The Improvement of Diabetes Care Concept - Essay Example

161346 INTRODUCTION Diabetes being a chronic disorder affecting 3% of UK population1, with almost definite possibility of hospital admission and sustainability by hospitals2, leading to excessive expenditure3, expenditure being mainly due to myocardial complications,4 remains the most common cause of blindness, foot problems leading to amputation, obesity, coronary artery disease and stroke. Complications during pregnancy can adversely affect the child. Juvenile diabetes is definitely more troublesome, as the patient has to deal with complete 'packing up' of pancreas. This study focuses on research and evidence based practice for the improvement of diabetes care concept by examining the recent evidence of research articles to apply for the use of self, professionals and families in order to improve care and empowering professionals. It is acknowledged that evidence based practice is rational and logical and research keeps moving forward amassing more and more knowledge, opening many possibilities. Such evidence corroborated research should be implemented in the management so that updated knowledge could improve interventions and quality. The care provided must be constantly evaluated and improved based on new and refined knowledge (Burns and Grove, 2003). Evidence based practice also ensures treatment interventions on the basis of reliable research by integrating clinical expertise, patient information and evidence guidance. The nursing profession is accountable to society for providing high quality, cost-effective care for patients (Burns and Grove, 2003). This study will give two Executive summaries of two articles and an in-depth analysis of another similar research based article. With more research coming out in the field, medical practitioners feel that research evidence based practice is more important for a long term disease like diabetes. Research connected practice is of great significance for my practice and I have chosen this module because of its pertinence to my career. There will be connected literature review closely linked with regional and cultural backgrounds, psychological mindsets and disease management. Di Censo et al (1998) explains evidence-based practice (EBP) as 'The process by which nurses make clinical decisions using the best available research with their clinical expertise and patient preferences in the context of available resources'. Research based practice relies on systematic research studies while evidence considers nurse's clinical experience, practice trends and patient preferences (Newell and Burnard, 2006). EXECUTIVE SUMMERY OF AN INPATIENT DIABETIC CARE PATHWAY: This study depends on the development and testing of a care pathway for diabetes management examining the impact of length of stay, re-admission, CP driven care advantage and improvement parameters. CP was developed in consultation with ward staff mainly to improve nurse knowledge; but for the use of both medical and nursing staff. Requirement of constant support for staff was examined by measuring staff knowledge before and after trial using questionnaire. Patients were randomised for normal and CP care. According to discharge patient notes assessment CP maintained better care while standard of documentation was similar. Baseline demographics like age, diabetes duration, sex, type of diabetes etc. including intervention period, and follow-up of patients being randomised to either normal care or a care pathway (CP), with a knowledge questionnaire, regarding analyser comparisons between staff located and CP groups were all attended to. Frequency of blood glucose monitoring was monitored and was found to be more appropriate to CP group as CP was significantly better quality of care with standard documentation, of both CP and non-pathway groups. Result showed improvement in hospital stay and HbA1c control, but not significantly. CP group had higher knowledge in staff and patient both, with reduction in length of hospitalisation and better quality of care. The study concluded that non-specialist staff may require support in CP and CP method is significantly of better quality in the diabetes management with improved nurse knowledge and much lesser admissions after one year with better diabetes control. It is also concluded that CPs could be useful to healthcare inpatient diabetes management by non-specialists. EXECUTIVE SUMMARY OF MANAGEMENT OF DIABETES: Study depends on meta-analyses and systematic reviews of RCT. It focuses on reviewing of earlier guidelines, providing aims of guidelines, setting a new bunch of guidelines depending on recent research. It acknowledges the national diabetes initiatives, defines the condition, mentions diagnosis, and reiterates the importance of constant review, updating and renewing research based guidelines. It discusses therapy, home based programmes of initial management, importance of continuous management with and without insulin regimen as part of comprehensive support package though it favours the individually tailored regimen. Study emphasises the psychological intervention, use of cognitive coping strategies and early screening and lifestyle interventions by trained health professionals. It focuses on diabetic complications and risk factors It refers to WHO diagnostic criteria for diabetes mellitus that were implemented in UK