Free Nursing Essays - Research Proposal On Perceived Competence And Actual Knowledge Of Diabetes Among District Nurses
In this proposal we shall consider the actual knowledge that community nurses have in the field of Diabetes Mellitus. We consider the rationale and also examine the logical links between the knowledge of the community nurses and the actual degree of morbidity in the community as a result of the burden of diabetes, together with the evidence that supports the logical links between the two. In doing so we shall also consider the various pronouncements of Government ministers and such bodies as NICE and recommendations of the National Service Framework
Diabetes Mellitus is a comparatively common condition. The British Diabetic Association tells us that it currently affects about 2% of the population in the UK but, there are certain groups - both ethnic and environmental - who suffer from it with a higher incidence than other groups. (UKPDSG 1995)
Diabetes Mellitus is also a major problem in terms of morbidity in the community. It has been estimated that there are currently 120 million diabetics in the world at present and somewhere in the region of 1.3 million are in the UK at the present. (Amos et al 1997)
Somewhere in the region of 9% of the total NHS budget is spent dealing either directly with diabetic control issues or with its complications. In terms of expenditure, the biggest diabetic complication is the diabetic foot ulcer which, in the context of our consideration here, is very relevant, as its care tends to fall mainly to the nurses in the community and this alone accounts for the biggest single section of financial expenditure on diabetic complications (Newrick 2000). Despite this consideration, we should not think only of Diabetes Mellitus in terms of financial costs. The social costs and the cost to the quality of life of the affected patient can be incalculable. (Carter 1996)
This article is primarily concerned with the knowledge that the community nurse has about Diabetes Mellitus. This begs the questions - why is it important:
a) that they have the knowledge in any event, and
b) that we should wish to know just what there knowledge level is anyway? (Christov et al 1995)
One could argue that we all know that a nurse, at any level, has to have a certain core base of knowledge simply to become qualified. This core base is expanded by both experience and professional development as they progress through their career. As in any profession, nurses will accumulate specialist knowledge in different areas as they become exposed to it. So why then is it important to know what the typical level of knowledge is in the body of community nurses with specific regard to Diabetes Mellitus?
This question can be answered in many ways. The National Service Framework for Diabetes Mellitus (Department of Health 2001) has specified a number of goals and targets to be achieved nationally. It required minimum standards to be achieved. The implication of this is that, in order for these standards to be achieved, it will require a basic standard of knowledge to be demonstrated by the various healthcare professionals involved. Studies that have already been done on the basic level of knowledge relating to Diabetes Mellitus in various subsections of the various healthcare professions have shown a serious short fall. (Dolan et al. 1984) This clearly needs to be addressed before we can feel confident in moving forward to improve the basic standard of care for the diabetic patient.
The second element in our considerations must be that a substantial proportion of the care of the diabetic patient is carried out by the primary healthcare team and arguably by the nurses in the community in particular. Given the fact that empowerment and education is one of the targets of the National Service Framework for diabetes, it follows that in order to both empower and educate the patient, those healthcare professionals who have contact with them, must have a sufficiently comprehensive knowledge base to be able to impart the relevant details to the patient. Without a tool such as an audit or direct intervention by some other means (such as the DBKT), it is not possible to know what the level of knowledge, and therefore perhaps competence, in the healthcare professional community base actually is. (El-Deirawi et al 2001)
Thirdly, there is a large body of evidence which tells us that the long term outcome of the diabetic state is determined by a number of factors. Perhaps the strongest determinant statistically is the degree of overall diabetic control and achievement of near-normal glucose levels. (Hughes 2002)
This is a matter of considerable skill and judgement and is generally arrived at by a consensus of advice and interaction from a multitude of various healthcare professionals and the patient based on the experience of all parties involved. Although the patient will obviously have potentially a great deal of advice and expertise to call on in order to try to achieve this optimum level in the shape of the primary healthcare team, and the hospital based specialist teams, it is very often the community nurses who are the day to day contacts with many of the diabetic patients in the community. It follows directly from this argument that a substantial responsibility for the long term level of morbidity in the population as a whole therefore falls on the healthcare professionals most closely involved in the fine management of the diabetic state - the community nurses. Wincour (et al 2002)
We know and appreciate that many nurses in the community will have had specialist training and knowledge. Many will have been on specialist training courses that have been set up in response to the delivery strategy for the National Service Frameworks (2003) and some may well have spent time gaining their knowledge working in specialist hospital based clinics. Many community nurses will however, still consider themselves generalists.
