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Understanding and Managing Type 2 Diabetes Mellitus

Jul 11, 2023 | 0 comments

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Jul 11, 2023 | Essays | 0 comments

Abstract

The dissertation discussed the role of nurses in managing patients suffering from type 2 diabetes mellitus. In discussing the roles of the nurses, the dissertation critically analyzed several articles. From the articles reviewed, the dissertation summarized them in four themes which include; nursing consultancy and education, empowering patients to take care of themselves, clinical care, and updating their knowledge base to be up-to-date with the current research-based evidence and practices. The dissertation first discussed the method the dissertation employed in the literature search. Some of the highlighted methods in literature search include the use of search engines, libraries, and online databases to get relevant articles. Moreover, to get more focused items, short focused phrases were used to reduce the number of HITS. In the themes, the dissertation discussed each theme independently using relevant articles to validate the arguments. The dissertation then discussed the recommendations for nursing practices from the dissertation discussions. Some of the practice recommendations include; clinical recommendations, also recommendations for treatment to delay or prevent progression from pre-diabetes to diabetes, and education and self-management recommendations which included nutrition, physical activity, and weight management. The dissertation then summarized the paper in a conclusion where findings from the discussion were highlighted in summary.

 

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1.0 Introduction

According to Great Britain (2011), approximately 3 million people in the United Kingdom are diagnosed with diabetes mellitus type 2 yearly in addition to 850,000 people who are ailing from the condition and are not aware. Mohan & Unnikrishnan (2014) defined diabetes as a long-term condition or illness caused by increased glucose levels in the bloodstream. The levels of glucose increase in blood could either be due to insufficient production of insulin by the pancreas or the pancreas not producing the amount of insulin that is sufficient (Gloyn & McCarthy 2014). The hormone produced by the pancreas to control the levels of glucose in the bloodstream is insulin. Insulin helps in taking up of glucose in the bloodstream by the cells to produce energy (Mohan & Unnikrishnan 2014).

Pereira (2014) indicated that there is two types of diabetes conditions; diabetes type 1 which is a type of diabetes where the body of the patient is incapable of producing the needed insulin to regulate blood sugar levels and therefore requires the usage of artificial injections of insulin. The second one is diabetes type 2 where the body produces insulin but in insufficient amount and therefore requires regulation of body sugar levels through medication, exercise, and diet (Obrosova et al 2014). Obrosova et al (2014) further elaborated that diabetes type 2 begins with insulin resistance where the body cells do not react to insulin in the manner they are supposed to react. In normal cell and insulin reaction, insulin binds to the cell receptors hence activating glucose transporter molecules of the cells to form a doorway on the cell membrane that permits entry of glucose to the cell. However, when resistance to the insulin occurs, there is a reduced response to the signals of insulin hence less formation of doorways. This results in locking out of some glucose out of the cells

The dissertation developed an interest in diabetes and narrowed down its focus to diabetes type 2 because of the alarming statistics in the United Kingdom. Statistics indicate that amongst the people who are ailing from diabetes, approximately 90% of the cases are affected by type 2 diabetes in the United Kingdom (Diabetes UK 2013). Even though the condition is more prevalent among the people aged above 45 years, Vincent & University of Waterloo (2014) pointed out that diabetes type 2 Mellitus cuts across all ages, and there are even increasing recorded cases of children, teenagers, young adults, and, the aged suffering from diabetes type 2. Another factor that was of interest to the dissertation and the reason for choosing it was because of NHS estimation that by 2035 in the United Kingdom, the approximate cost per year for diabetes will be £17 billion (Lerma & In Batuman 2014). Therefore, there is much need for public awareness of the looming menace. The main focus of the dissertation was on the role of nurses in managing patients suffering from type 2 diabetes mellitus. The dissertation believes that nurses have many significant roles they can play in the management of type diabetes mellitus. To highlight some of the roles the nurses can play in the management of patients with diabetes type 2 Mellitus include; creating public awareness of the health risks associated with the disease, providing the patients or their clients with the information that are relevant to the management of their diabetic condition (Chopra & Kapoor 2014). This is also referred to as educating the patients to live healthy lifestyles and also to check on their diets (Bergman 2014). Similarly, the nurses have a role of updating their knowledge base to be up to date with the current practices and evidence in the management of diabetes type 2 Mellitus. Goedecke & Ojuka (2014) noted that a nurse practitioner who has sufficient knowledge about the disease is the one who also has the capability of educating their clients, and eventually lead to public awareness.

The dissertation will first discuss the literature search and the search strategy applied by the dissertation to get relevant information and articles. Next will be the background of diabetes type 2 Mellitus where it will provide background information, signs and symptoms, complications, causes, health risk factors, and diagnosis. After the background, the dissertation will then discuss the main themes from the several articles analyzed related to the role of nurses in managing patients suffering from type 2 diabetes mellitus. Some of the major themes identified in the dissertation include nursing consultancy and education from the nurses to the diabetes type 2 Mellitus patients, empowering patients to take care of themselves, clinical care by the nurses, and updating their knowledge base to be up to date with the current research-based evidence and practices. The dissertation will be looking at all aspects of the role of nurses in managing patients suffering from type 2 diabetes mellitus. After discussing the themes, the dissertation will then provide recommendations for practice before concluding the dissertation.

2.0 Literature search

According to Kulinskaya et al (2008), an all-inclusive search strategy development requires the expertise or assistance of a librarian is needed if the investigator is not skilled enough in literature searches. According to Rosenthal (2011), several decisions must be made when adopting the search strategy. First of all, the researchers’ must decide on the databases that would be searched, and the detail level in the search strategy.

Kulinskaya et al (2008) pointed out that during the process of search, a large number of the possible studies will be produced, many of which should be excluded from the basis of their abstract or titles. However, a more detailed analysis of individual studies is needed for the studies that are passing the first screening. This dissertation employed different search strategies to get literature and information. First and foremost, the university library and online websites and libraries were used. Secondly, different search engines such as Google were used in searching relevant information on the internet on different websites for an online journal to access the relevant ones. To get exact and the relevant article or any online article or journal needed, different databases that had possibilities of obtaining the exact articles or the related articles were searched. The online database for the university was very much helpful when searching different articles since it was easy to access and free, unlike most online websites which are for commercial purposes and needed subscription which the dissertation did not want to subscribe to.

