Utah area had yet to be investigated. Although they are public schools, charter schools in northern Utah operate more independently than traditional public schools within school districts. The purpose of this study was to explore the T1D knowledge of charter school personnel (administrators, staff, and teachers). Descriptive statistics were used to analyze the data from the questionnaire. The questions and participants’ responses were organized into five different tables. Table 1 and Table 2 contain responses that answer research question number one: Do school personnel know how to spot the signs and symptoms of hypoglycemia? Tables 3, 4, and 5 contain responses that answer research question number two: Do school personnel know how to treat someone suffering from hypoglycemia? A total of 31 school personnel participated in this portion of the questionnaire. Multiple choice questions and yes and no questions were divided into correct and incorrect responses. The number was then converted into a percent. Likert-type questions were divided into strongly disagree, disagree, not sure, agree, and strongly agree. The responses were then given in percentages. Spotting the Signs and Symptoms of Hypoglycemia Table 1 contains responses from the questionnaire that answers research question one. Questions included in the table (see Appendix A) are 6, 8, 9, 10, and 13. Responses show that most of the personnel were able to spot common signs and symptoms of hypoglycemia, except SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 27 for the effect stress has on their student’s blood glucose (BG), responses were about 50/50 (56.7% correct, 43.3% incorrect). Table 1 Spotting Signs and Symptoms of Hypoglycemia Question Answered Correctly Answered Incorrectly 6. Common signs and symptoms of hypoglycemia 96.8% 3.2% 8. Exercise’s effect on T1D 96.8% 3.2% 9. Stress and illness’ effect on BG 56.7% 43.3% 10. Complications of unmanaged T1D 83.9% 16.1% 13. Hypoglycemia and hyperglycemia’s effect on cognition 96.8% 3.2% Note. n = 31 Table 2 contains Likert-type responses from the questionnaire that answers research question one. Questions included in the table are 21 and 23 (see Appendix A). Most participants reported that they do not feel stressed when they find out they have a student with T1D (64.5%). School personnel also reported that they felt like the parents of the students with T1D had educated them well about how to care for their child with T1D (61.3%). Table 2 Confidence of Spotting Signs and Symptoms of Hypoglycemia Reported in Percentages Questions Strongly Disagree Disagree Not sure Agree Strongly Agree 21. I feel stressed…when I have a student with T1D. 22.6% 41.9% 12.9% 19.4% 3.2% 23. Parents…have educated me well. 3.2% 9.7% 25.8% 48.4% 12.9% Note. n=31 SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 28 Most of the participants of this study were able to choose the correct responses for recognizing the signs and symptoms of hypoglycemia (overall 86.2% correct). They also felt confident in their knowledge. Treating Hypoglycemia Table 3 contains responses from the questionnaire that answer research question two. Questions included in the table are 5, 7, 11-19 (see Appendix A). In exception of questions 5, 11, 15, and 16, the majority of participants were able to choose the correct response to the questionnaire. Some participants (22.6%) did not know how to properly treat hypoglycemia; 42% of participants did not know how to respond to students having a hypoglycemic episode during a test; 64.5% of school personnel do not allow their students to check blood sugar in class; and 41.4% of school personnel do not allow students to bring their backpacks in class. Table 3 Treating Hypoglycemia Questions Answered Correctly Answered Incorrectly 15. Students are allowed to check blood sugar in class 35.5% 64.5% 16. Students are allowed to have backpacks in class 58.6% 41.4% 11. Taking a test with low BG 58.6% 41.4% 5. How to treat hypoglycemia 77.4% 22.6% 17. Students with T1D are allowed to eat in class 80.6% 19.4% 14. Sending students with low BG to the office by themselves 90.3% 9.7% 19. People with T1D can eat sugar 93.5% 6.5% 13. Hypoglycemia and hyperglycemia’s effect on cognition 96.8% 3.2% 12. High BG and frequent bathroom use 96.8% 3.2% 7. How to raise BG 100% 0% 18. People with T1D can cure their disease by eating healthy 100% 0% Note. n=31 SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 29 Table 4 contains Likert-type responses from the questionnaire that answer research question two. Questions included in the table (see Appendix A) are 20 and 22. A large portion of the participants (45.1%) felt like they knew how to treat students with T1D, 35.5% were not sure in their abilities and 19.4% did not feel confident. Most of the participants did not feel like their students used T1D as an excuse for eating in class or using the bathroom frequently. Table 4 Confidence in Treating Hypoglycemia Questions Strongly Disagree Disagree Not sure Agree Strongly Agree 20. I feel