Effect of Nurse-led Training on Self-Management of Diabetes Among Diabetic Patients Attending Medical Out-Patient Clinic in General Hospital Odan, Lagos State
Chapter One
Objective of the Study
The main objective of the study is to evaluate the effect of nurse-led training on the self-management of diabetes among diabetic patients. The specific objectives are to
- assess diabetic patient’s knowledge of self-management of diabetes pre/post-intervention;
- determine diabetic patient’s practice of self-care activities pre/post-intervention;
- implement the nurse-led training on self-management of diabetes;
- determine the effect of nurse-led training on diabetic patient’s knowledge of self-management of diabetes pre/post-intervention and
- determine the effect of nurse-led training on diabetic patient’s practice of self-care activities pre/post-intervention.
CHAPTER TWO
REVIEW OF LITERATURE
Introduction
A comprehensive literature review was done using journals and textbooks on the following:
Definition of diabetes mellitus, causes, symptoms, complications and types of Diabetes mellitus, Epidemiology of DM, Impact of diabetes mellitus in Nigeria, Organization of Diabetes care in Nigeria, Profile of patients with diabetes in Nigeria, the way forward, Previous Research in Diabetes self-management intervention, Diabetes self-management Education, Diabetes self-management, Barriers to diabetes care and Conceptual model.
Definition, cause, symptoms, complications and types of Diabetes Mellitus
Diabetes mellitus is a metabolic disease in which glucose level in the blood is high over extended periods (World Health Organization, 2014). DM results when the pancreas is unable to produce insulin or cell of the body is not responding to insulin produced (Shoback, 2011). Increase blood glucose symptoms include polyuria, polydipsia, and polyphagia. Acute complications include diabetic ketoacidosis, non-ketotic hyperosmolar coma, or death. Chronic complications include heart disease, stroke, kidney failure, foot ulcer and eye defect (WHO, 2014).
Buckley, DeCraen, Murray, Preiss, Sattar and Seshasai, et al., (2010) reported other causes of DM which include: Genetic defect of β-cell function, Genetic defect in insulin processing or insulin action, Exocrine pancreatic defect, Endocrinopathy, Infection and Drug.
There are three type of DM
- Type1 Diabetes Mellitus result from inability of pancreas to produce insulin. Another name for type1 is called “insulin-dependent diabetes mellitus”(IDDM)/juvenile diabetes ‘because this disease occurs mostly in children’. The cause is unknown. (WHO, 2013) T1DM characterize loss of beta cell of the islet of Langerhans in pancreas, this result in insulin deficiency. WHO (2013) state that T1DM is immune-mediated in nature, this is due to T-cell-mediated autoimmune attack leading to loss of beta cell and insulin. 10% DM case in North American and Europe is caused by autoimmune attack. People affected are healthy in appearance. In the early stage, sensitivity and response to insulin is normal, T1DM can affect children or adult. Brittle DM, also called unstable/labile diabetes was used in describing recurrent swing in glucose level. Irregular and unpredictable high blood sugar level accompanies T1DM usually with ketosis and sometime low blood sugar level. Complication of T1DM includes impair counter regulatory response to low blood sugar, infection, gastroparesis (which lead to erratic absorption of dietary carbohydrate) and endocrinopathy (e.g., Addison disease). This complication is believed to occur in 1% to 2% of person having T1DM (Standard of medical care in diabetes, 2010).
- T1DM is inherited with multiple gene it includes certain Human leukocyte antigens (HLA) genotype which is known to increase the risk of DM. Its incidence reflects modern lifestyle (Couper, Harrison, Penno, & Phillips, 2016). In genetically susceptible people, environmental factor, such as a viral infection can trigger the disease. (Knoch, Petzold, & Solimena, 2015). Several viruses can be involved but too date there is no rigid evidence to support the assumption (Butalia, Kaplan, Khokhar, & Rabi, 2016; Knoch, Petzold, & Solimena, 2015). The mechanism among dietary factors, such as gliadin have a role in the development (Camhi, Fasano, Serena, Sturgeon, & Yan, 2015).
