Therese Rehnberg Diallo
Bachelor of Science in Nursing, 180 ECTS, Department of Health Care Sciences
Independent Degree Project, 15 ECTS, VKGT13, 2020
First cycle degree programme not requiring previous university study
Handledare: Anna Klarare Examinator: Elisabet Mattsson
Self-Management among type 2 diabetes - An interview study
with nurses in Guinea
Egenvård bland diabetes typ 2 - Intervjustudie med sjuksköterskor i
Guinea
Abstract
Background: Type 2 diabetes has increased worldwide, and there is a strong increase in low-income countries. One connection that can be seen in the reason for the increased prevalence is that people in low-income countries go from living a more traditional lifestyle and high-fiber diet, to a more Western lifestyle and a less active life. The high-fiber diet is replaced by an energy-rich diet of fat and sugar, which is a contributing factor to the increased incidence of type 2 diabetes. The focus of this study is to examine nurses in Guinea about their perspective on self-management for patients with type 2 diabetes.
Aim: The purpose of the study was to describe nurses in Guinea on their perspective in teaching self-management to patients who had recently been diagnosed with type 2 diabetes.
Method: The method used in the study had a qualitative design, semi-structured interviews were conducted on four nurses and then the analysis was done using content analysis.
Results: The results of the study were divided into three sub-themes that involved creating confidence in the patient in their own ability to
self-management, creating awareness, about diet and activity, as well as financial and educational difficulties.
Discussion: The discussion highlighted the nurse's important role in education to those patients who have a low knowledge of type 2 diabetes. It appeared that nurses experienced difficulties in performing their profession in educating patients in self-care as patients could not afford to pay for aids.
Sammanfattning
Bakgrund: Diabetes typ 2 har ökat i hela världen, och det syns en stark ökning i låginkomstländer. Ett samband som kan ses i anledningen till den ökade förekomsten är att människor i låginkomstländer går från att leva en mer traditionell livsstil och fiberrik kost, till en mer västerländsk livsstil och ett mindre aktivare liv. Den fiberrika kosten ersätts med energirik kost med fett och socker, som är en bidragande faktor till den ökade förekomsten av diabetes typ 2. Fokus för denna studie är att undersöka sjuksköterskor i Guinea om deras perspektiv på egenvård för patienter med typ 2-diabetes. Syfte: Syftet med studien var att beskriva perspektivet hos sjuksköterskor i
Guinea i att undervisa egenvård för patienter som nyligen fått diagnosen typ 2-diabetes.
Metod: Metod som användes vid studien hade en kvalitativ design,
semi-strukturerade Intervjuerna gjordes på fyra sjuksköterskor och sedan gjordes analysen med hjälp ut av innehållsanalys.
Resultat: Resultatet från studien delades upp i tre sub -teman som handlade om att skapa självförtroende hos patienten i deras egen förmåga till egenvård, skapa medvetenhet, om kosten och aktivitet, samt ekonomiska och utbildnings svårigheter.
Diskussion: Diskussionen lyfte fram sjuksköterskans viktiga uppgift i utbildning till de patienter som har en låg kunskap om diabetes typ 2. Det framgick att sjuksköterskorna upplevde svårigheter med att utföra sin profession i att utbilda patienterna i egenvård då patienter inte hade råd att betala för hjälpmedel.
Innehållsförteckning
INTRODUCTION 4 BACKGROUND 4 Diabetes type 2 ... 4 Prevalence ... 4 Impact ... 5 Healthcare in Guinea ... 6Nursing and caring ... 7
PROBLEM STATEMENT 8 AIM 8 THEORETICAL FRAMEWORK 8 METHOD 9 Design ... 9
Setting and participants ... 9
Data collection ... 10
Data analysis ... 11
RESEARCH ETHICHAL CONSIDERATIONS 11 RESULT 12 DISCUSSION 17 METODOLOGICALCONSIDERATIONS ... 17
RESULTDISCUSSION ... 18
CLINICAL IMPLICATIONS 20
PROPOSALS FOR CONTINUED RESEARCH 20
CONCLUSION 21
REFERENCES 22
APPENDIX 1. INTERVIEW GUIDE 25
APPENDIX 2. CONSENT LETTER 26
APPENDIX 3. LETTER OF INTRODUCTION 27
INTRODUCTION
Type 2 diabetes is the most common form of diabetes that increases greatly among the world's population. Previously, it was seen as a disease that affected the elderly, which has now gone down in age. The increment in the prevalence of diabetes is closely related to the context of overweight and obesity.
During my nurse training within primary care I was involved with patients who were diagnosed with type 2 diabetes, and what the conversation about self -management could look like for these patients. Given that this disease is becoming more common in developing countries, and since I been in Guinea previous it felt for me as obvious to go there, as there is an increase in type 2 diabetes among Guinea's population. I wanted to investigate nurses’ perspectives on self-management for patient with type 2 diabetes in Guinea.
BACKGROUND
Diabetes type 2Diabetes type 2 is the most common form of diabetes, which also increase significantly around the world (Ericson & Ericson, 2008). The sharp rise in diabetes in many countries can be seen in the context of obesity in the population. What usually occurs in the development of type 2 diabetes is that the insulin resistance in insulin-dependent tissues causes the beta cells to increase insulin secretion.
This, in turn, causes hyperinsulinemia and forms high insulin concentration in the blood (Ericson & Ericson, 2012). When the disease persists between 10 to 15 years, beta cells usually decrease their insulin production and that, consequently, leads to deficiency in insulin. When the function of beta cells decreases by 50% the diabetes symptoms occurs such as thirst, large amounts of urine, fatigue due to high blood sugar. Risk factors for developing diabetes type 2 are smoking, heredity and overweight.