in June 2000, as part of national diabetes initiatives, so that guidelines could serve as a standard of clinical care, with referable parameters of practice, as part of scientific knowledge updated with ongoing research. Study agrees that despite guidelines, final decision would be of physician, in concurrence with the patient, depending on data provided by him. Juvenile diabetes has altered diagnosis and epidemiology that has to be updated with current knowledge prevailing in the field of Type 1 diabetes. Study is aware of dangers of cystic fibrosis that could lead to diabetes. It focuses mainly on initiating therapy as part of home-based management of children's diabetes, guidelines for insulin regimen, so as to arrive at a comprehensive support package for both intensive and non-intensive insulin therapy. Dietary management for children and pregnant women with psychological intervention and regular psychological assessment, keeping risk of micro vascular complications and associated conditions to minimum, monitoring with regular screening for thyroid, coeliac diseases etc. is dealt with by the study. It is based on theoretical framework of lifestyle management and lifestyle interventions. It lays stress on self-monitoring of glycaemic control, improving quality of life and reducing depression, smoking cessation, exercise, physical activity and their assessment. It also emphasises awareness of results of alcohol intake, prevention, treatment and management of visual impairment, management of cardiovascular complications, risk of dyslipidaemia, hypertension, prevention of coronary heart disease, pharmacological therapy, glucose lowering, problems of age inhibition, LPID lowering, and coronary revascularisation. It discusses peripheral arterial disease and management of acute stroke, prevention, treatment and management of diabetic nephropathy, rehabilitation of patients with diabetic eye disease. Study covers issues like management of diabetic foot disease, structured foot review, footwear, arterial reconstruction, tissue replacement, reducing risk of painful diabetic neuropathy, charcot's foot. It gives attention to management of diabetes in pregnancy, pre-pregnancy and post-pregnancy care, obstetric complications, care of infants of diabetic mothers, gestational diabetes, and development of guidelines with literature review. ANALYSIS OF ISSUES AND INNOVATIONS IN NURSING PRACTICE - BELIEF ABOUT HEALTH AND DIABETES IN MEN OF DIFFERENT ETHNIC ORIGIN This report mainly focuses on various beliefs and practices prevailing amongst people of diverse ethnicities regarding diabetes which has racial variations (Walter, 1991, p.18). This approach is rather rare and shows one of the initial studies in this direction. It explores differences in beliefs of health and illness in Sweden giving a comparison between Swedes and two groups of immigrants from Arabic countries and erstwhile Yugoslavia. Different cultural backgrounds exploration is felt to be necessary in recent years, to learn more about the possibilities of better care and cure. Beliefs have a role to play in treatment and management. Method of sampling for the explorative study is good with focus group interviews of 35 men with diabetes within the age group of 39 and 78. Focus group number is adequate and highly diverse age group is excellent with 14 from Arabic countries, 10 from former Yugoslavia and 22 from Sweden. The lay model of illness and healthcare seeking behaviour (Hjelm et al, 2003, 2002, 1999, 1998) was used as the main analytical category in finding causes and health-restorative activities of culturally diverse target group. Interesting findings came out in the result. Arabs and Yugoslavians felt that being economically independent, working with ability to be occupied and employed is important in their lives. Along with these factors, sexual functioning is considered to be the most important factor for health. While Swedes thought that heredity, lifestyle and management of sickness is important, influence of supernatural factors and emotional stress relating to immigration and mobility related factors are harrowing for non-Swedes, who think that these factors are responsible for the onset of diabetes and other health problems that could be tension related. According to study Arabs described health as 'freedom from disease' and former Yugoslavians described it as 'wealth and the most important thing in life'. Knowledge about diabetes is rather limited, though Arabs showed information gathering tendency compared to complacency of the other two. They are employed, have the same sickness and sufficiently informed; but the sickness management is different according to each person's culture and spiritual beliefs, and mostly patients settle for much lesser than they really need (Fox, 1995, p.224). This study mainly focuses on self-care of the disease and how the belief parameters could affect such self care. Swedes think there is support from relatives and friends. Arabs are more dependent on family and society and thinks he should follow rules of host country5. The other two groups felt like aliens in Sweden. They face language problem, social security dependency and adjustment difficulties. Former Yugoslavians thought food was unhealthy and tobacco and alcohol dependency are not good for their sickness. Stress and smoking, they feel, are the root causes of