confident in my knowledge of diabetic care. 9.7% 9.7% 35.5% 41.9% 3.2% 22. I feel like my students with T1D take advantage of their disease 54.8% 22.6% 19.4% 3.2% 0% Note. n=31 The research investigated whether or not schools have access to a school nurse (see Table 5). Only 6.5% reported having access to a school nurse all of the time, with 16.1% reporting access a part of the time. The majority (77.4%) reported that there was no access to a school nurse, or that they did not know whether there was a nurse or not. Table 5 Availability of School Nurses Question All of the time Most of the time A part of the time Not at all Not sure 24. The school I work at has access to a school nurse… 6.5% 0% 16.1 51.6 25.8 Note. n=31 At the end of the questionnaire, participants were asked if they would like more training/information on how to care for their student with type one diabetes. The responses were SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 30 pretty even, 58.1% responded yes and 41.9 responded no. Using this information, different conclusions can be made about school personnel’s knowledge of T1D. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 31 DISCUSSION The primary investigator of this study heard multiple complaints from members of the diabetic community that their children were not receiving proper care in northern Utah schools. Prior research has shown that students do not receive proper diabetic care in their schools (Freeborn et al., 2013; Kise et al., 2017; Pansier & Schulz, 2015; Smith et al., 2012; Wang & Volker, 2012; Wodrich et al., 2011). This research was conducted to examine if the parents’ complaints were valid and to guide the researcher to further action that might need to be taken. Test results show that the majority (86.2%) of the participants (school personnel at three charter schools) were able to recognize the signs and symptoms of hypoglycemia, answering the first research question. These results are strikingly different from the results of Wodrich et al.’s (2012) study, in which 50% of respondents in 1990 and 12% of respondents in 2002 in Arkansas were able to recognize the signs and symptoms of hypoglycemia. Time needs to be considered when comparing the results of these two studies. One conclusion could be that school personnel are better educated in spotting the signs and symptoms of hypoglycemia than they were 28 and 16 years ago. Stress and illness can cause blood glucose (BG) to rise, and it can make it difficult for insulin to bring BG down. It is important for school personnel to be aware of this because high blood sugar can affect a student’s cognition and overall feeling (Gonder-Frederick et al., 2009). About half (43.3%) of the school personnel from this study were not able to recognize how stress and illness effects BG. This concept is not common knowledge, or quite as critical as recognizing the signs and symptoms of hypoglycemia. Perhaps this is the reason some participants did not know the correct response. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 32 When the participants were asked how they can help a student who is suffering from hypoglycemia, 77.4% responded, “Give them a snack with fast acting sugar in it,” and 22.6% responded, “Send them to the office”. This second response, though small, is quite concerning because research indicated that hypoglycemia needs to be treated as quickly as possible and that the student could faint or become confused on the way to the office (Silverstein et al., 2005). This result greatly affects the safety of the student. School policies should be created that require school personnel to give students suffering from hypoglycemia a snack immediately and allow them to relax in class. This way they do not need to make a trip to the office and avoid the risk of fainting and getting hurt. Participants were asked what they would do or have done when their student is taking a test and has low blood sugar: 58.1% responded that they would give them a snack and have them retake the test when they feel better. However, 22.6% responded that they would send them directly to the office. In the above paragraph, it discussed the problems with sending students suffering from hypoglycemia to the office. Another problematic response was that 19.4% of participants responded that they would give them a snack and have them continue the test. The problem with this response is that hypoglycemia effects cognition, and it can take up to an hour for someone to recover from a hypoglycemic event (Lawrence et al., 2015). Students would not be able to perform at 100% if they had to continue taking the test. Students must be treated fairly and be given equal opportunities (ADA, 2016, p. 3). School policies should reflect the issues around test taking and hypoglycemic episodes. One of the most concerning results of this study was that 64.5% of participants do not allow their students to check their blood sugar in class. This situation is tricky because bloodborne pathogens can be passed if the student