Introduction
Diabetes mellitus is a serious metabolic disorder, with a complex of symptoms, such as hyperglycemia, as a result of dysfunction in producing of the insulin, its synthesis or secretion. (Stöppler, 2014). This disease may lead to serious complications. The major risk factors that raise the prevalence of diabetes are hypertension, obesity, pressed immune resistance to the infectious illnesses and even cancer. (Bilous, 2002.) Patients with diabetes are more probable to develop neuropathic vascular diseases (National Diabetes Education Program NDEP 2000). Self-management and educational programs for this group of people can greatly increase their level of life. (Department of Health, 2005). According to National Diabetic Report (2014) diabetes can be cured and managed by the healthy diet and appropriate medications to reduce blood glucose levels.
The objective of this paper is to evaluate the importance and effectiveness of the health care education in patients with diabetes (NICE, 2004), as well as critically appraise the result of the evidence based practice ( Appendix 1). Assessment of the clinical practice is done to identify the benefit of patient’s education in the current clinical service with the use of the mini clinical audit managed in the health center. The model for clinical education in diabetes is defined by the NICE Health Technology Appraisal on patient-education as “a planned and graded programme that is comprehensive in scope, flexible in content, responsive to an individual’s clinical and psychological needs, and adaptable to his or her educational and cultural background.” The appraisal needs to be carried out to assess the existing conditions and establish suitable and effective management plan (International Diabetes Federation 2011a). Guidance for the appropriate exercise instruction can result in the successful treatment of the chronic disabilities and diseases as well as can have positive influence in the functional capability and slow or prevent exercise intolerance. (ACSM's Exercise Management, 2009)
Audit
In many cases there is opportunity to control and manage diabetes mellitus by the healthy diet, normal weight and physical exercises and regular checkups in the medical health care centers. Sometimes it is also essential to take medications, but the patient should strictly follow the prescriptions of the nurse practitioner or doctor. [Cleveland Clinic, n. d.). The research and professional development organization (2012) defined the clinical audit as: "A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change." Clinical audit s an evaluation of the service, in order to find out if the it is being implemented according to the federal standards and lets care providers and patients aware where their work is doing well, and where there could be enhancements. The purpose of it is to allow quality perfection to take place where it will be most effective and will improve outcomes for service users (NHS England, 2014) and to find out the adherence of clinical staff to the current healthcare protocols. Clinical audit resulted in the moderate improvements in the care from both the health professionals’ and patients perspectives. (Achille Kabore, 2009)
The theme selected in this mini audit is clinical education evaluation since it has a strong influence and impact on all types of diabetes. As mentioned previously, patient’s recovery from diabetes depends on the acknowledgement of the right lifestyle, healthy behavior and correct diet. This dramatic illness needs the methods of prevention of the complications more and more urgent and an exciting topic to review and audit. This mini audit was conducted in order to ensure that all health professionals in the health centre are following the latest guidelines to improve the healthcare service and make the life of the patient more productive. An audit tool was made and revised with the mentor and the assesor and it was conducted under the supervision of the mentor and permission was obtained from the health institution in charge. The permission for the audit and review was obtained from the health centre authority. The aim and objective of conducting this mini audit were clarified to the nurses. Patient’s files an direct observation were used to obtain the data for analyzing. The purpose of the first method of the direct observation was to verify that patients physically existed in the clinic and were not defaulting. The selected group or sample consists of 15 patients. 9 of them have the course of health education , 6 refused or left the clinic. (Appendix 1). The audit focused only on whether the education was done or not.
Results (Appendix 2)
There were 15 diabetic patients that were audited; out of those 15 patients 60% had gone through clinical education, whereas, 40% did not. According to the nurse and the doctor, the reasons for not performing the clinical education for some patients was that, some of them usually come refused to visit the course, or left the clinic. The results showed that healthcare education was carried out on most of the patients who were in healthcare center for the treatment or on the urgent complaints, regular visits and, similarly, the annual visits. Although the results did not meet the standards that were set, it is important to mention that most of the patients (60%) who underwent healthcare education were those who came for either initial examination, regular follow up or annual follow up. Besides, from the observation, it is perceived that other areas in the assessment should be audited in the future, such as the assessment technique performed and who should perform the assessment.