Prevalence
According to WHO, people with diabetes had increased worldwide from 108 million to 422 million between 1980 to 2014, it can also be seen that diabetes increased sharply in middle- and low-income countries (https://www.who.int).
Diabetes often increases among people who leave behind a traditional lifestyle from rural areas and move into the cities (http://diabetes.se). Developing countries go from a traditional to a more western lifestyle with consequent urbanization and cultural change. Consequently, this change of lifestyle leads inhabitants to have a decreased physical activity. Besides that, energy-rich food with a lot of fat, salt and sugar replaces previous high-fiber habits
(http://diabetes.se).
Impact
A high number of people with type 2 diabetes that could prevent, or delay complications as described by Dao, Spooner, Lo, and Harris (2019). According to the investigation of possible causes that effect the use of self-management, there are various reasons. Reasons that has an influence on self-management were socio-ecological, interpersonal, organizational, and societal level which involved motivation and time constraints, support from family and friends, issue for accessing allied or specialist care, and societal level.
The study by Whitehead, Crowe, Carter, Maskill, Carlyle, Bugge and Frampton (2017) showed that with the help of educational intervention carried out with the help of nurses in primary care, the blood sugar of those who participated in training activities was lowered. The training activities included basic pathophysiology, understanding of diabetes and glucose, understanding the risk factors and complications associated with diabetes, self-management of diabetes through diet and exercise.
Hill (2019) depicts the increase in diabetes among the ageing population and by 2035 and it is predicted that diabetes has increased to 592 million people in the world. An ageing population is a risk factor to diabetes, where the elderly is considered older than 60 years. Diabetes affects age due to the increased risk of physical disability and an increased risk of developing dementia. Age also affects diabetes development, and it in turn increases the risk of memory problems and visual impairments. The condition of the elderly living with diabetes varies and individualized care is crucial as it differs in physical function, wellbeing, mental capacity, and various abilities to self-management. Accordingly, health care professionals must take into consideration the various abilities in order to appropriately weigh up the treatment objectives.
Healthcare in Guinea
Guinea is located in West Africa, Guinea is impoverished even though it is rich in natural resources (https://www.UI.se). The country has a population of 12.7 million and a young population where 42% of the population is under 14 years of age. The educational level is low, and the majority of the population can’t read or write.
Healthcare in Guinea is defective because of the lack of medicine and you can’t count on the equipment to be sterilised that is used in the hospital (https://www.swedenabroad.se) As a patient you should be prepared to pay the medical care and the stay in advanced. The article by Camara, Camara and Camara (2015) describes how the healthcare in Guinea were and how it changed between year 1958 and until 2014. During the period between years 1958 until 1984, the healthcare system was controlled by the state. At that point Guinea had two teaching hospitals that offered health care, and the hospitals were a place for teaching students. Guinea was divided in to four regions where each region had their own regional hospital. There were also two industrial hospitals in Guinea that were sponsored by industrial companies in the mining industry, among others. Health condition that were more serious were treated at the teaching hospitals or at the industrial hospitals because of larger access to resource services. This health system was based on a free healthcare system and if the patient needed to pay it was just a symbolic amount. Between year 1984 to 2004 the healthcare system changed because of the military regime toked over the control of the country.
Healthcare system changed do to approved of the private structures and the public sector were shut down. Private pharmacy was also approved and with that the prices of medication raised. Privatization of the healthcare and the pharmacy made the cost for the care impossible for the population access healthcare, the cost went up and the qualitive of care went bad.
A concern for healthcare in Guinea among the population due to poverty which makes lack of accessibility to health services (WHO, 2015). Many diseases who are containable that is usually common in Guinea, that is the main factor for the population to seek care. Among the not containable diseases where diabetes is one of the diseases that has increased. The existent among diabetes is 3,5% of the population between the age 15 to 64 years. Guinea is one of the countries in West Africa with the highest incidence of diabetes, and that the availability of diabetes care in large parts of Guinea is lacking (https://www.worlddiabetesfoundation.org). In Guinea, those living with diabetes are with an estimate between 100,000-500,000
Nursing and caring
The International council of nurses (ICN) works to make sure that the nurses have a voice in development and to complete health politician to ensure the real needs of patient, families and community around the world (International council of Nurses, 2020). ICN works to promote the quality in care, a global health policy and promote knowledge in care.
The ethical codes are divided in to four areas, the first area is nurses and people and it describes that the nurse’s responsibility in first hand points to the person in need for care (International council of Nurses, 2012). The second area is about nurses and practice, where the nurse has a personally responsibility for continue learning to maintain professional competence. The third area is about the nurse and the profession where the nurse works for sustainability environment and conscious about the environments meaning for health. Nurses and co-worker which is the fourth area where the nurse among severely things works for a good cooperation and respects colleges.
The central idea of self-care described by Orem (Orem Taylor & Renpenning, 2001) where the demands on the nurse is conducted to make sure or see the patient’s individual limits related to health. The patient could be in a dependent position that makes the patient whole or partially unconscious about the demands are to be able to take care of himself or he does not know the manageable factors to maintain his selfcare. In order to promote the development of the patient's self-care capacity, the nurse must use the capacity of her nursing care by
supervising, teaching, providing physical and psychological support (Kristoffersen, 1998). In order to create a common understanding between the nurse and the patient, it is a requirement to use communication where communication is seen as part of caring (Baggen & Sanden, 2014). Caring through communication where the nurses using conversation can happen through a health conversation. When the conversation is the main activity there is often a goal that has to be obtained during the meeting, and also make it possible for the nurse to make an estimate and plan the measures that is needed to make a survey where the tasks are collected, and this could be for example about how the patient diet is, exercise looks like that can affect the health for the patient. The conversation is an important tool in the work whit the patient who has diabetes type 2 to promote health in the patient self-management as a support and guidance (Amsberg & Anderbro, 2012).
