Disability and Workability with Diabetes - Coursework Example

Structured Research Appraisal on Diabetes I. Introduction Diabetes is a common and growing health problem worldwide. According to World Health Organization (2008), at least 171 million people worldwide have diabetes and this figure is likely to be more than double by 2030. Annual mortality attributable to complications of diabetes accounts for about 3.2 million yearly. In UK, particularly, approximately 1.4 million people have diabetes – around three in 100 people (NHS Education for Scotland, 2004, p. 23). With this factual information about how serious diabetes as an illness, this research appraisal attempts to investigate on the three actual research studies about diabetes conducted by medical and nursing researchers from different parts of the world, most particularly those conducted in the United Kingdom. This research appraisal aims to broaden the awareness of the healthcare providers of the latest status and trends in nursing research and practice, specifically on: (1) identifying the similarities and differences of the qualitative and quantitative research designs, (2) to identify the implications of the three studies in relevance to the nursing practice particularly in the perspective of occupational health nursing, and (3) to gather information on the proper nursing management of clients with diabetes at work, their legal rights as to the limitations set forth on the Disability Discrimination Act of London (1995) in order to make their activities of daily living more meaningful in spite of having diabetes. II. Review of Related Literature Appraised for this purpose are the three recent research studies on diabetes conducted by the renowned medical and nursing research teams in United Kingdom. These are: (1) Disability & Workability: Diabetes – An Occupational Health Nursing Case Study (NHS Education for Scotland, 2004, pp.21-24) – a qualitative research; (2) The Socio-Economic Factors and Outcomes in Type 2 Diabetes (Coates, et al., January 2008, pp. 1-113) – a quantitative research; and (3) Effectiveness of Self-Management Intervention in Patients with Screen-Detected Type 2 Diabetes (Thoolen, et al., November 2007, pp. 1-6) – a quantitative research. Research Study #1. Disability and Workability: Diabetes By NHS Education for Scotland (2004) < http://www.nes.scot.nhs.uk/documents/publications/classa/Occupationalhealth.pdf > Summary This case study highlights some of the issues to be considered in the workplace for an employee with newly diagnosed insulin-dependent diabetes. It also illustrates the need for collaborative working between the multidisciplinary professionals caring for the employee in the community and occupational health services. The implications of this study for nursing practice, particularly to occupational health nurse, are as follows: Be aware what illnesses and disabilities are taken into account under the Disability Discrimination Act (1995) and ask your client if his or her disability affects the ability to carry out tasks at work. Make links with occupational health services and the Employment Medical Advisory Service in your area, where appropriate, regarding required adjustments. Be aware of the employers’ responsibility with regard to an employee with a long-standing medical condition or disability. Understand that the employee with a medical condition or disability who works night shift is entitled to a medical assessment in relation to his or her working hours/job description. Research Design and Methods A case was presented with Rita as the diabetic client, whose actions were planned with the involvement of her manager, the company’s HR department and the Occupational Health Nurse Advisor (OHNA). An action plan was purposely developed through the application of realistic nursing management for a diabetic patient at work. Data were collected incorporating the best nursing management including the legal rights of the diabetic patient in relation to his/her employment with reference to Disability Discrimination Act (1995) of London as well as the terms and conditions applicable to an ill employee referred to The Working Time Regulations (1998) of London. After making a clear and systematic plan on how the patient should be managed, this plan was put into action in Rita’s case, whilst the researcher observed her attitudes and behaviour on the process. Findings This study found out the following: Interprofessional collaboration is a crucial component of effective partnership working between primary care and occupational health staff. A holistic approach should be taken to the client’s needs. Supporting an employee in the workplace suffering from a disability is an ongoing process. Employers have an obligation to make ‘reasonable