Discussion
The healthcare education is one of the perfect methods of providing treatment. The large health and financial impact of diabetes and the existing gaps in achievement of treatment and prevention goals prompted the National Diabetes Education Program (NDEP) to work with key partner organizations to develop the Guiding Principles.(2014) Education play a significant role in prevention of the complications.(NICE, 2004)
American Diabetes Association said: “The National Standards for Diabetes Self-Management Education are designed to define quality Diabetes self-management education and support and to assist diabetes educators in providing evidence-based education and self-management support. The Standards are applicable to educators in solo practice as well as those in large multicenter programs—and everyone in between.” (2012) It is essential to provide appropriate education for controlling blood sugar level, because it is the main method of investigation in diabetes. (Weisenberger J., 2014.) Worldwide the indication for the HbA1c test for the last three decades has been to measure the level of glycaemic control for patients with diabetes as a follow-up strategy in newly diagnosed diabetes and in long-term conditions. This approach is used to determine the effectiveness of treatment plans for the health care provider and patients.(Christopher D. Peyrot M.,Rubin R., 1989). Systematic self-management education effectively encourages patients with type 2 diabetes to control their blood sugar levels, and deserves further promotion.(Chen H., , Liu Z., Li X., Zhou Q., Zou F., Wu L., 2009) The health care authorities and policy makers, highlighted that nowadays treatment focuses on the interventions, that are done for reasonable cost. One of the method of control is glycemic control that makes the cost-effective strategy. (CDC Diabetes Cost-Effectiveness Group, 2002.) Self-management lessons are also included in the program of the health care education, they inspire patients with chronic diseases to self manage. (Cantor R., Goetzel R., Harrison M., Ozminkowski R., Shaughnessy A., Smith M., 2000.) The change of the lifestyle is crucial to positive results in self-management. Diabetes educators are professionals at fostering effective behavior change in patients with diabetes. The CMS and many other payers reimburse for diabetes self-management education/training, implicitly recognizing the importance and value of the intervention. (Department of Health and Human Services, Health Care Financing Administration. 2000.) The purpose of diabetes education is to achieve optimal state of the health and improve the quality of everyday life and also lower the need for costly health care. One of the aims of this study is to increase understanding of the economic value of diabetes education. (Boren A., Fitzner, Karen A., Pallavi S., Specker E., Panhalka, 2009.) Most professional diabetes educators are members of the American Association of Diabetes Educators. Some diabetes educators are certified diabetes educators (CDEs) or Board Certified Advanced Diabetes Managers, having met certain eligibility and exam requirements. The American Association of Diabetes Educators advocates diabetes education that is provided by a diabetes educator and focuses on 7 self-care behaviors (Boren A., Fitzner, Karen A., Pallavi S., Specker E., Panhalka, 2009).