PROBLEM STATEMENT
Diabetes type 2 is a major growing public health problem for the population all over the world which affects not only elderly but also younger people. Complications of diabetes can give physical and psychological consequences and often depends on how the patient blood sugar is regulated. Information and guidance are of great importance in diabetes, both for newly diagnosed and even those who have diabetes for a long time need updated knowledge. The aim of the teaching the patient is to equip with adequate knowledge in managing their disease and to enable them to live a good life as much as possible. The subject needs attention at the individual level where motivation and knowledge are highlighted so that the individual can keep the blood sugar at a steady level. Given that, the disease is a major growing general disease in the world, it feels important to examine the experience of nurses in Guinea on questions about how their diabetes care is shown in terms of information and teaching. The study can help health professionals in Guinea to recognize the importance of self-management through information and teaching on type 2 diabetes. This study can also contribute to new and updated knowledge for health professionals in Guinea in teaching of self-management for patients with diabetes type 2.
AIM
The purpose of the study was to describe nurses in Guinea on their perspective in teaching self-management to patients who had recently been diagnosed with type 2 diabetes.
THEORETICAL FRAMEWORK
Dorothea Orem's self-care theory is described as a function which is performed by the individual himself or done for someone else, to maintain their physical and mental health. Self-care is something that the individual learns and is carried out consciously, and that it must comply with the individual's state of health (Orem, Taylor & Renpenning, 2001). Orem describes the lack of self-care as a fundamental component of self-care deficit in nursing theory, which then expresses reasons an individual has that requires nursing.
The theory has a foundation in which the persons has their own ability to self-care (Wiklund Gustin & Lindwall, 2012). The individual has the ability to control his own development and act in different situations suitable for its purpose in promoting health. Occasionally the need for self-care may increase due to human power and the ability.
However, it may not be enough to promote health. Even if the nurse's task is to teach and support the patient in self-care, focus needs to be given to the patient’s life situation and personality. It is important to create a pleasant and motivating environment so that the patient can achieve their goals. There are three levels of self-care. The first level is when the self-care is completely compensated if the patient, for example, is in a coma. The second level is partially compensated self-care when the patient can perform some self-care himself but may need help to reapply a wound. The third is supportive or teaching self-care where the patient, for example needs to lose weight where the caregiver can contribute with support and
guidance while the decision lies with the individual. As for this study, the theory is
appropriate as it describes the importance of nurse support and guidance to the patient's self-management. Moreover, it provides a better opportunity to the patient in achieve well-being and promoting health. Orem’s theory is appropriate to the study since the focus will be on teaching self- management due to a disease which can be controlled by self-care. The study will be focused on nurse’s perspective on teaching of self-management among patients with diabetes type 2.
METHOD
DesignThe author chose a qualitative method according to Henricson and Billhult (2017). A qualitative method refers to studying people's lived experiences of a phenomenon. This method is suitable when seeking understanding and knowledge. The qualitative design has its origins in holistic tradition and through this intends to study people's lived experiences and this design is fitting as the author has chosen to interview the nurses about their perspective on teaching self-management.
Setting and participants
The author chose semi-structured interviews, where open questions were used, which provide the opportunity for the questions not to be addressed in a particular order and it provides an opportunity for the author to adapt to what comes up in the interview (Danielson, 2012). The author chose qualitative studies research to gain a better understanding of experiences and therefore, the author interviewed nurses in Guinea. Inclusion criteria was that the nurses should have had experience of dealing with type 2 diabetes patients. The author conducted the interviews in a department that was for diabetes patient and this department belongs to a large
hospital, located in the capital of Conakry. The interviews were conducted with the help of an interpreter when the participants spoke French and the author only speaks English. The participants interviewed consisted of four female nurses aged between 45 and 53. Their average experience as nurses was between 24 and 30 years.
The hospital is owned by the government and is the largest hospital in Guinea which is also a teaching hospital (Chughtai, Loua, Beavogui, & Qureshi, 2015). The department was at the time not in the main building due to renovation of the hospital, the department had been placed in a military area. The diabetes unit was divided into different rooms, where women and men were separated. The nurses' role in the department was to care for the sick with nursing, teaching in self-management of diet, exercise, and aids. The nurses registered
patients' information where they filled in different metrics, also to be able to make follow-ups around the patient. The author was assisted by a contact person in Guinea who was informed of the study and was given the task of contacting this hospital in Conakry to see if there are any volunteer nurses who might be involved in an interview study. The author arrived at the department, which was determined by the head nurse. The author got to meet the manager at first and was able to hand over information and documentation (Appendix.3), the manager then approved that the interviews could be carried out in the department. There was a nurse on site who at the time did not know about the study, she volunteered after receiving information about the study (appendix.2) then when the head nurse arrived on the spot, the same procedure was done with the nurses selected by the head nurse. The interviews were done during working hours in the department, we were generally disturbed when there was a lot of movement around us and the nurses' phones rang that caused the interviews to be interrupted.
Data collection
According to Henricsson and Billhult (2017) qualitative data can be collected through interview, the author interviewed four nurses in Guinea and the author used an interview guide (appendix.1) which was semi-structured, the aim of semi-structured interview is to make the participants speak openly and the author were able to adjust to what is being said by using follow up questions such as asking can you describe or give an example. The author chose open questions as an interview approach, and through open question the opportunity was given to make a broader understanding do to the participants with the focus on the meaning of the interview (Danielson, 2012). The author conducted a semi-structured
have to be asked in a fixed order, the author will adapt to the way the interview turns out, (appendix 1).