diabetes. They thought that financial situation is limiting their capability of attaining health. They feel they should eat better, but cannot do that with social security money. Arabs thought telephone bills are expensive because they feel the need of being in touch with homeland and relatives back home. The extensive findings are presented in table form and they describe the themes and categories emerging out of the data. Study finds that men have lower level of knowledge about health and sickness compared to women of the same group. Swedish women definitely have higher awareness of health. Other two groups are distinctly different, being brought up in different societies under different socio-economic circumstances and these factors show the inherent difference in thinking about illness and health. Study limitations show because the group is too small to make sweeping conclusions. It notices distinct cultural differences and variations in outlook and beliefs. Loss of employment is seen as the greatest threat to public health. It argues that Health care has to be aware of life situations, gender, social and economic paradigms of different cultural groups even though illness is the same. There are many social and legal aspects of diabetes which will apply to all and most of them were worried about it, especially about employment (Oakley et al, p.162). Impotence, a main complication of diabetes (Alberti et al, 1997), but very rarely discussed as part of treatment (Hulter and Sundkvist 2002). Individualised teaching with gender and cultural differences in mind and involvement of relatives might be necessary where culture demands it, especially involvement of the partner where sexual problems are relevant. Non-Swedes seem to be having a more virulent form of diabetes and were hospitalised earlier for certain periods. Diabetes has social consequences and respondents and can affect sexual relationship with the spouse and intrude in social norms like not being able to share food with others in social gatherings etc. Intrusion of disease in people's self-identity is prevalent as they have to be socially set apart in their day-to-day existence and these are difficult social problems (Leventhal, 1965) in Shillitoe (1988, p.208). When diagnosed, Swedes tried to deny it, fighting against believing it, while Arabs were shocked, but accepted, and Yugoslavians were surprised, but without much reaction. Most Swedes remained true to instructions and monitored daily. Non-Swedes are trying to avoid responsibilities because they will be stressed and cannot afford to be so due to disease. Migratory background is causing uncertainties and diverse reactions towards sickness and management. This shows that many psychosocial and cultural issues prevail in diabetes6. Illness is considered to be caused by individuality, nature, social relations and supernatural sphere (Helman 2000) and in some cultures faith-healers, family, friends and professionals (Kleinman 1980) could offer care and help. Health belief model is explained by researchers (HBM; Rosenstock et al, 1988) and is perceived as locus of control (Rotter 1966). Different cultural beliefs have to be understood from the target group's perspective and it reflects participants' priorities and sensitivities (Krueger 1994, Kitzinger 1995, Basch 1987). Swedes focussed on lifestyle and inheritance and foreign-born people were unhappy with their migratory experiences. Arabs showed adaptational problems as immigrants living in Sweden. They wanted to be breadwinners for the family and bring up their children. Positive mood enhances perceived self-efficacy; mastery experiences have the greatest impact (Bandura 1995). In the context of stressful life transitions, such as migration, general beliefs about efficacy may serve either as a personal resource or a vulnerability factor (Jerusalem & Mittag 1995). For Swedes their lifestyle was more important and focus on being breadwinner was comparatively unimportant. Arabs came from 'masculine' societies and had patriarchal attitudes and cannot find themselves out of stereotype roles. Goal of providing for family remains very important to most of them. It is proved that the disease is a source of conflict in the family, especially when impotency follows it. Another study presents cultural beliefs of diverse nature7. This study was conducted without the benefit of earlier studies, as early studies mainly focussed on how to live with the condition with certain beliefs about health and illness (William-Olsson 1986, Hawthorne et al. 1993, Quatromoni et al. 1994, Maillet et al. 1996, Glasgow et al. 1997, Chin et al. 2000). Some studies explained the causes of the condition (Lang 1989, Dechamp-Le-Roux et al. 1990, Luyas 1991, Rios-Itturino 1992, Cosby & Houlden 1996, Gittelsohn & Harris 1996, Hunt et al. 1998, Alcozer 2000, Thompson & Gifford 2000) and also described factors like salutogenic perspective. There is a certain lack of comparative approach and mainly concentrated on non-Scandinavian people with the possible exception of particular study (Dechamp-Le-Roux et al. 1990), which had a comparative approach. Present approach is slightly different from the previous approach where Middle East societies are paternalistics sed on 'dependent cullectivism' and not 'independent individualism, where men are assertive and women have a lesser role (Hofstede 1984). Principle