To begin the search, the researcher started the search with the most comprehensive database that is Cumulative Index to Nursing and Allied Health (NINAH) (Kennedy 2009). The search then continued to search engines such as the British Nursing Index, MEDLINE. Moreover, PubMed and NCBI were other major search engines that assisted some of the relevant articles for the dissertation. These search engines were used because they contained most of the peer review articles and books. To limit and narrow down the search for articles, internal searches of the databases were used by inserting the full length of texts and searching the relevant articles from the list of journals displayed. According to Nes et al (2012), to narrow down the search, limits were used in the databases. To avoid “full text” limitation, one or two limits were used at a time, as there were chances of missing important articles. To narrow down the search for “the role of nurses in managing patients suffering from type 2 diabetes mellitus,” the researcher used research articles after the year 2000 in reader to find up to date research and to avoid outdated research articles. This brought about 371 hits from 1278, which was a fair number, not too broad and not too narrow. I did also similar searches on topics such as “causes of diabetes mellitus type 2” “health risk factors for diabetes type 2,” “symptoms and diagnosis of diabetes type 2,” “role of nurses,” “role of nurses in type 2 diabetes patients.” Williamson, Bellman & Webster (2012) stated that it is important to use the exact specific words in search engines to get related articles. All relevant databases were searched and scrutinized all the terms used in the search for alternative spellings or terms. Furthermore, an assessment of the search strategy used was done to ensure that some relevant studies that could be a great source of information were not left out by being too specific. In data extraction, the factors considered include the following; study design, performing year, publication years, characteristics of the population of study for instance sex and age; the geographical setting, variance, and risk estimates, and assessment procedures. The dissertation used different sources in the search strategy which include electronic databases, conference abstracts, hand searching, and the internet.

3.0 Background

3.1 Diabetes type 2 Mellitus

According to Ford-Martin & Baker (2013), diabetes type 2 Mellitus is a heterogeneous syndrome that is characterized by fat and carbohydrate metabolism abnormalities. Type 2 diabetes mellitus’ causes are multi-factorial and include both environmental and genetic elements affecting beta-cell function and insulin sensitivity of the tissues (pancreas, adipose tissue, liver, and muscles). although there is a great debate on the contribution of dysfunction of beta cells and reduced sensitivity of insulin to the pathogenesis of diabetes, it is agreed generally that both of these factors play significant roles. However, it is unclear the mechanisms that control the interplay of the two impairments.

Pereira (2013) stated that in diabetes type 2, the body either produces insulin in inadequate amounts to meet the body demands or the body has developed insulin resistance. Insulin resistance is when the body cells such as the fat, liver, and muscle cells fail to respond to insulin even if the levels are very high (Gadsby 2012). Instead, in the fat cells, the triglycerides are broken down to free fatty acids for the production of energy; muscle cells are deprived of any sources of energy and the cells of the liver fails to build up sores of glycogen. Consequently, this leads to a general rise in glucose levels in the blood. The stores of glycogen get reduced and there is less available glucose for release when it is needed. Scheen (2003) asserted that it is believed that a lack of physical activity and obesity are the major causes of insulin resistance. Several factors have been suggested as a possible linkage between beta-cell dysfunction and insulin resistance in type 2 diabetes pathogenesis. A majority of people who suffer from type 2 diabetes are obese and have central visceral adiposity. Hence, the adipose tissue plays a significant role in type 2 diabetes pathogenesis (Scheen 2003).

Additionally, Boyko (2013) pointed out glucose buildup in the blood is also associated with other problems such as body damage, dehydration, and diabetic coma. Body damage is a condition where there are high levels of glucose over time in the blood that can damage small blood vessels and the nerves of the heart, kidneys, and eyes leading to atherosclerosis which can cause a stroke or heart attack. Moreover, dehydration is a condition where glucose buildup in the blood can cause urination increase which eventually causes dehydration (Diabetes UK & Tesco (Firm) 2013).

3.1.1 Type 2 diabetes health risk factors

According to Pereira (2013), what causes type 2 diabetes is less well understood. However, the disease is likely caused by multiple things. Goldstein & Mueller-Wieland (2013) stated that diabetes is a collection of diseases involving hormone insulin problems. Even though not everyone who has type 2 diabetes is overweight, lack of physical activity and obesity are two common causes of type 2 diabetes. To understand the cause of type 2 diabetes, the dissertation will discuss the causes, what happens when diabetes type 2 occurs in the body, and some health problems that increase type 2 diabetes risks (Gadsby 2012).

Diabetes will occur when these scenarios occur; when the pancreas produces very minimal insulin when it does not produce insulin at all, or when the body does not appropriately respond to insulin or insulin resistance. People suffering from type 2 diabetes produce insulin but the secretion from their pancreases is either not enough for the body or it is not recognized by the body to be used appropriately or insulin resistance (LeRoith 2012). When these two scenarios occur, that is, there is not enough insulin in the body or the produced insulin is not being utilized by the body as it is supposed to be, the glucose or sugar will not get into the cells of the body and therefore build up in the bloodstream causing damages to several areas of the body. Moreover, given that the cells are not getting the required glucose, they cannot function properly (Qiao 2012).

Farming history is the first risk factor for type 2 diabetes. Drucker (2012), indicated that there is a strong belief that type 2 diabetes has a strong link in genes. This means that it tends to run in families. Therefore, the risk of developing diabetes type 2 increases if a sibling or a parent has other risk factors for type 2 diabetes. Gestational diabetes is another risk factor and it occurs when a woman gives birth to a baby who weighs more than 9 pounds or develops gestational diabetes when they are pregnant. When a woman has gestational diabetes, their risk of developing diabetes type 2 increases (Edelman & Henry 2001). Being obese or overweight is one of the primary risk factors for developing diabetes type 2. The more fatty tissues an individual has the more resistant the cells become to insulin. However, a person does not have to be overweight to develop diabetes type 2 (Sheehan & Ulchaker 2012). Body fat distribution is also another significant factor in type 2 diabetes. The individuals whose body stores fat mainly in their abdomen have a greater risk of getting diabetes type 2 than if the body stores the fat deposits elsewhere such as thighs and hips (Ford-Martin & Baker 2013).