Danielsson (2017) describes how some negative effects can destroy the interaction in the interview by having a to detailed questionnaire where the author can be too controlled by the interview guide. That is why the interview guide should only be on one paper and only as a support for the person who is doing the interviews, the author therefore chose to use open questions and only have the paper to support the interviews. The author audio recorded all interviews and the same questions were asked for all four participants.
Data analysis
The author analyzed the collected data consisting of four interviews, by listening through the audio recordings and then the author transcribed the interviews. The author repetitively read the transcribed text to create a greater understanding of the collected data. The method for the analysis that was used is described by Graneheim and Lundman (2004) is a qualitative content analysis. The method has its weight on the understanding of course of action with the analysis and its often used in nursing research. The author used the latent approach in which the author analyzed the underlying meaning of the text.
The author read through the collected data several times to reduce the risk of
misunderstandings, as the author read through the interviews, meaning units were selected that responded to the purpose. The author condensed the sentences by shortening the text without removing the meaning from the meaning unites. An interpretation of the underlying meanings of the condensed sentences was made, thereafter the author created three sub themes based on the expression in the interpretation, where three themes described the participants' perceived experiences. The three themes were, create self-confidence in the patient’s own ability, creating awareness of diet, exercise, and complications and financial and teaching difficulties (Appendix 4).
RESEARCH ETHICHAL CONSIDERATIONS
Research ethics involves protecting people's equal value integrity and autonomy among those who take part of in a degree project, and ethical consideration are made for thesis work and during the process of work (Kjellström, 2017). The Research Ethics Committee at the Department of Health Care Sciences at Ersta Sköndal Bräcke University College, approved
the study, decisiondate 22/1-2020 and Dnr: 1909-A
.
The information about consent were provided both orally and in writing, participation received an explanation in which the participation is made on a voluntary base and can withdraw whenever they wish without any explanation. The author also gave information to the participants that it is confidentially, and participants in the study will be anonymous, i.e. they will not be identified in the text. A safe data storage for the recordings were used where it was kept locked and only the author had the access, it was used only for the study and it will be deleted when the study is finished. All material was stored on a protected server. The author went through the purpose of theinterviews and the questions that will be asked to avoid that participants would feel taken by surprise during the audio recording, the author went through the consent letter orally to ensure that the participants understood what the consent meant.
RESULT
The result of the study that were conducted could be identified into three sub-themes: Create self-confidence in the patient’s own ability, creating awareness of diet, exercise and
complications, financial and teaching difficulties (Appendix 4).
Nurses perspective on teaching for patient with diabetes type 2.
The common thing during the interview of the nurses at the hospital were about their own perspectives in teaching of patients of diabetes type 2 in their self-management where they had to support, educate and, they were all talking about financial and teaching difficulties which created the three sub-themes.
Create self-confidence in the patient’s own ability
The participants explained how the patient acted and felt downhearted when founding out that they were diagnosed with diabetes type 2. Patients would not really understand what was expected from them and the participants thought that the patient needs a lot of education. Participants needed to reassure the patient by giving them support to build patients self-confidence so they could be able to self- manage their disease. Participants thought that by giving the patient support and confidence of manage their disease they will be able to live a functional life, with the patient’s own effort and ability.
“Whit a diabetic patient we have to give a lot of advice, but the patient will not understand at the same time that’s why we have to give him confidence. Patient thinks it is the end of the world” (Participant 1)
Some participants described, when the patient mentioned that they did not have anyone at their home to help them and support them with their self-management, they were offered to stay at the hospital to get the most of the support and educate from the nurses before
homegoing.
“Some, they may say we don’t have anybody at home to help and support them with self-management, so they stay here and follow everything by respecting our instruction as of diet and medications, after they will be going home” (Participant 2)
Participant declared the important of explaining to the patient about the disease is an
incredibly significant job for the nurses at the hospital due to the lack of knowledge that the patient had. The patient believes that the disease is fatal and that will make some negative thoughts and can cause feelings of defeat. To make the patient feel more hopeful about the future and that the disease is manageable is to make patient know it is up to them to make the best of their health progress.
“I explained to the patient the reason for why he was here and told him diabetes is not a fatality” (Participant 4)
Creating awareness of diet, exercise, and complications
The hospital is the main hospital that is provided by the government, and it is where the nurses are special educated in diabetes care, and with their special knowledge they use it to
educate the patient, and patient will come from far away to receive care. Participants described that the nurses at the hospital, who work in the department with diabetes patients, believe that it is of great importance to create knowledge about diet and exercise as the patient who has been diagnosed has no idea that their diet or exercise is affecting their health. The patient who was then diagnosed can feel extremely ill as described above where they think it is the end of world. With this, participants try to calm the patient by informing the patient that it is possible to check blood sugar values but not to be too calm. Increased activity and not going directly to bed after a meal but trying to keep moving as often as possible. Giving knowledge about simple things like diet and exercise is of great importance in these patients who have absolutely no knowledge of how they can promote good health and thereby contribute to normal blood sugar level.
“I can tell the patient not to be too much calm, sometimes in other words to do some exercise. You know there are some people when they eat, they will go directly to bed for a rest, which is not good.” (Participant 1)
The participants describe what it is like to provide information about managing the disease, where foot care, among other things, is of great importance in providing information. The information is given in different steps. The different step depends on which patient you have in front of you. The first step, for example, can be about the symptoms of hypoglycaemia and how hyperglycaemia may appear. The second step can be about how important it is to
maintain good foot care as this can cause a common complication in diabetics.