adjustments’ in the light of a disability affecting the activities of daily living covered under the Disability Discrimination Act (1995). Research Study #2. The Socio-Economic Factors and Outcomes in Type 2 Diabetes By: Vivien Coates, Maurice O’Kane, Brendan Bunting, Adrian Moore, and Mary McMenaminCoates (January 2008) < http://www.science.ulster.ac.uk/inr/pdf/type_2_diabetes_FINAL_REPORT.pdf > Summary This research project aimed to examine the role of socioeconomic deprivation and associated behavioural and psychological attributes which may adversely influence clinical outcomes in type 2 diabetes. This project was unable to confirm any strong or consistent effect of deprivation on clinical outcomes or outcome indicators. This may suggest that active management of diabetes in a structured primary/secondary care setting with explicit treatment targets negates any clinical detriment associated with socioeconomic deprivation. An important legacy of this study is the creation of a comprehensive file for the cohort incorporating the socioeconomic, clinical and psychosocial datasets which will enable further longitudinal studies on this cohort. Research Design, Methods and Analyses All 1,300 patients with type 2 diabetes from a district general hospital (Altnagelvin Area Hospital, Londonderry) diabetes clinic database were profiled using area based deprivation indicators (Noble Index, 2001) at enumeration district level. From this dataset a random sample of 541 patients stratified by area deprivation category was generated and invited to participate in the study. Each of the 446 (252 males) participating patients underwent a questionnaire interview to determine a range of behavioural, psychological and social attributes (social integration, lifestyle, perceived mastery and powerlessness, health status, attitudes and self management of diabetes). Clinical information for each patient was extracted from the hospital diabetes clinic database. The socioeconomic, psychosocial and clinical datasets were combined in a single file for further analysis. Cardiff’s Teleform® automates the process of collecting, evaluating, validating, and storing data via forms (Cardiff Teleform, 2002) and this software enabled the questionnaire to be stored on the RA’s laptop (in PDF format) and allowed live data entry. Findings The study found out the following: The mean age of the cohort was 64.7 [11.4 (SD)] with a mean duration of diabetes of 11.2 (6.2) years. The breakdown by antidiabetic treatments was: diet alone 7.4%, oral hypoglycemic agents 54.3%, insulin 38.3%. With the relationship between clinical outcomes, socioeconomic circumstances in terms of tissue complications, it was found that currently level of deprivation had no or little effect on clinical outcomes. The study cohort had high levels of deprivation with 29.6% and 8.7% in the most and least deprived quintiles respectively of the N Ireland population as a whole. Almost three quarters of the cohort declared a total household income of < £19 999 with 21.7% < £9 999. Two thirds of the cohort held no formal educational qualification. This findings support that levels of deprivation did not have an effect upon the specified risk factors. The only exception being that of BMI was correlated with income and level of education. Behavioural, psychological and social attributes were measured across the spectrum of deprivation and whilst differences in behaviours and attitudes were identified they did not form a consistent trend. There were few statistically significant relationships between these variables. Overall there was an 81% attendance at the diabetes clinic. There was no strong association between socioeconomic deprivation and clinic attendance. The level of deprivation made little difference to the prevalence of diabetes risk factors or to clinical outcomes. Found was variance in dietary and exercise behaviour, in knowledge and attitudes across the spectrum of social circumstances but they could not be used to help explain the clinical outcomes as so few differences were found. The possibilities for using spatial techniques and methodologies were explored within the context of this study and it was found that there are indeed some very clear patterns in the spatial distribution of important behavioural factors in the management of type 2 diabetes. These are independent of the personal socioeconomic circumstances of patients and not evident in the conventional spatial analysis. The techniques used also demonstrate the value of including geographical data and how Geographic Information Systems can be utilized in the future for research and planning. Research Study #3. Effectiveness of Self-Management Intervention in Patients with Screen- Detected Type 2 Diabetes by Bart Thoolen, PhD, Denise