of saturation in data analysis (Krueger 1994) had been used to analyse the sampling procedure of beliefs about health and illness. Beliefs are culture based and transmitted through culture and langue (Berger and Luckmann 1991) and they determine the attitudes and behaviour (Purnell and Paulanka 1998). Arabs bemoaned about not having Sun and being unable to perspire. All agreed that obesity, bad diet, lack of exercise, not caring for health, stress, infections, inactivity and heredity are all causal factors of diabetes. Only Arabs mentioned the Will of God. All non-Swedes mentioned evil eye, death of relatives, disturbed relationships, influence of evil people, as possible causes. Most of the Arabs left it to God to decide. All were ignorant of repercussions like kidney failure. Study has continued simultaneous data collection and analysis till no new information could be obtained (Krueger 1994). For Arabs fasting is compulsory during Ramadan. For Yugoslavians celebrations are a kind of social solidarity, but they are conscious that they should not eat too much or forbidden food. To Swedes celebrations did not matter too much and during Christmas they adapted their food habits into tradition. Cultural diversities could contribute more in the direction of more family involvement and self-care. People brought up in a society based on 'dependent collectivism' with a high degree of power distance and hierarchical relationships learn to obey authorities, which implies less independent behaviour with lowered self-efficacy and higher reliance on others (Oettingen 1995), e.g. health care staff. This concept is entirely different from the Western way of life where 'independent individualism' treats all as equals and children are encouraged to be more independent K.G. Hjelm et al. 48 _ 2005 Blackwell Publishing Ltd, Journal of Advanced Nursing, 50(1), 47-59, increasing the perception of self-efficacy, and thus act more on their own, being more independent (Oettingen 1995). CONCLUSION Culture based research is going on in US and we come across many papers on the subject and many barriers have to be crossed to render proper care to patients (Phillis et al, 2004) and it is a welcome phase. According to this Study, loss of employment is considered to be the greatest threat to public health (Magnusson 1995) and unemployment costs dearly to the person and the society (Behrenz and Delander 1997). Again the health care suffers more expenses due to caring, monitoring and medicinal costs. All cultures do not seek professional care in the same way. Here they are guided by social, economic and cultural circumstances. We can easily conclude that cultural beliefs and socio economic factors reign supreme in this chronic illness and caregivers have to keep in mind the diverse cultural backgrounds and beliefs. Most of them might be anti-scientific; still people who are grown into it would not agree. Research and consideration of these beliefs would be more pleasant than conflicts. Gender based care is necessary and social background should be considered while adopting methods of treatment. Study depends on knowledge from every quarters and this evidence based research should be one of the guiding principles of practice. Impotence as one of the connected problems deserves more attention. BIBLIOGRAPHY 1. Burns N, Grove SK (2003) Understanding Nursing Research (3rd ed), USA, Saunders. P28, 299 2. Beck C, Polit D, (2006) Essentials of Nursing Research Methods, Appraisal and Utilisation. (6th ed) USA, Lippincott 3. Covington, Maggie B., 'Traditional Chinese medicine in the Treatment of Diabetes', Diabetes Spectrum, 14:154-159, 2001. 4. Di Censo A, Ciliska D, Cullum N, (1998) Implementing Evidence Based Nursing: Some Misconceptions. Evidence Based Nursing. P1 5. Fox, Charles and Pickering, Anthony (1995), Diabetes in the real World, Class Publishing, London. 6. Gerrish K, Lacey A (2006) The Research Process (5th ed), Great Britain, Blackwell Publishing Ltd 7. Haber J, LoBiondo-Wood G (2002), Nursing research, Methods Critical Appraisal and Utilization (5th ed) USA, Mosby 8. Halloway Hewlitt-Taylor J (2001) Use of Constant Comparative Ways in Qualitative research. Nursing Standard. 15 9. Oakley, W.G., D.A. Pyke and K.W. Taylor (1975), Diabetes and its Management, Blackwell Scientific Publications, Oxford. 10. Phillis, Andrea et al, 'Improvement in diabetic care of underinsured patients', Diabetes Care, 27:110-115, 2004. 11. Shillitoe, R.W. (1988), Psychology and Diabetes, Chapman and Hall, London. 12. Watkins, Peter J., Paul L. Drury and Keith W. Taylor (1995), Diabetes and its Management, Blackwell Scientific Publications, Oxford. ONLINE SOURCES: 1. http://medicine.plosjournals.org/perlserv/request=get-document&doi=10.1371/journal.pmed.0030215 2. http://www.ias.ac.in/currsci/dec252002/1556.pdf 3. http://pmj.bmj.com/cgi/content/full/82/967/347 4. http://taylorandfrancis.metapress.com/content/hp57upnbeg5t38rw/ 5. Macnee C L, (2004) Understanding Nursing Research, Reading and Using Research in Practice, USA, Lippincott Williams and Wilkins. P259-260 McKibbon KA (1998). Evidence based practice. Bulletin of the Medical Library Association 86 (3): 401. Burnard P, Newell R, (2006) Vital Notes for Nurses, Research for Evidence-Based Practice. UK, Blackwell Publishing Parahoo K, (2006) Nursing Research (2nd ed) China, Palgrave Macmillan p 170 Read More