“We consult in different steps due to much of information at once, so the second step if, is to inform foot hygiene. (Participant 1)
The participant declares that many patients who comes to the section have no knowledge of the disease. This can create far too wide information and it can be difficult for the patient to comprehend. To ensure that the patient has understood what has been learned. So, the
department has routines to conclude a summary of what went through during the hospital stay and this is done to ensure that the patient understands the information that was given.
” We make a summary of what been taught during the hospitalizing to see that the patient understood everything.” (Participant 3)
Financial and teaching difficulties
Participants in the interviews described the lack of financial conditions for the patients that prevent them from receiving the care they need. The patient must pay daily for his or her medical residence, the food must be provided by relatives. The nurses can only provide medicine if the relatives or the patient has paid for them in advanced. This becomes an obstacle as a nurse in their profession, that they will not be able to show how diabetes material works for example a blood sugar meter, in case the patient can’t afford to buy the blood sugar meter, the nurses can’t teach that step in how to control the blood sugar in their self-management.
“Anyway, those who are provided by family or have money can continue buying products.”
(Participant 1)
Participants describe how they see their patient’s difficulties surrounding paying to gain knowledge and good care because of the disease. They describe that it is difficult for patients to just get to the hospital which is located in the capital because of the of traveling costs.
“There are difficulties especially financially. For instance, most of the patient live far from here so the transportation is costly for them.” (Participant 3)
This in turn, with the cost of the trip, reduces the chance for the patient to come back to get feedback about his or her own care and how it went after the first visit to the hospital, which
in turn should be able to evaluate whether the goals regarding self-management achieved or if there are some changing that need to be made in the patients self-management.
“I just want the patient to be able to get consulted regularly” (Participant 4)
Participants shares that care for the patient with type 2 diabetes is nothing the state provide
for, the patient must pay everything for himself and this contributes to the difficulties for the nurses to do their job. As well as difficulties for the patient when they do not have the conditions to accomplish with their self-management.
“I want the government to take of the cost for the patient of diabetes type 2” (Participant 2)
The consequences for healthcare costs and access to a hospital with competence are far away
for many patients. This, in turn, creates complications that are very difficult to manage for both the patient and the medical staff, while at the same time increasing the cost for the patient sooner or later.
“Difficulties for instance is the caring of diabetic feet is difficult and also patient are not motivated to follow our instructions” (Participant 3)
Instead, patients resort to using traditional medicine, which in turn contributes to patients waiting too long with the correct care about how he or she should be able to manage their illness and thus comes to the hospital with wounds that are almost out of control.
“Patient prefer going to traditional medicine and when it’s too late the patient will come to the hospital with bizarre sores.” (Participant 3)
Since patients have a low knowledge of type 2 diabetes, it may be helpful to include relatives in the teaching of self-management so they in turn can be involved in the path to a healthier life, and it can create feelings in the patient that they receive support even at home. It would make it easier for both the patient and the department of the bigger hospital if primary care had equal competence to teach about type 2 of diabetes, and also the patient would not have to go far to get the necessary care and this could ease the financial burden.
DISCUSSION
METODOLOGICAL CONSIDERATIONS
When the author arrived at the booked appointment at the hospital the author meets the only nurse who was on site at the time and the nurse assumes that the authors presence was due to the fact that she was there to control their work. So those who read this may have in mind as the nurses were a little unsure of the purpose at first.
Head nurse selected the nurses who had had the longest experience with work in diabetes care, so anyone who reads can take it into consideration that they were selected.
At the beginning of the interviews, the atmosphere was a bit stiff but the author tried to small talk a little about how the hospital itself were built and how long the participant has been working as a nurse and this in turn made the atmosphere a bit more relaxing and the nurses began to talk more lightheartedly.
The author enlisted the help of a translator to enable because the language spoken is French and the author mastered English. The role of the interpreter, also described by
Hadziabdic and Hjelm (2013), shall provide translation between two languages and maintain an independent appearance. What could be seen as a minor advantage in the choice of the translator was that it was a male translator and the participants interviewed by the author were female and this could have created difficulties for participants to talk more openly and
relaxed. Therefore, the author went through the questions before with the participants and which allowed the participants to considerate the questions if it felt comfortable answering the questions.
The disadvantage was the interviews were conducted at the hospital where the location chosen was not the most optimal for interviewing and could have created less richer content. Danielsson (2017) describes the environment where the interviews are taking place as an advantage if the place is not being disturbing to create safety. A good environment gives an opportunity for the interviews to be rich in content and create a deep relation to the aim of the study. What may possibly have affected the participants may be that the manager was always somewhere nearby, and it may have affected the participants in their responses.
As described by Danielson (2012) that in situations where the place of interviews takes place in the ward, the interviewer may be responsive to what is offered. The place were
chosen by the nurses themselves, and this place was not the most optimal as there were disturbing factors, as their phone rang during the interviews, the interview also happened during working hours, and this may have made the nurses feel stressed.
The author used semi-structured interview to create an opportunity for a deeper understanding, and that participants could tell more openly about their experience and perspective (Danielson, 2012). The author used the same questions for all participants to create a trustworthiness as described by Granheim and Lundman (2004) the importance to question the same area for all the participant. The four interviews were made using audio recording, when the four interviews were finished, the author started the analysis by listening to audio recordings and writing down word by word. The difficulty that the author
experienced was to analyze the text alone and not have anyone to discuss with, when meaning units were picked out. The author made sure to read through the text several times to gain a better understanding of the content and the author focused on units that responded to the purpose.
Difficulties in the analysis of the texts from the interviews was the interpretation as it was difficult to develop what was said and did not appear instantly in the text (Kvale &
Brinkmann, 2010).