According to Jabbour & Miller (2009), the age of an individual is also a risk factor for type 2 diabetes. The risk increases as a person get older particularly after the age of 45. This is because, at that age, many people tend to gain weight, lose muscle mass, and exercise less as they age. Similarly, diabetes type 2 is also increasing dramatically amongst younger adults, adolescents, and children. Furthermore, polycystic ovary syndrome according to Hsueh & Bryer-Ash (2009) is a risk factor for diabetes type 2. This is a condition for women characterized by irregular menstrual periods, obesity, and excess hair growth. Women with polycystic ovary syndrome have an increased risk of diabetes. Furthermore, inactivity or having a sedentary lifestyle or not exercising is a precursor or a risk factor for type 2 diabetes. According to Levene & Donnelly (2008), physical activity or exercises helps the body in controlling weight, utilizes glucose as body energy in addition to making the body cells more sensitive and responsive to insulin.

Ganz (2005) defined pre-diabetes as a condition whereby an individual’s level of blood sugar is higher than normal but has not reached the level to be classified as diabetes. Pre-diabetes is also a health risk factor for diabetes type 2 and if the condition is left untreated, Mohan & Unnikrishnan (2014) asserted that it can progress to diabetes type 2. Additionally, ethnic or racial groups are a risk factor the diabetes type 2. Gloyn & McCarthy (2014) indicated that as much as it is unclear where certain racial or ethnic groups including the Hispanics, blacks, Asian Indians, American Indians have a higher likelihood of developing diabetes type 2 compared to the whites. Another type 2 diabetes risk factors include the following; high levels of blood triglyceride, high blood pressure, high carbohydrate diet and fat, high intake of alcohol, have high blood pressure, and have high triglycerides or low HDL cholesterol

3.1.2 Diagnosis of type 2 diabetes

In diagnosing type 2 diabetes, Pereira (2014) stated that the physician first checks for any abnormalities in the blood such as a high level of blood glucose through screening tests referred to as a 2-hour glucose tolerance test or random fasting blood test. Similarly, a person can be blood tested through hemoglobin A1C which indicates the average blood sugar during the past two to three months. Moreover, testing can be done by looking for ketones or glucose in the urine.

By definition, Obrosova et al (2014) asserted that diabetes is having a blood level of glucose that is equal to or greater than 126 milligrams per deciliter (126mg/dl) after a fast overnight. Similarly, diabetes is having a non-fasting level of glucose equal to or greater than 200mg/dl besides the diabetes symptoms, or a level of glucose equal to or greater than 200mg/dl on the 2-hour glucose tolerant test. Moreover, it has an A1C that is equal to or greater than 6.5% (Vincent & University of Waterloo 2014).

4.0 Main body

Nurses have got a crucial role in ensuring clinical care of their diabetes type 2 patients and clients(Williamson, Bellman & Webster 2012). The role of a nurse in managing patients suffering from type 2 diabetes mellitus ranges from supporting and educating diabetic patients and also their families during all stages in their lives. Nowadays nurses become more involved in various aspects of diabetes type 2 Mellitus care related to health education, particularly related to the increase in the incidence of obesity (Obesity Resource Information Centre, 2000) and non-insulin-dependent Diabetes Mellitus (Department of Health, 2001). Therefore education among nurses should be a vital responsibility and the knowledge passed on to the client must be evidence-based (NMC 2008). So, nurses should be ensuring that their clients are clinically well and blood sugar levels are controlled to avoid such states because they are the only professionals that interact with them daily (White & Chanoff 2011). Therefore it is extremely important for the nurses, to fulfill their job roles successfully (Vora & Evans 2013). The roles of nurses have developed in the United Kingdom. Diabetes UK (2013) observed that about six decades ago, diabetes specialists’ nurses were introduced in the UK. The roles of the diabetes specialists nurses were developed because of the changes in the care of diabetes, increased prevalence of diabetes, and the directives of the government such as an Agenda for Change, diabetes National Service Framework, Working Time Directive of European and NHS plan. The dissertation will discuss the role of nurses in the management of patients suffering from diabetes type 2 Mellitus. Great Britain. (2011) asserted that diabetes is a disease that does not exist in isolation. Therefore, for the nurses, no matter the area of their specialization, they will still work with the people who are ailing from diabetes

4.1 Nursing consultancy and education

The role of the nurses under nursing consultancy is to focus on education, expert practice, training, and service and research development. According to Quinn (2001), education can be provided both in secondary and primary care locations and is delivered in different formats. These include e-learning, information provision, and group and one-on-one which is more popular. Adjustments in the nurse consultants’ teaching plans can significantly help in moving the patients from their current health condition to better health. Veves, Carver & Weinger (2009) suggested that nurse consultants should know what the patient he or she is educating is willing to change, use motivational interviewing, and should also have resources to make a follow-up. Similarly, Coates (1999) cautioned nurses against labeling diabetes patients as non-compliant.