does not follow the proper procedures of SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 33 checking their BG. The other problem with this checking their BG in class is that if a student is not feeling well it is vital for the student to check their BG as soon as possible. As stated before, it is not safe for a student to go to the office while suffering from hypoglycemia. Also, it is not safe for students to blindly eat carbohydrates without checking their BG because they could have high blood sugar and the symptoms are similar (Silverstein et al., 2005). School personnel could set up an area by the sink, if they have one, where the student can check their BG. They could leave band-aids, hand sanitizer, and disinfecting wipes to wipe the surface after checking. If the students are too young to check their own BG, someone from the office could come to the class to check, or the teacher could be trained how to do it. Another alarming finding was that 19.4% of school personnel do not allow students with T1D to eat in class. Although 80.6% of school personnel allow their students with T1D to eat in class, the only acceptable response is 100%. School personnel should be aware that it is a right of students with T1D to eat in class (ADA, 2016, p. 3). Students with T1D have the right to be treated fairly, which might not be equal. Other students may not be able to eat in class, but because of the students’ T1D condition, it is fair to allow them to eat in class to treat or avoid hypoglycemia. If students have to leave the class, they are missing out on opportunities to learn, and they are once again being put in danger of becoming confused or fainting on their way to the office. Most other students will understand that the “privilege” the students with T1D have is fair because it is vital to their health. A good way to ensure students with T1D always have snacks nearby is to allow them to keep a pencil box or backpack full of snacks at their desk. Another question concerning proper access for students with T1D is whether or not students are allowed to have backpacks in class. The trend of school personnel not giving students with T1D access to their supplies continues, with 41.4% not allowing backpacks in SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 34 class. These findings are similar to previous research (Kise et al., 2017; Pansier & Schulz, 2015). The reason students with T1D would need to have their backpack with them in class is so they have quick access to their diabetic supplies. Things like a glucose meter, insulin, glucagon shots, and fast acting sugars need to be used often and as soon as possible during hypoglycemic events. Research revealed that close access to these supplies improves BG levels (Kise et al., 2017). When students are required to keep their diabetic supplies in their locker or office, there is an increased risk of the student passing out while traveling to treat or monitor their blood glucose levels (Kise et al., 2017). One reason school personnel responded that they don’t let their students have backpacks in class may have been because the question was too vague. It would have been better to specify that students with T1D are allowed to have backpacks in class or another container with diabetic supplies nearby. It is not surprising that a little less than half of the participants felt confident in treating students suffering from a hypoglycemic episode because at least 50% of the participants were able to answer questions about diabetic care correctly. A good portion (35.5%) were unsure of their ability to care for a student with T1D, and 19.4% felt unconfident in their ability to care for students with T1D. If participants had more training available to them their confidence should go up based on the results of other studies (Kise et al., 2017; Pansier & Schulz, 2015; Smith et al., 2012; Wang & Volker, 2012; Wodrich et al., 2011). Participants were asked if their schools had access to a school nurse. Only 6.5% reported having access to a school nurse all of the time, with 16.1% reporting access only part of the time. An interesting note is of the 6.5% of participants who reported having access to a school nurse all of the time, worked at the same school as the other participants at the same school who reported that they had no access to a school nurse. The majority (77.4%) reported no access to a SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 35 school nurse, or that they did not know whether there was a nurse available. Having a school nurse available to students with T1D takes some of the responsibilities of caring for the student’s needs, allowing school personnel to focus on their other responsibilities. If the school is not able to employ a school nurse, trainingshould be available for all the school personnel who have students with T1D. Someone in the school (office staff, counselor, or administration) should be designated the expert to administer insulin to students who need help doing so. School personnel should