RESULT DISCUSSION
The results showed that the nurses needed to put a great deal of importance on informing patients of diabetes as the patients had little insight into what the disease required to their health. The nurses did this by encouraging patients to create motivation and self -confidence to work with their self-management. This indicates that by encouraging communication generated self-confidence in the patient own ability, and contributes to active role in the patient's own self-management by allowing the patient to be transparent and talk about fears of complications or how the diet should be followed (Du Pon, Wildeboer, Dooren, Bilo, Kleefstra, & Van Dulmen, 2019). In the study conducted by Gardsten, Blomqvist, Rask, Larsson, Lindberg, and Olsson (2018) It was seen that those who were recently diagnosed felt the challenges of accepting the diagnosis and motivation to change their habits as even
participants in Guinea told about the importance of motivating the patient in their lifestyle change. It is suggested that arranging group talks can lead to a motivational where group conversation with the inclination of an approach self- management (Kulzer, Hermanns, Reinecker & Haak, 2007). Enabling grouptraining for patients who have recently been
diagnosed can create the opportunity for patients to meet with different people in the same situation where they can support each other and also share different experiences.
Orem describes the lack of self-care as a fundamental component of self-care deficit in nursing theory, which then expresses to what reasons an individual has that requires nursing as when the need for self-care exceeds the individual's capacity for self-care and this leads to lack of self-care and it can be shown on insufficient knowledge to maintain balance and nursing is required to promote health (Orem, Taylor & Renpenning, 2001). Working with patients who diagnosed with type 2 diabetes is largely about teaching the patient about self-care to reduce risk of complications and promote health. The results also showed how nurses strategist designed information providence due to the patients’ lack of understanding and knowledge. By giving information in different step due to much information at once that could make it difficult for the patient to remember. By using small toles in nursing by teaching patient the importance of caring for your feet for example inspecting your shoes before putting them on (Moura, Lopes, Teixeira, Oria, Vieira & Guedes, 2019). Suggestion with an early discovery of diabetes type 2 at the clinic allows info on treatment to improve blood sugar control and thus minimize complications, the management consists of lifestyle changes as weight loss, healthy eating, physical activity and this is supported with training in self-management at the time of diagnosis (Chatterjee, Khunti, & Davies, 2017).
It appeared that nurses working at the bigger hospital have a broad and in-depth
knowledge of type 2 diabetes. This department that can provide care for type 2 diabetes is the only one found in the bigger capital, so the patients who visit clinics closer to their
accommodation with type 2 diabetes are sent to this hospital. This makes it difficult for many patients to get there as being of both financial and difficult transport there. This meant that many chose other alternatives to care as traditional medicine and this in turn created major injuries that also became difficult to manage for the care. The study by Ross, Benavides-Vaello, Schumann and Haberman (2015) where they could see the barriers in the self-management of type 2 diabetes that were partly influenced by the cultural diversity where traditional aids were used, and that the cost and availability provide obstacles to care needed to be able to get the training in self-management and this led to people with type 2 diabetes postponing the necessary care. This can be seen in the narrative from the participants in Guinea, who have experienced these difficulties due to costs, availability and that person with type 2 diabetes postpones care and ends up with wounds that are difficult to manage.
To improve health care, the government would ensure that the health care system is strengthened in the work on type 2 diabetes as in the study of Balde
et al. (2017) indicated that it is a high prevalence and low awareness of diabetes in Guinea and the proposal needs to strengthen primary care. Supporting primary care through diabetes education, so that the healthcare professional can perform the same type of care as the bigger hospital. This can contribute to a more accessible care for people with difficulty getting to the hospital, advantage may be that the person chooses not to postpone necessary care. Primary care can then capture these patients who have recently been diagnosed and teach the
necessary knowledge to promote health.
CLINICAL IMPLICATIONS
The results of the study where the Guinean nurses' perspective was in focus showed that it was the larger hospital that possesses with higher knowledge of diabetes and self-care. This led primary care to send patients to the bigger hospital, this in turn led to patients who could not afford to go there postponed the trip. It also turned out that those who came to the hospital could not afford the care, such as buying the diabetes materials so that the nurses could show how they worked. In order to reduce travel and the cost of getting to the bigger hospital, primary care should gain more knowledge in education for patients with diabetes. Thereby reduce the pressure on patients in the bigger hospital who can then focus on more the acute complications such as wound care. One proposal for development would be to review the opportunities for the larger hospitals to support primary care staff in diabetes education.
PROPOSALS FOR CONTINUED RESEARCH
The results of the study from the interviews of nurses in Guinea revealed that patients were transferred to the larger hospital because primary care lacks knowledge of diabetes. The patients avoided treatment for their diabetes, and this was because the patient had financial difficulties as it was a long and costly journey, and that the care at the bigger hospital also cost. Further research can be done on how nurses can carry out their work when patients cannot afford the treatment. Also, an intervention study to train nurses in primary care in diabetes care and self-management would be an interesting approach for further research.
CONCLUSION
The results of the study showed that Guinean nurses' work with type 2 diabetes patients was about supporting patients when they were recently diagnosed, where the nurses taught them about the disease and self-care in order to promote health. The nurses also told of the difficulties for patients to get the care needed because of patients' financial difficulties. In order to improve care in diabetes, support for primary care would be needed, which could then catch these patients at the start of their health journey, by allowing the hospital to teach primary care so that they can relieve the bigger hospitals so that this can help nurses at the hospital to focus on the acute health conditions such as wounds that are difficult to heal.