De Ridder, PhD, Jozien Bensing, PhD, Cora Maas, PhD, Simon Griffin, MD, PhD, Kees Gorter, MD, PhD and Guy Ruteen, MD, PhD (November 2007) at < http://care.diabetesjournals.org/cgi/reprint/30/11/2832 > Summary This study aims to examine the effectiveness of a theory-driven self-management course in reducing cardiovascular risk in patients with screen-detected type 2 diabetes, taking ongoing medical treatment into account. The self-management course was effective in achieving sustained reductions in weight and BP, independent of medical treatment. A combination of behavioral and medical interventions is particularly effective in reducing cardiovascular risk in newly diagnosed patients. Research Design, Methods and Analyses A total of 196 screen-detected patients, receiving either intensive pharmacological or usual-care treatment since diagnosis (3–33 months previously), were subsequently randomized to a control or intervention condition (self-management course). A 2 x 2 factorial design evaluated the behavioral intervention (self-management course versus control) nested within the medical treatment (intensive versus usual care), using multilevel regression modeling to analyze changes in patients’ BMI, A1C, blood pressure (BP), and lipid profiles over 12 months, from the start of the 3-month course to 9-month follow-up. A preliminary analysis was done for each outcome separately, examining whether outcomes varied over time, individuals, course location, and general practices. Subsequent analyses followed traditional regression analyses, taking relevant levels into account. Findings The self-management course significantly reduced BMI and systolic BP (-6.2 mmHg) up until the 9-month follow-up, regardless of medical treatment. However, intensive medical treatment was also independently associated with lower BP, A1C, total cholesterol, and LDL before the course and further improvements in systolic BP (-4.7 mmHg). A combination of intensive medical treatment and the self-management course proved to be most effective; patients who received both interventions ultimately had a mean systolic BP of 128.3 mmHg at the 9-month follow-up, compared with 144.9 mmHg for patients receiving only usual care. With regard to weight change, it was found out that regardless of medical treatment, patients in the control condition gained weight, while patients in the intervention condition lost weight leading to a difference in BMI of 0.77kg/m2 or 2.6 kg in 1 year, a difference that continued to increase. Patients receiving both intensive medical treatment and the self-management course therefore had the best outcomes. III. Discussion The three nursing research were all originally conducted in UK and were published in medical and nursing journals and publications online. The first research study, Disability and Workability: Diabetes, is a combined case study, action research and experimental research, therefore it falls as a qualitative research. It is subjective in nature and uses words instead of numbers. According to Hunt’s Qualitative and Quantitative Concepts in Proposal Writing: Similarities, Differences, and Controversy… “Examples of qualitative research methods are action research, case study, grounded theory, historical methods, and ethnography”. Dr. Debra King (August 4, 2005) in her article Qualitative and Quantitative Research Design, stated that “qualitative study uses ethnographic techniques to represent, interrogate, juxtapose and construct the experience of…” Rita, in the case study, as a diabetic patient observed and influenced by the researcher, the HR manager, and the OHNA. The involvement of researcher on the study supports to Marshall and Rossman (1980) claim on qualitative research… “The research techniques themselves, in experimental research, [can]...affect the findings. The lab, the questionnaire, and so on, [can]...become artifacts. Subjects [can become]... either suspicious or wary, or they [can become]...aware of what the researchers want and try to please them. Additionally, subjects sometimes do not know their feelings, interactions, and behaviors, so they cannot articulate them to respond to a questionnaire”. Derived on this study are insights useful for the nursing practice (especially the occupational heath nurse) is the nurse’s big role in managing diabetic patients at work as to his limitations supported by the Disability Discrimination Act (1995) and The Working Time Regulations (1998) both helpful in helping the patient achieve a meaningful life in spite of having such illness. An occupational health nurse must be aware therefore of the following: (1) Conditions covered by the Disability Discrimination Act (1995) of London are long-standing physical or mental health problems or disabilities (diabetes in