- Type 2 DM results when the cells fail to respond to insulin and may combine with relatively reduce insulins resistance (WHO, 2014). A lack of insulin may develop as it progresses. Another name for this type is referred to as “non-insulin-dependent diabetes mellitus” (NIDDM) or “adult-onset diabetes”. Excess weight gain and lack of exercise is the primary cause. (WHO, 2014). Type2 DM is the commonest type and its cause unknown. In the earlier stage insulin sensitivity is reduced (Shoback, 2011). High blood sugar can reverse in this stage by variety of measure and medication which can improve insulin sensitivity or reduce livers production of glucose. Type2 DM primarily is due to lifestyle factor and hereditary.(Hu, Risérus, & Willett, 2009). Poor physical activity, diet, stress, urbanization, obesity which is a body mass index of 30 and above are lifestyle factor known to be a cause of type2 diabetes, (Williams, 2011 ). 30% case in Chinese and Japanese is due to excess body weight, about 60-80% case in Europe and African, Pima Indians/Pacific Islanders is about 100% (Shoback, 2011). An increased risk of T2DM is associated with excess consumption of sugar-sweetened drinks (Bray, Després, Hu, Malik, Popkin, & Willett, 2010). Saturated and Trans fatty acid increase occurrence of T2DM while mono/polyunsaturated fat decrease its occurrence. A lot of rice consumption may also increase its occurrence (Hu, Malik, Pan, & Sun, 2012). 7% of cases is due to lack of exercise (Blair, Katzmarzyk, Lee, Lobelo, Puska, & Shiroma, 2012 ).
- Gestational DM occur when a pregnant woman develops high blood-sugar level without previous history of DM (WHO, 2014). GDM is like type2 DM, it involves inadequate insulin secretion and its response. National Diabetes Statistics (2011), report that 2-10% of all pregnancies in gestational diabetic women improve or disappear after delivery.5-10% of women with GDM are found to have T2DM. GDM can be treated. Treatment includes adequate diet, medication, and regular monitoring of blood sugar. GDM may harm the mother or fetus. Risk that can affect the fetus includes abnormal large weight, nervous system abnormality, heart disease present at birth and skeletal muscles malformation. fetal surfactant production which can cause respiratory distress syndrome is due to elevated level of insulin in the blood. When the blood bilirubin level is high it results in hemolysis. Perinatal death may occur in severe cases and is due to poor placental perfusions. Induction of labor may be initiated due to decrease placenta function. Caesarean section may be done when the fetus is distressed or there is a risk of injury associated with having macrosomia is present. (National Diabetes Statistics, 2011).
CHAPTER THREE
METHODOLOGY
Introduction
The aspect of this research study covers research design, population, setting, instrumentation, sample and sampling technique, validity and reliability of instrument, data collection procedure, procedure for data analysis and ethical consideration.
Research Design
A quasi experimental design, a one group pre/post-test designwas used to conduct the study.
Population
The target population for the research study were individuals diagnosed of diabetes mellitus and attend the diabetic clinic of the medical outpatient unit of the hospital. From the records the average figure is one hundred.
Inclusion criteria
Individuals diagnosed of diabetes mellitus and have glucometer.
Exclusion criteria
Individuals not diagnosed of diabetes mellitus.
The study was conducted in General Hospital Odan, Lagos (GHL), which is the oldest and first general hospital in Nigeria. It was founded in the year 1893 and serves as a referral center for many hospitals in the Southwestern Nigeria. The services offered in the hospital include general outpatient, inpatient treatment, general medicine, surgery, ophthalmology, orthopedics, physiotherapy, pediatrics, emergency services, nursing Care, pharmacy, pathology, dental Care, physical medicine, medical rehabilitation center, accident and emergency center, renal replacement therapy, conventional and laparoscopic surgical services. Hospital serve as a training center for Doctors, Pharmacists, Nurses, Radiographers and Laboratory scientists across the country. The institution is equipped with new technological structures and experienced staff.
CHAPTER FOUR
DATA ANALYSIS, RESULTS AND DISCUSSION OF FINDINGS
Introduction
This chapter deals with analysis of data, results presentation and discussion of findings. The study was designed to evaluate effect of nurse-led training onself-management of diabetes among diabetic patients attending medical out-patient’s clinic in general hospital Lagos. Data were collected from patients using a developed questionnaire on knowledge regarding diabetes mellitus and self-management.One-group pre/post-test quasi experimental research design was adopted for the study. The pre-test was administered at the beginning of the experiment followed by the training and the post-test towards the end of the experiment to measure the effectiveness of the training. Participants in both pre/post-intervention were administered the intervention using power point lecture and discussion method with handouts made up of latest instructions and directions on self-management during the month of February, 2017.
CHAPTER FIVE
SUMMARY, CONCLUSION AND RECOMMENDATIONS
Summary
Literatures on self-management of diabetes support the use of training program in improving diabetic patient’s knowledge and practice regarding self-management of diabetes. (American Diabetes Association, 2014; Anderson & Funnell 2013; Berard, Cheng, Hanna, Hagerty, Knip &Miller, 2011; Besancon, 2011; Dartigues, Helmer, Goff, Pimouguent &Thiebaut, 2011; Deakin 2009; Douglas 2011; Haidet, Naik, Rodriguez & Teal 2011; Mahendrappa, 2011; Nurez, 2011).The effect of training on self-management of diabetes among diabetic patient’s attending medical out-patient’s clinic in general hospital Lagos was the focus of this study.