REFERENCES
Amsberg, S., & Anderbro, T. (2012). Stöd baserat på kognitivt beteendeterapi (KBT). I K. Wikblad (Red.), Omvårdnad vid diabetes (s. 161-178). Lund: Studentlitteratur. Baggen, C., & Sanden, I. (2014). Omvårdnad genom kommunikativa handlingar. I F. Friberg
& J. Öhlen (Red.), Omvårdnadens grunder: Perspektiv och förhållningssätt (2. uppl., s. 507-532). Lund: Studentlitteratur.
Balde, N. M., Camara, A., Diallo, A. A., Kake, A., Diallo, A. M., Diakite, M., Bah, C., & Kone, M. (2017). Prevalence and awareness of diabetes in Guinea: Findings from a WHO STEPS. Journal of Endocrinology, Metabolism and Diabetes of South Africa,
22(3), 36–42. doi:10.1080/16089677.2017.1366091
Camara, M., Camara, A., & Camara, N. (2015). The healthcare system in Africa: The case of guinea. International Journal of Community Medicine and Public Health, 685–689. doi:0.18203/2394-6040.ijcmph20150933
Chatterjee, S., Khunti, K., & Davies, M. J. (2017). Type 2 diabetes. The Lancet, 389(10085), 2239–2251. doi:10.1016/S0140-6736(17)30058-2
Chughtai, M., Loua, T. O., Beavogui, K., & Qureshi, A. (2015). Neurological surgery in Guinea, west Africa. Journal of vascular and interventional neurology, 8(15), 12–16. Danielson, E. (2017). Kvalitativ innehållsanalys. I M. Henricson (Red.), Vetenskaplig Teori
och metod: Från idé till examination inom omvårdnad (s. 286–299). Lund:
Studentlitteratur.
Danielson, E (2012). Kvalitativ forskningsintervju. I M. Henricson (Red.), Vetenskaplig teori
och metod: Från idé till examination inom omvårdnad (1.uppl., s. 163-174). Lund:
Studentlitteratur.
Dao, J., Spooner, C., Lo, W., & Harris, M. F. (2019). Factors influencing self-management in patients with type 2 diabetes in general practice: A qualitative study. Australian
Journal Of Primary Health, 25(2), 176–184. doi:10.1071/PY18095
Du Pon, E., Wildeboer, A. T., van Dooren, A. A., Bilo, H. J. G., Kleefstra, N., & Van Dulmen, S. (2019). Active participation of patients with type 2 diabetes in
consultations with their primary care practice nurses – what helps and what hinders: A qualitative study. BMC Health Services Research, 19(1), 814. doi:10.1186/s12913-019-4572-5
Ericson, E., & Ericson, T. (2008). Illustrerade medicinska sjukdomar: specifik omvårdnad,
medicinsk behandling, patofysiologi (3. rev. och utök. uppl.). Lund: Studentlitteratur.
Ericson, E., & Ericson, T. (2012). Medicinska sjukdomar: Patofysiologi, omvårdnad,
Gardsten, C., Blomqvist, K., Rask, M., Larsson, Å., Lindberg, A., & Olsson, G. (2018). Challenges in everyday life among recently diagnosed and more experienced adults with type 2 diabetes: A multistage focus group study. Journal of Clinical Nursing,
27(19-20), 3666-3678. doi:101111/jocn.14330
Granheim, U. H., Lundman, B. (2004). Qualitative Content Analysis in Nursing Research: Concepts, Procedures and Measures to Achieve Trustworthiness. Nurses Education
Today, 24(2), 105-112. doi:10.1016/j.nedt.2003.10.001
Hadziabdic, E., & Hjelm, K. (2013). Working with interpreters: practical advice for use of an interpreter in healthcare. International Journal of Evidence-Based
Healthcare, 11(1), 69–76. doi: 10.1111/1744-1609.12005.
Henricson, M., & Billhult, A. (2017). Kvalitativ metod. I M. Henricson (Red.), Vetenskaplig
Teori och metod: Från idé till examination inom omvårdnad (s. 111–119). Lund:
Studentlitteratur.
Hill, J. (2019). The older person with diabetes: Considerations for care. British Journal Of
Community Nursing, 24(4), 160–164. doi.10.12968/bjcn.2019.24.4.160
International Council of Nurses. (2020). Nursing policy. Retrieved February 28, 2020, from International Council of Nurses, https://www.icn.ch/nursing-policy
International Council of Nurses. (2012). The ICN code of ethics for nurses. Retrieved February 28, 2020 from International Council of Nurses,
https://www.icn.ch/sites/default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf
Kjellström, S. (2017). Forskningsetik. I M. Henricson (Red.), Vetenskaplig Teori och metod:
Från idé till examination inom omvårdnad (s. 57-80). Lund: Studentlitteratur.
Kristoffersen, N. J. (1998). Teoretiska modeller i omvårdnad. I N. J. Kristoffersen (Red.), Allmän omvårdnad (s. 333-430). Stockholm: Liber.
Kulzer, B., Hermanns, N., Reinecker, H., & Haak, T. (2007). Effects of self-management training in type 2 diabetes: A randomized, prospective trial. Diabetic Medicine, 24(4), 415-423. doi:10.111/j.1464-5491.2007.02089.x
Kvale, S., & Brinkmann, S. (2010). Den kvalitativa forskningsintervjun (2. rev. uppl.). Lund: studentlitteratur.
Moura, N. dos S., Lopes, B. B., Teixeira, J. J. D., Oriá, M. O. B., Vieira, N. F. C., & Guedes, M. V. C. (2019). Literacy in health and self-care in people with type 2 diabetes mellitus. Revista Brasileira de Enfermagem, 72(3), 700–706. doi.10.1590/0034-7167-2018-0291
Orem, D. E., Taylor, S. G., & Renpenning, K. McLaughlin. (2001). Nursing: Concepts of
Ross, S., Benavides-Vaello, S., Schumann, L., & Haberman, M. (2015). Issues that impact type-2 diabetes self-management in rural communities. Journal of the American
Association of Nurse Practitioners, 27(11), 653–660. doi:10.1002/2327-6924.12225.