Diabetes education is essential in the management of diabetes because it requires day to day knowledge on monitoring, nutrition, mediation, and exercise. Unlike other diseases where medication alone can treat them successfully, diabetes needs a combination of many factors. There are several diabetes components which include nutritional management, disease process, medications, physical activity, psychosocial adjustments, and glucose monitoring. Diabetes education makes the patient more aware of the disease, what it takes in treating it, and also gives the patient power to control it (Alazri et al 2006). According to Al-Khawaldeh Al-Hassan & Froelicher (2012, p. 203), diabetes education allows the patients to incorporate education better into their lives and the changes necessary in improving their lifestyles. The aim of educating a diabetes type 2 patient is for the patients to improve their knowledge, confidence, skills and to enable them to take control of their health and condition, and to integrate self-management strategies that are effective in their daily lives. American Diabetes Association. (2004) asserted that high-quality education that is structured can have a significant effect on the outcomes of health and improve their quality of life. A structured program for diabetes education that covers all major diabetes type 2 Mellitus aspects and the reason for it should be availed to the adult patients with diabetes type 2 Mellitus in the months after diagnosis. According to Davis & Krueger (2010), the only way the regimen of diabetes will be successful is when the patients fully understand it and are also willing to follow it or do as the nurse consultants instruct. In most instances, the patients lack the skills, tools, and support to manage the condition properly. Therefore, it is the role of the nurse consultants to help with the pieces (Mertig 2012). Knowledgeable and competent nurse consultants can provide cost-effective and quality care and improve patient outcomes when they offer information in times when the nurse consultants have with the families or with the patients daily. Furthermore, nurses can provide the patients with alternative ideas on the kind of foods they should eat, suggests realistic activity goals, and also discuss foods measuring (Springhouse Corporation 2009). In his study, Bartol (2012, p. 270) discussed the role of the nurse practitioners in guiding and motivating patients ailing from type diabetes mellitus to be able to self-manage their diseases, have more treatment experience that is positive, and achieve their goals for treatment. Bartol (2012, p. 272) asserted that nurse practitioners play a significant role in patient education and in understanding the benefits of, and the need for improved control of diabetes type 2 Mellitus. However, the nurses are not playing their role well in educating and offering consultancy services because they do not share information. The study, therefore, suggested that to achieve improved control of diabetes, there is a need to go beyond information sharing. The nurses can be pivotal in assisting in patients’ motivation to play active roles in their own management of diabetes (Bartol 2012, p.275). From the study, the dissertation found the research robust and believe that the nurses can improve their experience of teaching the diabetes type 2 Mellitus patients, by motivating and educating them to make lifestyle changes that are beneficial and making commitments to tailored treatments to the patient’s individual expectation and needs.

There are many ways in which a patient can be educated. Every patient suffering from diabetes type 2 Mellitus is different and therefore different ways of education must be used. These could include models, picture games to improve their health. According to Baricevic (2007), the nurses need to hold individual diabetes education of every diabetes type 2 Mellitus patients, as well as group education. The diabetes type 2 patients in group education will feel comfortable because they are in one group and all the members have the same concern. Moreover, they can share their frustrations and experiences, and also hear the answers to questions which they could not have thought of themselves. However, Barnett (2010) pointed out that it is significant that the patients create individual plans with assistance from their nurses after the group sessions since everyone’s lifestyles are different from the other. Apart from the group and individual educational classes, an intensive Diabetes Management program is also significant for the patients who require frequent contact with their nurses or their health care providers to achieve cholesterol, control of blood sugar, and blood pressure. A variety of educational strategies that target groups or individuals through audio-visual, written, or verbal forms of information can be used in expanding and reinforcing lifestyle change and dietary messages (Springhouse Corporation 2009). However, the most significant aspect is for the nurse to match the level and type of information to the needs and abilities of the individuals. After diagnosing in the initial stages, Birckhead (2008) observed that many patients ailing form diabetes type 2 Mellitus may be able to get or to assimilate a limited amount of information. Furthermore, regular follow-up by the nurse is essential also in the evaluation of the change effectively and to continue the process of learning. CGNS & Burgess (2008) suggested that diabetes type 2 patients who are newly diagnosed and also those with special needs such as pregnancy, renal disease, poor knowledge, or perceived poor practice should be seen by the nurses more frequently. However, the follow-up frequency depends on the patient’s compliance, ability, overall diabetic control, and confidence. Krau & Prevost (2011) reported that a diabetic type 2 patient who can have a support system and the network is valuable in glycemic control maintenance. The patients who attend educational programs can contact the nurses with questions even after completion of their educational sessions or even group discussions. Nurses in their roles as consultants or educators can educate the diabetes type 2 patients since education is a very important way for a nurse can encourage patients to be involved in the management of type 2 diabetes mellitus. Education about lifestyle and diet is essential in preventing diabetes or delaying the onset in those people who are at risk of developing type 2 diabetes and for the management of the condition effectively in those with type 2 diabetes mellitus. Dieticians in collaboration with the nurses are placed uniquely for the provision of the input and in ensuring integration of consistent and accurate dietary messages through the community and hospital care teams. The aim is to provide individuals living with type diabetes mellitus the required information on making choices appropriate on the quantity and type of food which they consume and also their lifestyles (Redman 2001). Smith (2007) asserted that the advice must consider the individual’s cultural and personal preferences, lifestyle, and beliefs and must respect the wishes of the individual and willingness to change. Kinmonth, Murphy & Marteau (1989, p. 324) conducted a study to find out what patients expect in the care of diabetes. The results indicated that patients regularly attended the diabetic clinic, they wanted their nurses or general practitioners to get involved in their future care. On the other hand, some patients wanted to continue along with their hospital review. Furthermore, a conspicuous result from the study was the response from the patients which awarded the hospital general practitioners and doctors’ high ratings for their knowledge and management of diabetes. The results of the study clearly indicate that diabetes patients have the desire of nurses to continue getting involved in their care. This could be through consultancy or even education. However, this has not been forthcoming because the nurses do not have time because of their busy schedules, however, the practice nurses and the general practitioners were highly rated for their accessibility and communication (Kinmonth, Murphy & Marteau 1989, p. 324, p. 326). The most valued aspect of care was being given information is appropriate and clear about the management of diabetes. Further results indicated that patients thought that their diabetes ailment would have would impact significantly in the future on their health. Similarly, the patients rated the regular review of diabetes as very important to keep them healthy. The majority of the patients felt the likelihood that they would have a high level of blood glucose most of the time and develop complications of diabetes. From the study by Kinmonth, Murphy & Marteau (1989, p. 324-7), it is clear that there are minimal differences between the views of the type 2 diabetes patients who attend the clinic and the non-attendees. Similarly, from the study, there is no indication that the non-attendees had to reject the review actively. Type 2 diabetes patients who are non-insulin-dependent considered diabetes to be a very serious disorder that warrants regular care. Moreover, they expressed their confidence in the ability of the team that delivers their primary care. This is an indication that collaboration and sharing of information between the health care professional and the patient are paramount to proper management of the disease.