The dependent variables for this study were self-management of diabetes among diabetic patient’s while nurse-led training program was the independent variable. Two (2) research questions were answered and Two (2) research hypotheses were tested at 0.05 level of significance. The study adopted one-group pre/post-test quasi experimental research design. Sample size was determined using Leslie Kish formula for sample size determination and purposive sampling technique was adopted to select 20 patients from medical out-patient’s clinic of general hospital Lagos. The one week training program with a module of learning was designed and the module was administered to participants on each clinic day for one week within 1 hour through a lecture and discussion method. These training took place after data on patient’s knowledge and practice regarding self-management of diabetes had been collected through a questionnaire. The same questionnaire was used to collect data on patient’s knowledge and practice regarding self-management of diabetes two weeks after training program has been implemented.
Data collected were analysed using descriptive statistics of mean and standard deviation and inferential statistics of student t- test at 0.05 level of significance. Findings showed a statistically significant difference after intervention in knowledge and practice of patients in two hypotheses.
Therefore, finding revealed that nurse-led training program was effective in improving patient’s knowledge and practice regarding self-management of diabetes. Based on the finding, conclusion was drawn and recommendations were made.
Nursing Implication
- Primordial prevention is the earliest level of prevention that should start before birth. Therefore, greater attention to maternal care, including simple screening to detect GDM is critical as both low birth weight and high birth weight can predispose to higher diabetes rates in later life among offspring of GDM pregnancies.
- Pre-diabetic patients would benefit from primary prevention strategies, such as lifestyle intervention or the use of medication.
- Simple measures such as lifestyle changes, regular self-blood glucose monitoring, improved medication adherence, regular clinic attendance and follow-up are cost effective and in many countries, have led to improved health indices among the people having DM.
- Nurse should understand that group-based training for self-management strategies in people with T2DM is effective when fasting blood glucose level, glycosylated hemoglobin, diabetes knowledge, reduction of systolic blood pressure, body weight and requirement for diabetes medication are improved.
- Nurses should acknowledge that benefit of diabetes education for patients improve glycemic control as a consequence of understanding the disease, better patient motivation, adherence to treatment.
- Nurses should counsel against depression in diabetic patient for it may negatively affect how individuals take care of themselves such as reduce decision making ability, loss of interest and fatigue can contribute to poor self-management of DM.
- Nurses should encourage the use of standardized glucometers and test strips particularly for persons on insulin injection since provision of continuous blood glucose monitoring systems is expensive for our economy.
- Nurses should assess self-care deficits and intervene to promote self-care. Interventions include guiding, supporting, educating, doing for others, and providing a health promoting environment.
Conclusion
Based on the findings of this study, patients in general hospital Lagos did not have adequate knowledge regarding self-management of diabetes before training. Training program on self-management of diabetes improved patient’s knowledge and practice regarding self-management of diabetes. This study achieved a significant effect in post-intervention mean knowledge and practice score regarding self-management of diabetes. Hence, nurse-led training significantly improved patient’s knowledge and practice regarding self-management of diabetes.
Recommendations
- A well-organized and structured education/counseling programme should be established at General hospital Lagos for diabetic patients.
- Outreach programmes should be organized in schools, civil service centers and rural communities.
- Health care providers should take time to explain in depth on diabetes, causes and prevention/control through health and self-care measures to prevent complications.
- Family members of diabetic patients should also be counseled to adopt a healthy lifestyle in order to prevent diabetes.
- Programmes such as exercise and self-care monitoring should be organized to equip them to effectively monitor their blood glucose level as well as control their diet accordingly.
- Regular community screening can detect asymptomatic diabetes in large number of people therefore, hospital should conduct routine screening.
- A means of combating emerging trend of larger numbers of people afflicted with diabetes should be included in the national budget for health care.
- A well-funded communicable disease programs should combine with a less privileged non-communicable disease. In this way, several centers for treating HIV/AIDS will serve as centers for treating DM, hypertension and other disease conditions.
- Improving health indices in Nigeria, such as maternal and child health, literacy, health education, poverty, insurance coverage and health care funding can lead to earlier diabetes detection and reduced disease prevalence and burden.
- Collaboration is important between healthcare providers, policy makers, pharmaceutical industries and National agency food drug administration and control (NAFDAC) to ensure adequate regulation of importation, local manufacture and use of anti-diabetic medications in Nigeria.
Suggestion for Further Studies
- Long-term effects on progression of diabetes probably requires intensive and lengthy training efforts and effects on other outcomes such as lipids, weight and blood pressure measurement, indicate the need for more studies to establish knowledge.
- Similar context with wider scope and much larger sample size are recommended for further study.
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