This essay does not seek to imply that there is anything wrong or detrimental about this, but the fact is that such generalists would probably not be expected to have the same degree of specialist knowledge that a specialist diabetic nurse would probably have. It seems therefore to be a reasonable conclusion to draw, that patients who were advised by community nurses who had less expert knowledge levels, would possibly not receive the best advice in any given diabetic-related situation. This may well be reflected in their degree of diabetic control which, in turn influences their likelihood of developing complications in the long term. There is therefore a clearly demonstrated logical link between the actual diabetic knowledge base of the nurses in the community and the overall levels of morbidity in the community.
We will examine each of these three precepts in turn.
What are the standards required by the National Service Framework?
In this context the National Service Framework is a large and unwieldy document which covers the whole spectrum of issues relating to diabetic care. In this article, we are specifically concerned with the framework in so far as it relates to Diabetes Mellitus in the community.
The whole issue of modern diabetic care in the community is encapsulated in a statement made by Aidan Halligan and Liam Donalson on both the intentions and the mechanisms for implementing clinical governance (2001). It was written as an article which was published in the BMJ and is a comprehensive round-up of the Government's plans for governance - setting out the need for evidence-based medicine (and in the context of this article, the need for evidence-based decisions), and the need for, and proposed role of both NICE (the National Institute for Clinical Excellence),and the National Service Frameworks.
The reason that we are setting out this background is because it is only by the collection of firm evidence, that solid, evidence-based decisions can actually be made. It is of no value at all (as any opposition MP will tell you) for the Government to set out it's intentions and strategies, if the assumptions and precepts that it is based on are not firmly based in fact. There is no merit at all in any body pontificating about the provision of diabetic services, if this provision is expected to be delivered by community nurses with a poor knowledge of the subject that they are supposed to be delivering.
In parallel to the National Service Frameworks, NICE has published national guidelines for information.(2000) In the section Key elements of the NHS strategy they quote (in addition to other items) Patient empowerment and education and better information for patients. Again this underpins the central argument here. Patient empowerment and education is dependent on them getting solid and accurate information from their professional advisors. If we accept that the nurses in the community is one of the prime contacts for the diabetic patient, then again this underlines the importance of the knowledge base of the community nurse.
The need for change is perhaps the most important guiding principal in the whole National Service Framework document. This came about after the Government had undertaken a massive fact finding exercise to establish the state of affairs with regard to the provision of many of the major aspects of Health Care. The DBKT was developed, in part, as a tool to help in this analysis. (BDA 1996)
The object of the exercise was to specifically target areas where provision was found to be deficient together with the setting of certain targets for achievement in areas where the provision was more than adequate. The major sections of the National Service Framework that are relevant to our considerations here are :
The NHS will develop, implement and monitor agreed protocols and systems of care to ensure that all people who develop long-term complications of diabetes receive timely, appropriate and effective investigation and treatment to reduce their risk of disability and premature death.
All people with diabetes requiring multi-agency support will receive integrated health and social care.
Generally speaking, there was agreement that the provision of care across the NHS as a whole was far from consistent. Some areas provided excellent care and others frankly, did not. (Croxson 2002)
The National Service Framework initiative aims to promote a more consistent level of care by publishing guidelines, standards and targets. Standard 11 and 12 are obviously general in their content but clearly they represent a basic minimum standard that must be achieved. Standard 10 suggests that all diabetic patients will receive specific and regular follow up for the possible complications of Diabetes Mellitus.
In addition to the Standards, the National Service Framework also defines intervention for the diabetic patient. It is not appropriate, in the context of this essay, to mention all of the interventions here, but the Framework specifically calls for regular surveillance of patients with Diabetes Mellitus to detect the commonly occurring complications, such as erectile dysfunction, depression and cardiovascular disease so that they may be offered the appropriate treatment in a timely fashion. It particularly calls for healthcare professional to ensure that people with Diabetes Mellitus can feel free to discuss problems with their sex lives such as impotence.
The relevance of this to our study is therefore clear. These targets and goals cannot be met if the people on the ground are not sufficiently knowledgeable in the subject to either meet or deliver the targets
As any healthcare professional who has worked in the community for any significant length of time will attest, pontification of medical dogma without being backed up by both knowledge and adequate reasoning is actually quite counter-productive. The community nurses who does not have a good and thorough understanding of the principles of diabetic management is unlikely to be able to successfully engage the typical diabetic patient (Peile 2004)
With this in mind we should also consider the provisions of Standard 3 of the National Service Framework which states:
All children, young people and adults with diabetes will receive a service which encourages partnership in decision-making, supports them in managing their diabetes and helps them to adopt and maintain a healthy lifestyle. This will be reflected in an agreed and shared care plan in an appropriate format and language. Where appropriate, parents and carers should be fully engaged in this process.