be familiar with the students’ T1D 504 care plans. They should be able to spot signs and symptoms of hypoglycemia and know how to treat it. Learning the basics of T1D can help further their understanding of diabetic care. Many schools created rules and policies to create a safe and orderly environment for their students; however, many of these regulations conflict with the needs of students with T1D (Pansier & Schulz, 2015). Policies should be put in place on the treatment of hypoglycemia, and access to diabetic supplies including eating in class and testing blood sugar in class. At the end of the questionnaire, participants were asked if they would like more training/information on how to care for their student with T1D. The responses were pretty even, 58.1% responded yes and 41.9 responded no. Some participants may have responded no because they already feel they know enough about diabetic care, they put the responsibility on someone else, they do not have time, or they do not have a student with T1D. When students’ health, safety; and wellbeing are considered, the school personnel’ mission should be to learn the most they can about providing that safe environment for all their students. Limitations One major limitation was the number of schools willing to participate. Ten different charter schools were contacted through multiple emails and phone calls. Out of those ten schools, SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 36 only four agreed to participate in the study. Of those four only three schools participated in the study, and only three participants came from school C. The bulk of the participants came from school A (21) and school B (10). Four participants did not report which school they worked. This small sample size does not represent all the charter schools across Northern Utah. Along the same lines of not having a good representation of charter schools in northern Utah, ultimately very few participants completed the questionnaire. Thirty-eight participants were recruited in this study, of those only thirty-one were eligible to continue with the study. This very small sample size of the school personnel represents only a fraction of those people who work at charter schools in the northern Utah area. More research needs to be done to begin to make valid assumptions of school personnel’s knowledge of T1D in northern Utah. It was difficult to find comparable data of similar studies. Most of the studies that were found in the review of existing literature were over 15 years old. So much has changed in diabetic care and awareness of diabetes in the community in these intervening years. It might be why the results that were found were so different from other studies; time could have played a major role. The questionnaire may have been written too simply or obviously. The researcher did not want to write the questions to be too difficult to avoid skewing the information. As a result of this oversimplification, the researcher may have written the questions to be too obvious and easy to spot the correct answer. Although the questionnaire was peer reviewed, it could have benefited from doing a pilot study with other school personnel and receiving feedback on the way questions were written. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 37 Recommendations Recommendations for further research would be to expand the sample size of schools and participants. More charter schools should be contacted and a personal meeting with the schools’ principals should be set up to try to get a wider representation of the northern Utah charter schools. It would also be interesting to compare the results of charter schools and public schools in the same area. Another interesting topic for further research is the difference between schools that have nurses available and schools that do not. Comparing school personnel’s beliefs of how well students with T1D are being cared for with parents’ beliefs could also be an interesting research topic. The more research done on this topic, the better informed schools can be to make policies for students with T1D. Conclusions After analyzing other studies and completing the current study, different suggestions can be made to schools and school personnel. If schools are not able to provide school nurses in their school, training should be provided for school personnel at least once a year. Many online training resources are available. It should be every school’s goal to keep their students safe, which is the bare minimum. Students must feel like they are being cared for and that their needs are viewed as important and not inconvenient. Participants who responded that they would let their student continue taking a test after giving them a snack is not treating their students fairly. They have met their need of treating their hypoglycemia, but they have not given them an equal opportunity to put their best effort forward on taking the test. Participants may be doing this out of ignorance, because they are not educated on the ways hypoglycemia effects cognition they do not see a problem with the student continuing their test. Education is the key to preventing situations such as this. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 38 Another conclusion that can be drawn from the research is that proper access is one of the major problems in northern Utah charter schools today. Most participants in this study were able to recognize the signs and symptoms of hypoglycemia and know how to treat it. Unfortunately, the results from this study shows that students with T1D are still not being treated fairly, and it could be because of school policies. School policies should be made, included in every student’s 504 plan, and made known to parents, students, and school personnel. Not allowing students with T1D eat in class is a human right’s violation. Students with T1D have the right to receive equal opportunities to education, by removing them from the classroom to eat, check their blood sugar, or get something out of their locker or from the office so they can treat their diabetes is not giving them the same chances as other students have to learn. A simple solution is for each school to work with a school nurse and a diabetes educator and come up with school policies to make sure each student is treated fairly. School personnel should be open to parents concerns and try their best to help their students feel cared for. Parents should feel like their concerns are being heard, so they don’t feel like they are wasting their time trying to get their student’s needs met. The initial concern at the beginning of the study was if school personnel could spot the signs and symptoms of hypoglycemia and if they knew how to treat it. In the researcher’s opinion, these two factors were the most important in preventing diabetic emergencies. The results of this study have shown that for the most part, school personnel can recognize the signs and symptoms of hypoglycemia and they know how to treat it. However, other discoveries were made that the lack of proper access could be what is preventing students with T1D from receiving proper care. These findings have guided the researcher to research this idea further and to make these problems known to charter schools in the northern Utah area. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 39 T1D is becoming more common in school-aged children each year (Wang & Volker, 2012). Action must be taken to be sure students with T1D are being cared for in school. Parents should not feel like they are solely responsible for their child’s diabetic care. Ensuring that school personnel are well educated in diabetic care and that school policies are in place will help provide a safe learning environment for students with T1D. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 40 References American Diabetes Association [ADA]. (2015). Living with diabetes. Retrieved from http://www.diabetes.org/living-with-diabetes/ American Diabetes Association [ADA]. (2016). Section 504 of the rehabilitation act of 1973. Retrieved from http://www.diabetes.org/living-with-diabetes/parents-and-kids/diabetes-care-at-school/legal-protections/section-504.html Bade-White, P. A., & Obrzut, J. E. (2009). The neurocognitive effects of type 1 diabetes mellitus in children and young adults with and without hypoglycemia. Journal of Developmental and Physical Disabilities, 21, 425–440. doi: 10.1007/s10882-009-9151-y Blasetti, A., Chiuri, R. M., Tocco, M. A., Giulio, C. D., Mattei, P. A., Ballone, E., Chiarelli, F., & Verrotti, A. (2011). The effect of recurrent severe hypoglycemia on cognitive performance in children with type 1 diabetes: A meta-analysis. Journal of Child Neurology, 26(11), 1383–1391. doi: 10.1177/0883073811406730 Botero, D., & Wolfsdorf, J. I. (2005). Diabetes mellitus in children and adolescents. Archives of Medical Research, 36, 281–290. doi: 10.1016/j.arcmed.2004.12.002 Center for Disease Control and Prevention [CDC]. (2017). New CDC report: More than 100 million Americans have diabetes or prediabetes. Retrieved from https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html Freeborn D., Loucks C. A., Dyches T., Roper S. O., & Mandleco, B. (2013). Addressing school challenges for children and adolescents with type 1 diabetes: The nurse practitioner’s role. Nurse Practitioner, 9(1),11–16. doi: 10.1016/j.nurpra.2012.11.005 SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 41 Gonder-Frederick, L. A., Zrebiec, J. F., Bauchowitz, A. U., Ritterband, L. M., Magee, J. C., Cox, D. J., & Clarke, W. L. (2009). Cognitive function is disrupted by both hypo- and hyperglycemia in school-aged children with type 1 diabetes: A field study. Diabetes Care, 32(6), 1001–1006. doi: 10.2337/dc08-1722 Herbert, L. J., Clary, L., Owen, V., Monaghan, M., Alvarez, V., & Streisand, R. (2014). Relations among school/daycare functioning, fear of hypoglycemia and quality of life in parents of young children with type 1 diabetes. Journal of Clinical Nursing, 24(9-10), 1199–1209. doi: 10.1111/jocn.12658 