such case) that interfere with the activities of daily living, so ask client if his/her disability affects the ability to carry out tasks at work; (2) Allow an open communication line with clients and make links with Employment Medical Advisory Service for setting of adjustments at work; (3) The employer’s responsibility with regard to an employee with a long-standing medical condition or disability; (4) The diabetic employee who works night shift is entitled for a medical assessment in relation to his/her working hours with reference to and The Working Time Regulations (1998) of London. The second research study, The Socio-Economic Factors and Outcomes in Type 2 Diabetes, is a quantitative research for it deals with numbers where results of the study had been based on the quantitative or numerical results of the survey/interview conducted. In quantitative research, social facts have an objective reality and researchers are detach and impartial. It has a sample size and systematic pattern of data collection method deriving into a realistic conclusion. Quoted on Hunt’s article… “Quantitative research is the time honored scientific method. It is about prediction, generalizing a sample to a larger group of subjects, and using numbers to prove or disprove a hypothesis. For a typical study using quantitative methods, researchers tend to draw a sample of persons at random from a broader population, if possible” (York, 1998). A prospective or cohort study belongs to a descriptive type of quantitative research design where “some variables are assayed at the start of the study, then after a period of time the outcome are determined.” (Hopkins, July 2008). Hopkins (2008) also mentioned that “In quantitative research your aim is to determine the relationship between one thing (an independent variable) and another (a dependent or outcome variable) in a population”. In this study, dependent variables considered were age, duration of diabetes, BMI, HbA1c, Cholesterol, triglycerides, and BP. Independent variables were set forth on the interview questionnaire and these include social environmental variables: social support, friends and family, convenience to local amenities and safety, community involvement, general health section, smoking and alcohol, information retrieval, the general health questionnaire, mastery scale, diet, diabetes knowledge, diabetes integration scale, physical activity, biographical characteristics of respondents, housing, employment status, highest educational attainment, income, pilot study and ethical considerations. These are just some of the characteristics of this study that makes it fall under the quantitative research design. About the study’s implication to the nursing practice, results showed that there were no significant spatial patterns in the behavioural attributes of the type 2 diabetic patients when demographic, clinical, socio-economic and psycho-social attributes were considered base on the survey. A possible explanation for this may be that interaction with a structured diabetes service and the application of treatment of proven efficacy reduces any detriment associated with socioeconomic deprivation. The findings have implications for the organization of services for patients with type 2 diabetes. The third research study, Effectiveness of Self-Management Intervention in Patients with Screen-Detected Type 2 Diabetes, is also a quantitative research design. It has met the characteristics of a quantitative research as to being objective, number-oriented as to results, and having a: specified sample population (screen-detected type 2 diabetes patients), sample size (196 participants), time bound (1 year – 3 months course to 9 months follow-up), concrete dependent variables (BMI, systolic and diastolic PB, lipid profiles of HDL and LDL, Cholesterol and triglycerides level) and independent variables [medical treatments, education, disease duration, gender, sociodemographic factors, the self-management intervention course]. Also another characteristic of a qualitative research found on this study is the use of statistical analysis in deriving for the results. To differentiate one from the other, noted were the following distinct characteristics of each research methods: Qualitative Research is subjective in nature, there is a construction of the reality, words-oriented, flexible, there is portrayal, there is personal involvement of the researcher making it partial, doest not require a sample population, variables are complex, interwoven and difficult to measure, and the entire study is driven out to reach a predetermined result or outcome. It is interpretive in nature and emphasizes an "empathic understanding of social phenomenon from the actor or participants' point of view" (Rodwell, 1998, p. 15). Rodwell