Historically, nurses have been considered education to the patients as their responsibilities. However, accomplishing comprehensive and appropriate patient education has become more difficult. There are several reasons for this which include lack of available time for patient education in the managed care visits that are tightly scheduled, a huge influx of patients from different cultures, the shortage of written educational materials at readability levels that are appropriate, and also in the languages apart from English, and lastly lack of reimbursements by most hospitals for the spent time of patient education. Additionally, Barrier (2011) pointed out that several health care providers and nurses may be lacking specific training in the patient education provision, or in the development of health education material that are appropriate for the diabetes type 2 patients whom they serve. This section of the dissertation will discuss these problems, and also suggest the ethical dilemmas that are inherent in the provision of some patient education aspects. Although educating patients is significant in the health recovery of diabetes type 2 Mellitus patients, there also exist several problems in educating them. By including education in diabetes type 3 Mellitus management is considering the patient as a partner in the care. Therefore, as partners, the patients are expected to learn more about their health condition and also be able to fully participate in their own health care decisions. Bartol (2012) stated that the goal of patient education in diabetes type 2 Mellitus has changed from informing the patient about the best practices and actions to take, to assisting the patients in learning about their healthcare and to improve their personal health. Education to the diabetes type 2 patients is not an easy concept for many patients for the nurses and therefore needs intense communication between the nurses and the type 2 diabetes patients. Bastable (2006) found out that as much as the health care system tries to force the clients to have greater autonomy, not all health care providers want to work with the patients as partners.to acquire enough knowledge on the management of diabetes type 2 Mellitus ad to make informed decisions to some clines is hard to achieve. Some of the diabetes type 2 patients are not willing to learn as much as the nurses are willing to teach. Moreover, some of the patients do not have the educational background to absorb teaching on physiology and complex body systems. Therefore, it falls to the individual nursing then to assess what the diabetes type 2 Mellitus patient already knows, what they need to know, and the best way to achieve the goal of assisting the patient to learn enough in making informed decisions about their personal health. Beaser & Hill (1995) asserted that this required proper education of each diabetes type 2 Mellitus patient. Another problem experienced by the burses in educating their type 2 diabetes mellitus patients is difficulty in understanding the information. Therefore, Bellenir (2014) explained that the two most important principles in educating patients are simplicity and reinforcement. The principle of simplicity states that the educational messages to the patients must be delivered to the patient in a way that they can understand them readily. Topics that can be daunting to teach and also difficult to learn by a patient should be avoided

4.2 Empowering the patients to improve their conditions from getting worse

Nurses need to better engage with diabetes type 2 patients in the management of their own health, and this is possible by empowering the patients. Therefore, the nurses and other health care providers need to work with their type 2 diabetes mellitus patients in ensuring that they have the confidence and knowledge necessary in taking control of their own health outside the healthcare settings. Patients’ empowerment is not only about the ability of the patient engaging in quality improvement projects in their own health, but also how the nurses and the hospital entirely are ready to work with the diabetes type 2 patients. Diabetes type 2 Mellitus patients need to be empowered to improve their conditions from getting worse. There are many studies and researches that highlights the significance of patients patient empowerment in managing diabetes type 2 condition appropriately (Mitchell et al 2011; Nes et al 2012; Al-Khawaldeh Al-Hassan & Froelicher 2012empowering patients to improve their conditions from getting worse is important since it will enable the patients to control their health condition when at home away from the hospital setting. Moreover, empowering the patients is important and helpful in making decisions when the nurses are not around to assist. The patient can still do the activities of their own living, monitor their own sugar levels, understand what diet to take, and also engage in structure exercises since there are empowered and motivated. Many diabetes types 2 patients’ wishes to get the opportunity to get involved in their own care and management of the disease. This is reflected in many studies (Beaser & Hill 1995; ADM 2004).

There are several ways in which a nurse can empower a diabetes type 2 patient to improve their condition n from getting worse. When a patient is diagnosed with diabetes type 2, the nurses elaborate on the required treatment, management, and medication for the patient. Barrier (2011) indicated that the role of the nurse is to empower the patient who has been diagnosed with diabetes to get involved in their care for better results. According to Long & Deyoung (2003), it is the role of the nurse to motivate the patients to get involved in their care. This can be done through education, explaining the benefits of their involvement, motivating the patients, and even making recommendations to them to read the benefits in books and internet sources. The methods, when adopted by nurses, will be successful since the patients will be enlightened, and some will desire quick recovery, live healthily, and also be optimistic about their condition. Alazri et al (2006, p. 488-95) conducted a study on the experiences of patients in the care of diabetes type 2. The study aimed to explore the experiences and perceptions of empowering nurses in nursing from type 2 diabetes patients’ perspectives, focusing on the disadvantages and advantages of patient empowerment. The focus groups used in the design of the study were effective. Furthermore, the study used 79 types 2 diabetes patients from 7 practices in Leeds in the United Kingdom. The use of 79 from 7 practices was a good range for a qualitative study. However, all the 7 practices were based in Leeds which may have some bias and limitations as all could be under the same healthcare provider which means they all do the same thing. Therefore, the issues found may not apply to other areas since they were only found within Leeds care and may not be relevant in other areas such as Edinburgh or London because they do things differently. The study found out that the perceptions of empowerment of patients were influenced by multiple factors such as the personal relationships between the health care professional and themselves, their own behaviors and beliefs, diabetes presence, and the structures and systems of general practices. (Alazri et al 2006, p. 494). Similarly, this is also reflected in a study conducted by ADM (2004) in finding out whether patients ailing from diabetes type 2 Mellitus often get empowered, or get an opportunity to be involved in their treatment and management decisions, the results indicated few patients get the opportunity.