International Diabetes Federation. (2005). The rights of the child with diabetes in the school. Retrieved from http://www.idf.org/position-statement-rights-child-diabetes-school Kise, S. S., Hopkins, A., & Burke, S. (2017). Improving school experiences for adolescents with type 1 diabetes. Journal of School Health, 87(5), 363–375. doi: 10.1111/josh.12507 Lawrence, S. E., Cummings, E. A., Pacaud, D., Lynk, A., & Metzger, D. L. (2015). Managing type 1 diabetes in school: Recommendations for policy and practice. Pediatrics & Child Health, 20(1), 35–39. Mayo Clinic. (2017). Type one diabetes. Retrieved from https://www.mayoclinic.org National Association of School Nurses [NASN]. (2012). Position statement: Diabetes management in the school setting. Retrieved from http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/smid/824/ArticleID/22/Default.aspx Pansier, B., & Schulz, P. J. (2015). School-based diabetes interventions and their outcomes: A systematic literature review. Journal of Public Health Research, 4(1), 65–71. doi: 10.4081/jphr.2015.467 SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 42 Patil, R., Nasrin, N., Datta, S. S., Boratne, A. V., & Lokeshmaran. (2013). Popular misconceptions regarding the diabetes management: Where should we focus our attention? Journal of Clinical and Diagnostic Research, 7(2), 287–291. doi: 10.7860/JCDR/2013/4416.2749 Patton, S. R., Dolan, L. M., Henry, R., & Powers, S. W. (2007). Parental fear of hypoglycemia: Young children treated with continuous subcutaneous insulin infusion. Pediatric Diabetes, 8, 362–368. doi: 10.1111/j.1399-5448.2007.00242.x Smith, C. T., Chen, A. M., Plake, K. S., & Nash, C. L. (2012). Evaluation of the impact of a diabetes education curriculum for school personnel on disease knowledge and confidence in caring for students. Journal of School Health, 82(10), 449–455. doi: 10.1111/j.1746-1561.2012.00721.x Silverstein, J., Klingensmith, G., Copeland, K., Plotnick, L., Kaufman, F., Laffel, L., … Clark, N. (2005). Care of children and adolescents with type 1 diabetes. Diabetes Care, 28(1), 186–212. doi: 10.2337/diacare.28.1.186 Tolbert, R. (2009). Managing type 1 diabetes at school: An integrative review. School Nursing, 25(1), 55–61. doi: 10.1177/1059840508329295 Wang, Y., & Volker, D. L. (2012). Caring for students with type 1 diabetes: School nurses’ experiences. The Journal of School Nursing, 29(1), 31–38. doi: 10.1177/1059840512447123 Warren, R. E., & Frier, B. M. (2004). Hypoglycaemia and cognitive function. Diabetes, Obesity & Metabolism,7(5), 493–503. doi: 10.1111/j.1463-2004.00421.x Wodrich, D. L., Hasan, K., & Parent, K. B. (2011). Type 1 diabetes mellitus and school: A review. Pediatric Diabetes, 12(1), 63–70. doi: 10.1111/j.1399-5448.2010.00654.x SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 43 APPENDICES Appendix A: Questionnaire Appendix B: Cover Letter Appendix C: Informed Consent Statement Appendix D: Permission Letters SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 44 Appendix A – Questionnaire Answer the following questions about yourself. 1. Y/N I have or a family member has type 1 diabetes. If yes to this question they will be thanked for their time and exit the questionnaire. 2. The job description that best describes mine is a… a. Teacher b. School nurse c. Teachers aid d. Office staff e. Administrator 3. The grades I work with (circle all that apply). a. K-3 b. 4-6 c. 7-9 d. 10-12 4. I work at Based on your own knowledge of type one diabetes and school policies choose the response that best answers the question. 5. When a student is suffering from hypoglycemia (low blood sugar), I can help them by… a. Giving them insulin b. Sending them to the office c. Have them eat a snack with fast acting sugar in it d. Have them lay their head on their desk until they feel better 6. What are the common signs and symptoms of hypoglycemia (low blood sugar)? a. Sweating, dizziness, lightheadedness, confusion, shaking, and overall unwell feeling b. High fever, goose bumps, dilated eyes, and itchy skin c. Nausea, head ache, mood swings, and nervousness d. There are no signs of hypoglycemia SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 45 7. Out of these four choices, which would raise blood sugar the quickest? a. Diet Coke b. A bagel c. Fruit juice d. Beef jerky 8. What effect does exercise have on a student with type one diabetes blood glucose level? a. Lowers it b. Raises it c. Has no effect 9. Stress, illness, or having an infection in a student with type one diabetes is likely to cause… a. High blood sugar b. Low blood sugar c. No effect 10. Which is NOT considered a complication of someone who does not have well controlled diabetes? a. Kidney problems b. Nerve problems c. Eye problems d. Lung problems 11. When my student is taking a test and has low, I should… a. Let them re-take the test when they feel better. b. Have them finish the test, then send them to the office. c. Give them a snack and have them continue the test. d. Send them directly to the office. e. Give them a snack and have them retake the test when they feel better. 