further argued that the qualitative approach was much more aligned with the social work profession. Social workers value relationships with clients, the subjective experience of their clients, and the uniqueness of each individual. These ideals lend themselves to the qualitative method – a point of view so applies to this particular case study. Quantitative research, on the other hand, is objective in nature, time-honoured approach, definite, utilizes sample population, number-oriented, variables and their relationships are clearly identifiable and measurable, there is researcher’s detachment to the study making it impartial, begins with hypotheses and theories (Galvan, 1999), and results either accepts or rejects the predetermined hypotheses. Quantitative research focuses on tightly controlled variables in a structured setting to provide an explanation of laws. Its emphasis is on gathering and validating knowledge through systematic, objective observations (Schriver, 2001). In terms of the study’s implication to the nursing practice, findings showed that self-management nursing intervention can be effective in improving cardio-vascular risk in screen-detected patients recently diagnosed to with type 2 diabetes both on top of and apart from intensive medical treatment. The actual self-management care given to clients, which would supposedly be very useful to in terms of nursing practice, were not explicitly mentioned but only diet, exercise and medication were mentioned. According to the study, the development and evaluation of the course has been published previously, indicating that the course was highly effective in helping patients to both initiate and maintain self-care behaviours up to 9 months after the course. In spite of the many opposite views or differences between the qualitative and the quantitative research methods, there are many similarities between these two approaches. Anderson and Welk listed these similarities (on their Quantitative vs. Qualitative Concepts in Proposal Writing: Similarities and Differences) as: 1. Careful, deliberate research processes; 2. Systematic procedures on each step of the research process; 3. The diligent desire to study and understand social questions or problems; 4. The requirement that seven steps in the research be undertaken: (a) choosing a topic, (b) creating a research question, (c) designing the research study, (d) completing a literature review, (e) collecting the data, (f) analyzing and interpreting the data, and (g) writing a final report. IV. Conclusion Appraising the three research studies were helpful in identifying the qualitative and quantitative research methods as to its differences and similarities. The two approaches look at perceptions of reality differently. In the quantitative study, it is assumed that one reality exists and that it is objective. For the purposes of a qualitative study, it is assumed that multiple, subjective realities exist. Qualitative research tries to understand the subject's viewpoint, and quantitative research counts and measures behavior with scales, tools, or interventions. Quantitative focuses on tightly controlled variables, while qualitative research can have more flexible variables and is more dynamic. But both are similar for they follow the seven steps of scientific method research, they both begin with qualitative judgments or hypothesis based on a value judgment, and both are careful, deliberate research processes that have systematic procedures. Integrating both methods in a research study is a wise technique that would utilize the usefulness of both methods and in fact some studies had already utilized the so called mixed research method or the combination of qualitative and quantitative research methods. According to Stange and Zyzanski (1989), “If the only tool researchers have is a hammer, they tend to see every problem as a nail. An appreciation of both quantitative and qualitative approaches can enhance a researcher’s ability to answer complex questions in a manner which is efficient, internally valid, and generalizable.” In the occupational health nursing perspective, these studies emphasize the nurse’ vital role in helping a diabetic client achieve an acceptable level or performances at work as well as the great contribution of self-management care to help the client achieve a more meaningful life in spite of having the illness. But among the three appraised studies, not one had provided a sample of the self-management program useful in managing diabetic clients. Nevertheless, these studies somehow conveyed key points as to which particular areas or nursing should an occupational health nurse assess and focus with in managing diabetes. In rendering client teaching, educate the client to set goals on the