Whitehead, L. C., Crowe, M. T., Carter, J. D., Maskill, V. R., Carlyle, D., Bugge, C., & Frampton, C. M. A. (2017). A nurse-led education and cognitive behaviour therapy-based intervention among adults with uncontrolled type 2 diabetes: A randomised controlled trial. Journal Of Evaluation In Clinical Practice, 23(4), 821–829. doi:10.1111/jep.12725
Wikblad, K. (2012). Egenvårdsutbildning. I K. Wikblad (Red.), Omvårdnad vid diabetes (2. uppl., s. 129-138). Lund: Studentlitteratur.
Wiklund-Gustin, L., & Lindwall, L. (2012). Omvårdnadsteorier i klinisk praxis. Stockholm: Natur & Kultur.
World Health Organization. (2015). Country cooperation strategy at a glance. Retrieved february 28, 2020, from World Health Organization,
https://apps.who.int/iris/bitstream/handle/10665/246211/ccsbrief_gin_en.pdf;jsessioni d=9392EB159E41ADB07F81004C53F140E7?sequence=
APPENDIX 1. Interview guide
Could you tell me about your experiences of working with patients recently diagnosed with diabetes type- 2? Could you share an example of working with a recently diagnosed patient?
Is there any follows up about the patient’s self-management?
Do you see any continuing improvement in caring for patients with diabetes type- 2? Are there any challenges in teaching for patients recently diagnosed with diabetes type -2? How do you see your role as a nurse in caring for patients with diabetes type- 2?
Is there anything you would want to change in the care of patients with diabetes type- 2? And if what would that be?
Follow up questions
Can you describe or give me an example? What happened?
What did you do? How did it go?
My name is Therese Rehnberg Diallo and I`m a nurse student at Ersta Sköndal Bräcke University College, in Stockholm, Sweden. I have been given the opportunity to write my bachelor thesis in Guinea. The aim of the study is to describe the nurse’s perspectives on teaching for patients who recently been diagnosed with type 2 diabetes. I want to invite you to participate in the study to share your experienced based knowledge of how nurses work in teaching for those patients with type 2 diabetes. This study is part of a Bachelor of Nursing degree.
If you agree to participate in this study, you will be interviewed in English or with the assistance of an independent interpreter translating from English to French. The interview will take approximately 40-60 minutes and will be audio recorded with your permission. Data collected in this study will be confidential. No individual identities will be used in any reports or publications resulting from the study. All materials, recordings and notes from the interviews will be stored separately from any names or other direct identification of participants. The data will be on a
memory stick that only I have access to and will be deleted after the thesis has been completed. Your decision whether or not to participate in this study is voluntary. If you choose to participate, later you can withdraw your consent and discontinue participation at any time without
explanation.
The Research Ethics Committee at the Department of Health Care Sciences at Ersta Sköndal Bräcke University College, Stockholm, Sweden, has approved the study decisiondate 22/1-2020 and Dnr: 1909-A. If you have any questions about the study, please contact Therese Rehnberg Diallo by calling or e-mailing. You can also contact the supervisor, Anna Klarare, RN, PhD, with any questions related to this study.
My name is Therese Rehnberg Diallo and I have received a government grant to complete my Bachelor thesis abroad. I am doing
a study on nurse’s perspectives on teaching for patients who are diagnosed with type 2 diabetes. The design is qualitative, and I
would like to interview a minimum of four nurses about their perspectives of teaching patients with type 2 diabetes to create a
broad understanding. The interviews will take approximately 40-60 minutes, see the attached interview guide.
Data collected in this study will be confidential. No individual identities will be used in any reports or publications resulting from
the study. All questionnaires, tapes and transcripts will be given codes and stored separately from any names or other direct
identification of participants. Data will be kept in locked files at all times. Only persons involved in the study will have access to
the files.
Decision whether or not to participate in this study is voluntary. Participants can choose to withdraw the consent and discontinue
participation at any time without explanation.
The Research Ethics Committee at the Department of Health Care Sciences at Ersta Sköndal Bräcke University College,
Stockholm, Sweden, has approved the study, decisiondate 22/1-2020 and Dnr: 1909-A. If you have any questions about the
study, please contact Therese Rehnberg Diallo by telephone or e-mail. Please feel free to contact the supervisor, Anna Klarare,
with any questions related to this study.
Appendix 4. Meaning Units
Meaning units Condensed meaning Interpretation Sub -themes
“We as nurses have to give a lot of advice due to the lack of knowledge about diabetes type 2, the patient do not understand what it means to have diabetes, patient can think that it’s not manageable.”
Nurses gives many advices due to the lack of knowledge, the patient believes that the disease is not manageable.
Patient have lack of knowledge; patient is afraid of the unknown.
Create self-confidence in the patient’s own ability
patient, as of guidance, advising and inform the important of self- management of the disease. “
nurse profession. type 2 diabetes.
exercise and complications.
“Challenge in teaching the patients is the financial, those who have money can continue buying products for example by follow their blood sugar on the blood sugar equipment, and here in the hospital if the patient have all products we can teach them how to control the blood sugar but patient who doesn’t afford the products, makes it hard for us to teach.”
Patient who don’t afford the cost of treatment is missing out on the care that its needed.
Patients do not receive the necessary care due to a lack of money.
The lack of money creates
difficulties for the nurse to be able to teach about diabetes materials.
Financial and teaching difficulties