12. Y/N High blood sugar can cause students to need to use the bathroom frequently. 13. Y/N Hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) affect cognition. 14. Y/N I can send a student who is suffering from low blood sugar to the office by themselves. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 46 15. Y/N I let my student check their blood sugar in class. 16. Y/N My students are not allowed to have back packs in class. 17. Y/N I let my students with type one diabetes eat in class. 18. Y/N If my student eats healthy and exercises, they can cure their diabetes. 19. Y/N People with type one diabetes can eat sugar. 20. I feel confident in my knowledge of diabetic care. a. Strongly agree b. Agree c. Not sure d. Disagree e. Strongly disagree 21. When I find out I have a student with type one diabetes, I feel stressed. a. Strongly agree b. Agree c. Not sure d. Disagree e. Strongly disagree 22. I feel like my students with type one diabetes abuse their disease and use it as an excuse for eating snacks in class or using the bathroom frequently. a. Strongly agree b. Agree c. Not sure d. Disagree e. Strongly disagree 23. The parent or guardian of my student with type one diabetes has educated me well on their diabetic care. a. Strongly agree b. Agree SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 47 c. Not sure d. Disagree e. Strongly disagree 24. The school I work at has access to a school nurse… a. All the time b. Most of the time c. A part of the time d. Not at all e. Not sure 25. Y/N I would like more training/information on how to care for my student with type one diabetes. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 48 Appendix B – Cover Letter Date (Sample school) (Sample school address) Dear participant: My name is Laura Tzunun, and I am a master of education student at Weber State University. I am researching school personnels’ knowledge of type one diabetes. Type one diabetes is one of the most prevalent chronic childhood illnesses, effecting one in every 400-600 American children. Serious short-term and long-term conditions can develop if the condition is not properly cared for. Research has shown that many school personnel are unaware of when students need help, or do not feel confident in caring for students with type one diabetes. The diabetic community in northern Utah has concerns about children with type 1 diabetes in schools. It is important to collect data to determine what steps need to be taken to help improve diabetic care in our area. I recognize that your time as teacher or school staff member is very valuable. The questionnaire you will be filling out will take about 10 minutes or less. Your willingness to take the questionnaire could provide information to help students with type one diabetes avoid life threating situations. If you have type one diabetes or a very close family member or friend has type one diabetes, I kindly ask for you to not take part in the survey. I am interested in the general publics’ knowledge of type one diabetes. Your personal information will be kept confidential. All information will be kept anonymous and identifying information will be removed from the record. Thank you so much for you time and input, Laura Tzunun Weber State University Master of Education candidate lauratzunun@gmail.com SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 49 Appendix C – Informed Consent Statement WEBER STATE UNIVERSITY INFORMED CONSENT TEACHERS’ AND OTHER SCHOOL PERSONELS’ KNOWLEDGE OF TYPE ONE DIABETES AND ITS EFFECT ON THEIR STUDENTS You are invited to participate in a research study about school personnels’ knowledge of type one diabetes and the effect it has on students. You were selected as a possible subject because you work at a charter school in northern Utah. I ask that you read this form and clarify any questions you may have before agreeing to be in the study. The study is being conducted by Laura Tzunun and Weber State University master’s of education program. STUDY PURPOSE The purpose of this study is to identify school personals’ knowledge of type one diabetes, and how confident they are in aiding students in their diabetes care. NUMBER OF PEOPLE TAKING PART IN THE STUDY: If you agree to participate, you will be one of approximately 100 subjects who will be participating in this research. PROCEDURES FOR THE STUDY: If you agree to be in the study, you will do the following things: Complete a 10 minute anonymous questionnaire. RISKS OF TAKING PART IN THE STUDY: Participants may feel guilt for not caring for their students in the way they feel they should. Information will be shared with participants, so they can improve their knowledge. BENEFITS OF TAKING PART IN THE STUDY You will not receive payment for taking part in this study. However, your responses may help us learn what teachers know about type one diabetes, and how we can improve diabetic care in schools. ALTERNATIVES TO TAKING PART IN THE STUDY: You do not need to participate