Nursing Role
Nurses play a vital and significant role in diabetes service and enhancing outcomes for patients with diabetes. Health education is not the main, but also very important goal of the nurse care. Many clinical and observational trial researches have proved that nurses are capable of providing effective quality of care for patients with diabetes at all levels of health service and show a successful role in diabetes management and care education (Peimani et al. 2010). Training nurses under the supervision and guidance of a diabetologist has been shown to noticeably perfect patients’ outcomes (Davidson et al. 2003). They have skills to explain to the patients how to practice health behavior every day and achieve visual result in the long-term.(American Association of Diabetes Educators, 2014) Partnership and collaboration is the foundation of therapeutic relationships between patients and nurses. Hence, nurses should adopt patient-centered care in the management of diabetes by considering patient care preferences, and patient decisions need to be respected and taken into account during setting of the management strategy. Patient awareness about their proper lifestyle has shown great effectiveness in their diabetes control because good awareness leads to more understanding of the disease mechanisms and care required, increase patients’ self-confidence and motivates them to manage their disease (Prato et al. 2005). Nurses involved in diabetic care need to have specific qualities that qualify them as effective members of the diabetes management team. Those qualities are good interpersonal and communication skills, ability to educate and enhance learning for others, sensitivity to patients’ needs and ability to prioritise them, and ability to facilitate, direct and negotiate with patients and their families toward their care preferences (Royal College of Nursing 2006). The nursing role in diabetes management has become advanced and expanded. It includes coordination of care for patients and directing them to the proper and available services and resources, as well as ensuring and monitoring glycaemic control with the patient, ensuring regular follow-up and monitoring progress, and education and counselling. In advanced specialties, nurses engage in diagnosis, treatment establishment and decisions for referral to other health care providers (Royal College of Nursing 2006). The community nurse role is a continuation of nursing in the health centre. Moreover, maintaining well-controlled diabetes requires a multidisciplinary team based on collaboration from various specialties involving a physician, endocrinologist, nurses, nutritionist, psychologist, podiatrist and other health care professionals (Peimani et al. 2010). Teamwork and coordination is the cornerstone of the multidisciplinary team and could lead to early detection of risk. Achieving ultimate outcomes in diabetes care is a result of good communication between the team members and patient as well (Royal Australian College of General Practitioners 2012). Patients are central members of the team in managing diabetes and a partnership should be established with the health care provider in order to have a good understanding of patients’ needs and set an agreed treatment strategy (Royal Australian College of General Practitioners 2012).
Conclusion
In this paper a critical review for the current performance of assessment has been discussed in an evidence based practice manner and some weak areas in the service have been recognized through a mini audit that was conducted in one of the primary health institutions. The evaluation of the quality of the healthcare service was done by the clinical audit. Also some weak points were discovered, some proactive measures may be taken to reduce the risk of complications and to achieve effective patients outcomes. The involvement of nurses and practitioners should be deepest and their relationship with patient will show positive result. For the future improvement in the services, it is recommended to develop a set of diabetic education guidelines in an evidence-based manner and to utilize the risk classification categories in the referral and management pathway. In addition, a guideline should be developed for people with diabetes who are coming only for collecting medicine or for other blood investigations since it is considered as a visit in the clinic. Some other areas need to be audited in the future, such as the comprehensive partnership that will include the auditing of people who are performing the practice and whether they are trained or not, the tools used and whether they meet the updated guidelines and evidences or not and the referral and management pathway used to establish if it is effective or not. It has also been recognized that the shortage of trained staff in foot examination has a negative impact on the examination results, as well as increasing the incidence of risks, as the health provider is not familiar with the diabetic foot complications and problems. The referral and frequency pathway should be established based on evidence-based guidelines, which each health organization should have (NICE 2004). Community nurses are part of this team and play an effective role in empowering people with diabetes to participate in the prevention and providing health education (Fitzgerald and Rayan 2009). The main purpose of clinical education was proclaimed by AADE (2014): “Diabetes education helps individuals with diabetes learn how to manage their disease and be as healthy as possible. It focuses on seven self-care behaviors that are important to focus on to be healthy and fully enjoy life: healthy eating, being active, monitoring, taking medication, problem solving, healthy coping.” To provide successful partnership between patients and nurses, the healthcare workers should get fully involved in their mission of bringing health to the patients. The diabetes educators explain how to prevent increasing the blood level of glucose by eating healthy diet, as well as offer guidance how to avoid the risk of the diabetes complications. They also can give advice on everything from how to spend time doing physical exercise to the creating self-management plan. With the collaboration of health care providers, public education and utilization of the best available resources, this crisis will be avoided and managed, and people’s lives will be saved.
Appendix 1
Audit tool
Appendix 2
Results of the audit
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