The nurses in their effort to empower the patients to get involved in their own management of diabetes type 2 disease, face different problems. Some problems hinder nurses and the general health practitioners from empowering the patients. Some of the hindrances include lack of time by the nurses because of their busy schedules. Some nurses also lack knowledge about empowering the patients to self-manage their diabetes type 2. Similarly, other nurses prefer putting their patients in darkness about the management and treatment of the disease (Cherry & Jacob 2013). A qualitative study by Beaser & Hill (1995) which focused on reasons why nurses might face difficulties working with diabetes type 2 patients more collaboratively. The results indicated that factors such as the need for the nurses to perform the physical checkups that are basic, and lack of time. This implies that the nurses were always unable to empower the patients or encourage the participation and involvement of patients in the manner they desire. Similarly, FHS, FMG & ITN (2005) also pointed out that there exist constraints in collaboration working between the nurses and the diabetic type 2 patients such as working to meet the targets and limited time. Therefore, empowering the patients to be self-sufficient is significant. With the significance and need of empowering patients to improve their conditions from getting worse increasing over the years, Clark (2004) indicated that some patients desire to be empowered, while some have limited involvement in their care and management of their diabetes illness and are satisfied with that. Similarly, some patients would want to get empowered and to contribute actively to decisions, unlike others who prefer relying on the nurse’s clinical decisions (Vora & Evans 2013). All these types of patients are important when proposing or empowering diabetes type 2 patients to take care of themselves.

4.3 Nurses updating their knowledge on current evidence and practices for better management of type 2 diabetes

According to Cherry & Jacob (2013), nurses everywhere in the world including the United Kingdom have a big challenge of being abreast and keeping up to date with the current research, evidenced practices, policies that are related to professional and clinical practice. With the advancement in information technology, nurses tend to be overwhelmed to feel that they are expected to know everything in the nursing field. Moreover, when embarking on a study program or training, the nurses can feel often inundated by a large amount of information and the struggle of identifying what is important and what is not, especially in scenarios of limitations of time and guidelines for assessment are restrictive, and this also applies to the clinical practice (Mccormack, Manley & Titchen 2013). According to Williamson, Bellman & Webster (2012), nurses has a duty and a role to advance their knowledge base to provide quality care to diabetes type 2 patients according to the professional practice codes of Nursing and Midwifery Council which states that the nurses must provide high standards of care and practice all times, and also keep their knowledge and skills up to date (Mccormack, Manley & Garbett 2004). Therefore, care for diabetes type 2 patients must be based on best practice and available evidence. Feinglos & Bethel (2008) asserted that nurses during their nursing practice to diabetes type 2 patients are expected to have appropriate knowledge and skills for effective and safe practice, and recognize and work in high competency levels but within professional boundaries. Rael & Sally (1993, p. 497-502) conducted a qualitative study about revisiting the knowledge of the nurses about diabetes on update and practice implications. The study aimed to ascertain the knowledge levels of diabetes amongst nurses in a medical center in a university, to compare the diabetes knowledge levels between nursing units, and to describe correlates of knowledge of nursing. The study sample was convenient of about 99 from 6 different in patent units in addition to the ambulatory care center (Rael & Sally 1993, p. 499). The number of study samples and the spread of the research in six different units was balanced and suitable for a qualitative study. Comparing the units, analysis of variance showed a significant difference in the knowledge questionnaire between units (p=.04). Moreover, in a hierarchical, 4-step multiple regression analysis, the related variables to how competent the nurses were in the care of the diabetic patients, and the total number of the cared diabetic patients for the past month showed 28% of the variance in the knowledge of diabetes (Rael & Sally 1993, p. 502). The study confirms that nurses are knowledgeable about diabetes and also its care. Even though the study corroborates other earlier findings, the big question still concerns the nurses’ knowledge of general adequacy about diabetes type 2 Mellitus.

There are several ways in which the nurses can update their knowledge of current evidence and practices for better management of type 2 diabetes. According to Williamson, Bellman & Webster (2012), the internet has provided nurses to access to a plethora of knowledge and information. However, there is still a lot of available information that nurses can use from libraries, magazines, newspapers, broadcast Medias and the GP/ Practice team bulletins which provide the latest important information on health and social care development. The good starting point for a nurse as suggested by NMC (2008) is nursing in Practice (NIP). This is a website that provides free journals for medical nurses and mostly covers most current issues in primary care either professional or clinical. Similarly, Mccormack, Manley & Garbett (2004) indicated that the nurses need to enroll in higher education to provide them with the knowledge and skills related to their area of practices such as diabetes management, as well as equip them with skills of critical analysis and academic writing to assist them to learn how to read and even critique effectively different literature. Peters et al (2001, p. 179-88) conducted a study to find out the roles the nurses play in the care of type 2 diabetes in the community in a Delphi study. The objective of the study was to identify the nurses’ views on their future and current roles in care in the community for the persons ailing from diabetes type 2. The method used by the researchers in this study was complicated but the essential part was that the data were collected were verified and the article peer-reviewed hence validating the method. The study was used in eliciting and assessing consensus on opinions from various samples of random practice nurses, with a significant role in diabetes patients’ management, and specialist nurses of diabetes. Both groups had worked in the United Kingdom and had defined expertise levels in the care of diabetes. Moreover, the study used an appropriate instrument for data collection. From the study, among the themes, the study raised could be categorized under headings of responsibility, clinical practice, knowledge, communication rewards, education/experience, and the roles of the patients. The agreement level for the factors that relate to clinical effectiveness, knowledge, audit, experience, and education dissent occurred both between and within individual nurse categories on issues of prescribing, responsibility, resources, service delivery, and patient factors (Peters et al (2001, p. 186). In summary, the Delphi study identified key consensus areas care management of people ailing from type diabetes in the community, and also in other areas that additional work needs to be done to understand the identified differences. Most of the discordant items relate to the associated issues and separate roes of the two nurse categories.