in the study if you do not wish to do so. COSTS/ COMPENSATION FOR INJURY In the event of physical injury resulting from your participation in this research, necessary medical treatment will be provided to you and billed as part of your medical expenses. Costs not covered by your health care insurer will be your responsibility. Also, it is your responsibility to determine the extent of your health care coverage. There is no program in place for other monetary compensation for such injuries. However, you are not giving up any legal rights or benefits to which you are otherwise entitled. SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 50 If you are participating in research which is not conducted at a medical facility, you will be responsible for seeking medical care and for the expenses associated with any care received. CONFIDENTIALITY Efforts will be made to keep your personal information confidential. We cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. Your identity will be held in confidence in reports in which the study may be published Organizations that may inspect and/or copy your research records for quality assurance and data analysis include groups such as the study investigator and his/her research associates, the Weber State University Institutional Review Board or its designees, and (as allowed by law) state or federal agencies, specifically the Office for Human Research Protections (OHRP) and the Food and Drug Administration (FDA) [for FDA-regulated research and research involving positron-emission scanning], the National Cancer Institute (NCI) [for research funded or supported by NCI], the National Institutes of Health (NIH) [for research funded or supported by NIH], etc., who may need to access your medical and/or research records. CONTACTS FOR QUESTIONS OR PROBLEMS For questions about the study, contact the researcher Laura Tzunun at (801) 462-5629 or the researcher’s mentor Peggy Saunders at 801-625-3632. For questions about your rights as a research participant or to discuss problems, complaints or concerns about a research study, or to obtain information, or offer input, contact the Chair of the IRB Committee IRB@weber.edu. VOLUNTARY NATURE OF STUDY Taking part in this study is voluntary. You may choose not to take part or may leave the study at any time. Leaving the study will not result in any penalty or loss of benefits to which you are entitled. Your decision whether or not to participate in this study will not affect your current or future relations with Weber State University. SUBJECT’S CONSENT In consideration of all of the above, I give my consent to participate in this research study. I will be given a copy of this informed consent document to keep for my records. I agree to take part in this study. Subject’s Printed Name: Subject’s Signature: Date: (must be dated by the subject) Printed Name of Person Obtaining Consent: Signature of Person Obtaining Consent: Date: SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 51 Appendix D– Permission Letters SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 52 Dear Administrator of school A, B and C: My name is Laura Tzunun, and I am a master of education student at Weber State University. I am researching school personnel’s knowledge of type one diabetes. Type one diabetes is one of the most prevalent chronic childhood illnesses, effecting one in every 400-600 American children. Serious short-term and long-term conditions can develop if the condition is not properly cared for. Research has shown that many school personnel are unaware of when students need help or do not feel confident in caring for students with type one diabetes. The diabetic community in northern Utah has concerns about children with type 1 diabetes in schools. It is important to collect data to determine what steps need to be taken to help improve diabetic care in our area. Would you be willing to let the staff at your school participate in my study? They will be sent a survey and complete it on Google Forms. As a teacher myself, I recognize that your staffs time is very valuable. The questionnaire they will be filling out will take about 10 minutes or less. Your willingness to allow your staff to take the questionnaire could provide information to help students with type one diabetes avoid life threating situations. After your staff complete the study of their involvement in my study will be complete! I will provide information to you to let you know how much your staff knows about type one diabetes. Thank you for your time and consideration, Laura Tzunun Weber State University Master of Education candidate lauratzunun@gmail.com SCHOOL PERSONNEL’S KNOWLEDGE OF T1D 53 School A Administration Tue, Sep 18, 7:02 AM Laura, I would allow my staff to participate. Let me know what is next. School B Administration Sep 11, 2018, 9:14 AM Absolutely! I hope you are doing well. School C Administration Mon, Sep 10, 4:28 PM Laura, Yes, if you will send me a link to the form, I will forward it to my teachers. Best Regards