following: (1) Get an HbA1c test done every three to six months; (2) Work hard to lower HbA1c level by eating less fatty foods (like fried chicken, bacon, sausage, and pork) and routine exercise (walking around the block three times a week); (3) Be physically active by engaging in sports; (4) Remind the doctor to check bare feet at every office visit but personally check feet for blisters or sores and wash feet daily; (5) Get a flu shot this fall and a pneumonia vaccine if did not had one; (6) Strict adherence to diabetic and low fat diet to reduce blood sugar and cholesterol by eating fresh fruit, salads with low-calorie dressing, eat less meat and more fruits and vegetables, eat smaller portions; (7) Stop smoking or reduce smoking cigarettes per day; (8) Have an eye exam done every year or as indicated by my doctor; (9) Check blood sugar as instructed by my doctor or nurse care manager; and (10) Talk to the doctor or nurse care manager when having trouble reaching the goals. Other than the nursing management that the diabetic client is entitled to, the occupational health nurse should also be knowledgeable of the legal rights and limitations of the client in relation to his employment. Thus, the core objective of providing a holistic care for the clients can be achieved. Bibliography Anderson, J. and Welk, D. Quantitative vs. Qualitative Concepts in Proposal Writing: Similarities and Differences. A journal publication available at: < http://www.und.nodak.edu/instruct/wstevens/PROPOSALCLASS/AndersonP1.htm > Cardiff Teleform. (2002). Getting started with Teleform. Cardiff Software Europe: Middlesex. Available at: < http://www.cardiff.com/TELEform/ > Coates, V. et al. (January 2008). Socio-economic Factors and Outcomes in Type 2 Diabetes. Project commissioned by the Research and Development Office, Belfast. A collaborative project between Western Health and Social Care Trust and the University of Ulster. Available at: < http://www.science.ulster.ac.uk/inr/pdf/type_2_diabetes_FINAL_REPORT.pdf > Disability Discrimination Act (1995) London, The Stationery Office. Disability & Workability: Diabetes. (2004). Occupational Health: A resource Pack for Primary Care. NHS Education for Scotland pp 21-24. Available at: < http://www.nes.scot.nhs.uk/documents/publications/classa/Occupationalhealth.pdf > Galvan, J.L. (1999). Writing Literature Reviews. Los Angeles, Pyrczak. Harvard System of Referencing. (September 12, 2007). Anglia Ruskin University, Cambridge and Chelmsford. University Library. Available at: < http://libweb.anglia.ac.uk/referencing/harvard.htm?harvard_id_remove=2#2 > Hopkins, W.G. (July 2008). Quantitative Research Design. SportsScience Perspectives: Research Design. Available at: < http://www.sportsci.org/jour/0001/wghdesign.html > Hunt, C.A. Qualitative and Quantitative Concepts in Proposal Writing: Similarities, Differences and Controversy. University of North Dakota. Available at: < http://www.und.nodak.edu/instruct/wstevens/PROPOSALCLASS/Huntpaper.htm > King, D. (August 4, 2005). Qualitative and Quantitative Research Design. Learning Connection. Online article available at: < http://www.unisanet.unisa.edu.au/learningconnection/student/research/qualquan.asp > Marshall, C., & Rossman, G. (1980). Designing Qualitative Research. Newbury Park, CA: Sage. Noble Index. (2001). Measures of Deprivation in Northern Ireland. Department of Finance and Personnel: Demography and Methodology Branch. May 07, 2001 ISBN1899203435. Rodwell, M.K. (1998). Social Work Constructivist Research. New York, Garland. Schriver, J.M. (2001). Human Behavior in the Social Environment: Shifting Paradigms in Essential Knowledge for Social Work Practice (3rd ed.). Boston: Allyn & Bacon. Stange, K.C. and Zyzanski, S.J. (1989). Integrating Qualitative and Quantitative Research Methods. Fam Med. 21:448–451. The Working Time Regulations 1998: Terms and Conditions of Employment (Statutory Instruments: 1998:1833). London, The Stationery Office. Thoolen, B. et al. (November 2007). Effectiveness of Self-Management Intervention in Patients with Screen-Detected Type 2 Diabetes. Diabetes Care 30:2832–2837. Available at: < http://care.diabetesjournals.org/cgi/reprint/30/11/2832 > UK Clinical Research Network. (2007). The Diabetes Research Network: A Department of Health Initiative. Available at: < http://www.ukdrn.org/downloads/DRNbrochure.pdf > U.K. Prospective Diabetes Study (UKPDS) (1998) Group: Intensive blood glucose control with sulfonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 352:837–853 World Health Organization. (2008). Diabetes Available at: < http://www.who.int/dietphysicalactivity/publications/facts/diabetes/en/ > York, R.O. (1998). Conducting Social Work Research: An Experiential Approach. 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