Even though the nurses need to update their knowledge of current evidence and practices for better management of type 2 diabetes, they face numerous problems in their endeavors. The excessive workload was the first problem faced by their nurses in their endeavor to be updated on the current evidence and practices for better management of type 2 diabetes. Nurses spend most of their time attending to patients in the hospitals in addition to other duties such as administrative for the senior nurses. This hinders or limits their time of doing research or reading current researches on evidence practices. Complex researches also hinder nurses from updating themselves (Birckhead 2008)). Nurses vary in educational levels and therefore some find it hard to understand complex researches have done which uses complex terms. Another problem is lack of time by the nurses since they spend most of their time offering service to the patients hence lacks time to read (Bergman 2014). Shaheen et al (n.d) conducted a study on the nurses’ knowledge, perceptions, and barriers in adopting the evidence-based practice in decision making in clinic settings. The objective of the study was to explore the nurse’s knowledge of, awareness of, and attitude towards the evidence-based practices, and the factors likely to create barriers or create adoption. The study also investigated the sources of information used by the nurses and their skills for searching the literature. The results of the study indicated that nurses expressed a positive attitude towards evidence-based practice. However, a key outstanding factor from the study was that the nurses pointed out that because of the heavy workload; it is hard for them to keep up with the new evidence. Daily excessive workloads on the patients limit their time for doing further research as much as they are willing to read the latest researches and developments in the nursing fields. Moreover, on the self- efficacy of related abilities of evidence-based practice, the nurses had a perception that they possess skills of moderate levels. Similarly, they felt that evidence-based practice training, availability of time, and mentoring by fellow nurses with experience in evidence-based practice would encourage them in implementing evidence-based practice (Shaheen et al n.d). However, the barriers to adopting evidence-based practice were the inability to understand the jargon used in most research articles, inadequate understanding of the statistical terms, and lack of time. Similarly, on the search of the literature, most nurses used basic features of search and most were not familiar with proximity operators (Shaheen et al n.d). From the study, even though the nurses showed a positive attitude towards evidence-based practice, there still exist certain barriers that hinder their adoption smoothly. Therefore, the management of hospitals in the United Kingdom should develop a comprehensive strategy for building competencies of evidence-based practice through proper training. Furthermore, the libraries of the hospitals should play their role actively in developing adequate skills for information literacy amongst the nurses.

4.4 Offering clinical care to diabetes type 2 patients by the nurses

Generally, clinical service to patients is the primary role of nurses to all patients admitted to a health care facility. According to Barnett (2010), the nurses in conjunction with the physicians or the general practitioners decide on the treatments a patient ailing from type 2 diabetes will take. The health care professionals often work in collaboration in the process of decision making when offering clinical service to type 2 diabetes patients. There are several reasons why nurses need to offer clinical care to diabetes type 2 patients. First, in the United Kingdom, there are approximately 2 million people with diabetes type 2 Mellitus and the projection is on the rise (Cherry & Jacob 2013). Many of the patients seek health care from the hospitals and health care centers where nurses offer their clinical services. Moreover, nurses offer clinical care services since they are qualified and have the ability to manage and treat diabetes type 2 Mellitus patients (Burant & Young 2012).

There are multiple ways in which nurses offer clinical care services to their type 2 diabetes patients. First of all, Chopra & Kapoor (2014) indicated that nurses provide bedside nursing care to critically ill diabetes type 2 patients. Moreover, they carry on medical regimens and advice the diabetes type 2 Mellitus patients on medication in their clinical care duties. According to Clark (2004), nurses also promote health, help diabetes type 2 Mellitus patients cope with illnesses, and prevent disease in their clinical care. When providing their patients, they record, assess, and observe symptoms, progress and reaction s from the diabetes patients. Lastly, the nurses also collaborate with the physicians in the performance of examinations and treatments, medication administrations, direct patients care to diabetes type 2 Mellitus patients.

Despite the fact, nurses offer clinical care to diabetes type 2 Mellitus patients, they are faced with a myriad of problems in delivering effective diabetes care. First of all, there challenges in clinical to areas of high large minority ethnic groups, high socio-economic deprivation. Moreover, the high prevalence of diabetes is also a challenge to clinical care. Studies indicate that diabetes type 2 Mellitus is highly prevalent in some ethnic groupings. This poses a challenge to the nurses in their bid to provide clinical care and to combat that disparity (Davis & Krueger, 2010). Similarly, high socio-economic deprivation is a great challenge to nurses working in such areas. Access to proper health care services is not adequate due to limited resources (Coates 1999). Lastly, the prevalence of diabetes type 2 diabetes also hinders proper clinical care for diabetes type 2 patients because of the limited resources, fewer nurses with many patients. The nurses tend to be overworked because of the high number of patients. The nurses are highly involved in the management of diabetes type 2 Mellitus, however, Burant & Young (2012) stated that the role of the nurses majorly is limited to physical checks. This was also echoed by English & Williams (2001) who highlighted that some nurses dealing with type 2 diabetes mellitus often see themselves mainly as physical measurement monitors. Even though the physical checks are important, especially in the prevention of the diseases, they form part of diabetes clinical service and diabetes management.

Phil et al (1999, p. 1492-1499) conducted a qualitative study to determine the issues that arise from the intervention of improving the involvement of patients in their own care. The study aimed to explore reasons that underlie a surprising observation, that a designed intervention to change the professional behavior in consultations in general practice in South Wales, was sustained poorly despite the nurses’ initial enthusiasm. The baseline of the nurses and the new approach’s continuing responses with non-insulin-dependent diabetic patients was described, drawing on interviews and observations with 18 nurses in 15 experimental practices. This was an adequate number for a qualitative study and experimental research. Phil et al (1493) indicated that the nurses fell into two categories; the nurses showing an understanding of the underlying principles of the approach, and an attitude that is more reflective of their work, and the nurses who adapted the provided simple technology to their usual style of consultation. Generally, from the results of the study, this variation clearly indicates that it was due to the nurses’ perception of their attitude and roles to diabetic care, especially the challenge by the difficult patient. Moreover, from the study, it is evident from the results also that the nurses were less willing to allow freedom of the patient to make a decision on what to do once control of diabetes type 2 Mellitus was deteriorating as indicated from the biochemical measures (Phil et al 1999, p. 1498). This could be because of the decision of the nurses for the well-being of the patient to avoid anxiety or pacing a lot of burden on the patients. Nurses tend to withhold information from patients especially if the information can worry about the patient and worsen their conditions. The study concluded that the nurse’s failure to sustain the change of behavior over a period of time stems from one single dilemma, that is, what are the boundaries of their responsibility, and how should they change it? The dissertation believes that there is a need for more research in this field especially on the perspectives of the professionals on chronic care, the applied strategies they adopt in patients management and in coping with their own personal feelings, and the strategies implications for patients.