It clearly follows from this that community nurses with a less than optimum grasp of the principles of Diabetes Mellitus management, will not be able to fulfil either the spirit or the letter of the Standard.
In the interests of providing a balanced view of this issue we should consider the paper by Checkland (2004) who argues the very point that we are investigating. He suggests it is because the healthcare professionals in contact with the patients do not have a particularly good knowledge of the subject that the National Service Frameworks are currently failing. His arguments are based on the premise that the reason that they are not delivering their goals is because they are incorrectly structured. He rather dismissively describes then as well-established sociological perspectives of deprofessionalisation and proletarianisation, and points to the success of the more clinically based models such as those guidelines proposed by the British Hypertensive Society in the detection, assessment and control of hypertension in the UK over the last decade with their emphasis on education of the healthcare professional to achieve good clinical results
What are the reasons for needing to measure the degree of knowledge in the nurses in the community?
To some extent we have answered this particular question in the context of the arguments put forward in the previous discussion. We suggest that it only by assessing the status and standard of knowledge of the nurses in the community that we can make a judgement on the likely standard of care that is being provided for the typical diabetic patient. In this context, the paper by Huang and Goran (2003) is helpful as it sets out the structure of the current (2003) services. Basically it looks at the issues under four headings, the first examining the epidemiological and physiological evidence, the second is an examination of the behavioural issues in relation to the Type II diabetic . This is then expanded in a third section which looks at the existing interventions available to the population and itthen concludes with a section on sustainability of services and risk definition. It is the last two sections that are of interest to us in this article. It defines the provision of diabetic services in terms of the abilities of the healthcare professionals to actually provide them. The implication being that if the healthcare professionals are not well informed then the provision will suffer as a result.
Thus far we have examined the problems relating to the uncertainty of the knowledge base in the community nurses in relation to the benefit of the patients in general. We should not leave the subject without considering the overall benefits of increasing the community nurse's knowledge base to the whole of the primary healthcare team. The Clinical Governance Support team produced a fact sheet in 2004 in which it advocated the creation of diabetic nurse specialists. As part of the rationale for this it suggested that the benefits would be that an increased knowledge would lead to :
a) increased job satisfaction and greater responsibility
b) reduced demand on other members of the primary healthcare team
c) reducing wasted time for community nurses waiting for prescriptions to be signed
d) reduce waiting time for patient wanting a prescription.
The benefits are clear to see - but this is still based on the premise that they already know just what the base knowledge of the community nurses is. This goes back to our original point about not being able to make evidence-based decisions if the evidence is not available.
What is the evidence to link this level of knowledge to better control of Diabetes Mellitus and therefore to a reduction in morbidity in any event?
This is probably the most fundamental of all of the questions posed and answered by this piece. To a large extent it would be a pointless exercise measuring the depth of the knowledge of diabetes of the community nurses if, in the last analysis, it made no real clinical difference. In the interests of evidence-based medicine, we should therefore look at what evidence there might be to suggest that improved knowledge leads to improved diabetic control and thereby reducing overall morbidity.
Firstly, to the best of our knowledge it is not possible to prevent the impending onset of Type I diabetes mellitus. Type II diabetes is different and there are a number of different measures that can be taken to try to minimise the likelihood of either progression or development of the full blown disease process (UKPDS 33: 1998). It follows therefore that a community nurse with the appropriate knowledge could help to empower and educate a patient who was at risk of developing Type II diabetes mellitus to reduce their chances of getting the disease in the first place.
We also know that there is an increased mortality rate which is associated with Diabetes Mellitus currently quoted at about 5.4% (which is twice the normal population rate). We also know that the life expectancy of the typical diabetic patient is reduced by between 5-10 yrs. which is primarily due to the cardiovascular complications. (Donnelly et al.2000). Another piece of the jigsaw comes from Stratton (et al 2000) who states that the better the control of the diabetic state, the fewer the long term complications.
More evidence comes from UKPDS (13: 1995) which tells us that early detection of Diabetes Mellitus is important in order to bring the situation under control quickly before the condition announces itself with the development of complications as presenting symptoms. This, effectively is the argument for routine screening of the at risk group of patients. Again this implies that the community nurses has the knowledge to know which groups are actually at risk in the first place.
We do know that the majority of the major diabetic complications are largely irreversible once developed. Cardiovascular disease and neuropathy can be arrested or slowed by good control but the pathological processes cannot be undone once they have occurred. (Adler et al. 2000)
The district nurse and the specialist community diabetic nurse
In the context of this project we have examined the importance of the knowledge base of the district nurse. Since the publication and general adoption of the National Service Frameworks, the emergence of the specialist community diabetic nurse has been seen as a major point of contact between the patient and the diabetic specialist healthcare professionals. In this article we have mentioned several times the importance of the empowerment and education of patients.