5.0 Recommendations for practice

Diabetes type 2 Mellitus is a chronic complex illness that requires continuous medical care with risk reductions that are multi-factorial beyond glycemic control (Baricevic 2007). Ongoing education on self-management on the part of the patient and support are important in reducing the long term complication risks and in preventing acute complications. The recommendations for practice and standard of care must be applied in the excellent clinical care context with adjustments for individual comorbidities, preferences, and other factors of patients, and should not also preclude clinical judgment. The recommendations for clinical care include diagnostic, screening, and therapeutic actions that are believed or known to affect health outcomes favorably of diabetic patients. The recommendations for diabetes type 2 Mellitus management in the dissertation have been presented in different components. In clinical actions, the dissertation recommends that focus should be on the reduction of cardiovascular risks such as control of blood pressure, statin use and control of the low density of lipoprotein cholesterol, and cessation of tobacco use. Moreover, the A1C levels should be individualized per patient. Moreover, glycemic control and blood pressure control should be aggressive to maintain the blood sugar level as recommended. Moreover, microvascular complications should be prevented through biannual or annual foot risk assessments, eye exams, counseling on foot care, and proteinuria assessment. Lastly, initial therapy with metformin and lifestyle treatment is recommended unless contraindicated.

The dissertation also recommends treatment to delay or prevent the progression of diabetes type 2 Mellitus. Identified patients with pre-diabetes should be referred for lifestyle interventions and education. Moreover, the dissertation suggests that modification of lifestyles such as exercise, nutrition, and modest weight loss are some of the recommendations for delayed or prevention of pre-diabetes patients. Similarly, pharmacotherapy can be applied like metformin. Furthermore, to delay or prevent the progression of diabetes, there should be individualized cardiovascular risk reduction. Similarly, there can be an intensive behavioral change of lifestyle including activity plan and nutrition by a health educator, registered dietician, or nurse. Reassessment and annual follow-up for the risk of developing diabetes for the patients who positively responded to lifestyle interventions is another factor that can delay or prevent diabetes progression. However, the patients who are not responding to the lifestyle interventions and are at high risks need intensification of counseling and education on lifestyle interventions.

The dissertation also recommends that the patients with diabetes or pre-diabetes should receive medical nutrition therapy (MNT) that is individualized, and provided by a knowledgeable registered dietician to achieve goals of treatment. Moreover, overweight and obese diabetic patients at risk of type 2 diabetes should lose weight. The recommended weight loss include calorie-restricted diets such as low fat, low carbohydrates, or Mediterranean foods. The patient should utilize meal plans incorporating a mix of fat, protein, and carbohydrates, and can be adjusted to meet individual preferences, metabolic goals, and the recommended daily intakes/recommended daily allowances (DRIs/RDAs). Diabetes type 2 patients or newly diagnosed diabetes patients can monitor carbohydrates by experienced-based estimation, choice, or carbohydrate counting to achieve glycemic control. Moreover, there should be a reduction of Trans fats, saturated fats, and cholesterol intake, an increase of soluble fiber, omega-3-fatty acids, plant stanols/sterols to improve the lipid profiles. The patient should include the dietary pattern of Dietary Approaches to Stop Hypertension (DASH-style in lifestyle therapy for weight loss and hypertension, and increased physical activity. The dissertation suggests that diabetes type 2 patients should perform moderate-intensity aerobic exercises (50%-70% of maximum heart rate) at least 150 minutes a week three days a week. Moreover, the nurses should encourage resistance training in the absence of contraindications three times a week at a minimum. Similarly, to manage type 2 diabetes, the type 2 diabetic Mellitus patient needs to change his or her lifestyle incluiding5%-7% loss of weight which is equivalent to 10-15 pounds in a person who weighs 200 pounds, and at least physical activity of 150 minutes weekly. This can significantly reduce the onset rate of type 2 diabetes. The programs for weight loss should have behavioral modifications, physical activity, and lifestyle change. Similarly, for adults with a BMI>35, consideration can be given to bariatric surgery if the diabetes type 2 Mellitus or comorbidities cannot be controlled with pharmacological therapy or lifestyle change.

6.0 Conclusion

In conclusion, nurses play a significant role in managing patients suffering from type 2 diabetes mellitus. The major roles of nurses in managing patients ailing from diabetes type 2 Mellitus include educating the patients on healthy ways of living, empowering the patients to take care of themselves, offering clinical care, and updating their knowledge base to be updated on the latest developments and technological advancements in the field. There is an increasing number of people who develops diabetes type 2 condition in the United Kingdom from the statistics moreover, statistics indicates that the United Kingdom incurs a lot of costs in management and treatment of the condition. In educating and offering consultancy service to the patients suffering from type 2 diabetes, the nurses can liaise with other health caregivers such as dieticians in recommending proper dieting, offering educational sessions in focused groups, or individual classes. Similarly, another role of nurses is to empower the patients to take care of themselves. Diabetes type 2 conditions require the goodwill of the patient to make some changes to his or her personal lifestyle. These might be hard sometimes but with the assistance of a nurse, the patient can be empowered to live healthily and to manage his or her condition. Clinical care is a major function of nurses since they operate from clinical settings. Clinical care includes diagnosing, offering medical treatments, and scientific methods of managing the conditions. This also forms a major role of the nurses in managing the conditions among the patients. Lastly, the nurse needs to continue his or her knowledgebase concerning treatments and management of diabetes type 2 Mellitus. With the rapid technological and knowledge base advancement, there is a need for the nurses to continuously update themselves. This is to avoid using outdated methods or educating the patients using past methods while the latest methods are available. Lastly, the dissertation recommended some important factors that are useful in clinical practice. These included clinical recommendations, also recommendations for treatment to delay or prevent progression from pre-diabetes to diabetes, and education and self-management recommendations which included nutrition, physical activity, and weight management.

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