To a large extent, the National Service Frameworks call upon the specialist community diabetic nurse to be the main link in the chain to maintain the good professional links with the rest of the diabetic carers. The National Service Framework describes the role pictorially as the hub from which the links to all of the other diabetic resources are accessed. It follows that this scheme will only work effectively if the community nurse has the basic knowledge to be optimally effective. This has been examined by Wincour (et al 2002) with a major survey of the diabetic provision in the primary healthcare teams.
We will not discuss the paper in detail, as much of it is only of peripheral relevance to our considerations here. One element of the paper which is extremely relevant however, is the observation that underpins most of the arguments that we have advanced thus far and that is the observation that 96% of the patients that were surveyed stated that the community nurses were the main point of contact and resource for their education and information about Diabetes Mellitus. As if to prove our point for us, Wincour stated that in his survey 20% of the specialist community diabetic nurses stated that they had not undertaken any specialist training for their role. In other words they were community nurses who had simply put on another hat. The paper remarks in its conclusion section, that there were many fewer specialist staff (at nursing level) currently employed than the National Strategy Documents cited above and that there was a marked variation in the calibre and the training available throughout the country.
What is currently known about the level of specialist knowledge in the community nurse discipline.
Despite an extensive Literature Search we could find very little firm evidence of documented levels of diabetic knowledge in District Nurses. There are excellent papers that look at the knowledge levels in other branches of the service such as Thomas (2004) and Findlow (2002) who make excellent assessments of paediatric and general hospital based nurse's levels of knowledge of diabetes but neither are directly referable to the community nurses. Interestingly, they did find that nurses tended to have a better and more comprehensive understanding of Type I diabetes mellitus than they did of Type II diabetes they also found that the nurses studied were more knowledgeable on theoretical matters than they were in practical issues - which may well be a reflection of their experience levels and their teaching. (Fealey, 1997)
Interestingly, and with a possible significance to our considerations here, the Findlow paper actually tried to make an assessment of the relevance of the nursing grades to the knowledge base (as assessed by DBKT). When the sample was analysed by grade into D/E grade group and a F/G grade group they found very little difference in either their percieved or actual knowledge in the area of diabetic care.
The paper by McDonald (et al 1999) was a good attempt to define the topic. It mailed 200 community nurses at random, but disappointingly only got a 60% response rate. The paper is very detailed but the relevant passage from our point of view states that:
These nurses also perceived that they, as nurses, needed more education to improve their care of diabetes patients; few nurses believed it was within the scope of their practice to change treatment regimens. The perception of most nurse respondents was that acceptance of diabetes, knowledge deficits and non-compliance were primary patient problems in the management of diabetes. Nurses' perceptions of solutions to the problems centred on education of nurses and patients, and reinforcement of the importance of follow-up care.
Adams and Cook (1994) used the DBKT test to define the use of a specific Diabetic Educator who went round various primary healthcare teams to educate the nurses. In essence, they found that the Educator improved the scoring on the DBKT by an average of 20% which is quite substantial.
Drass (et al 1989) looked more specifically at the issue in a provocatively entitled paper Perceived and actual level of knowledge of diabetes mellitus among nurses.
The significance of this paper was that the authors asked the community nurses to initially indicate what they felt was their actual level of knowledge relating to Diabetes Mellitus and then administered the DBKT to see what the actual demonstrable level was. Rather soberingly, they found that the average perception of knowledge was 25% higher than the average actual knowledge. Which ultimately is the rationale for this article
In this article we have been critically considering the evidence for the value of an assessment of the actual knowledge of the community nurse's knowledge of Diabetes Mellitus.
We have considered the guidance and advisory frameworks that have been published and established in the recent past together with the pronouncements of Government spokesmen and officials and the extent to which they have been responsible for a reshaping of the service
In essence, we have established that Diabetes Mellitus is a comparatively common condition that has a significant morbidity and that this morbidity is directly related to the degree of control of the diabetic state. We have also established a link between patient empowerment and education and the degree of diabetic control, and that, in turn, patient empowerment and education is a function of the knowledge base of the prime point of contact that 96% of patients have with the primary healthcare team - the community nurse. By a totally logical progression we can suggest that there is therefore a direct link between diabetic patient well-being and the knowledge levels of the community nurses. This is therefore the rationale for our attempts to assess this knowledge base in our investigation.
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