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Utilizing Nurses as Diabetic Educators: Sri Lankan Experience

Author(s) Manuj Weerasinghe1, Deepani Siriwardhana2.
Affiliation(s) 1Department of Community Medicine, University of Colombo, Colombo, Sri Lanka, 2Department of Disability Studies, University of Kalaniya, Colombo, Sri Lanka.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Health Systems
Summary A new initiative was started in Sri Lanka to train a special category of nurses to deliver diabetic education in hospitals. Three years into the programme an evaluation was done to assess the extent of utilization of DENOs for diabetic education and the systems developed to optimize their services to the patients. A qualitative methodology was used in this study. It was found that in different hospitals were used for diabetic education in varying degrees and had different working arrangements. There were many obstacles to use DENOs in an efficient manner. However, when given the opportunity, DENOs performed in a positively as an innovative method of patient education.
Background Non Communicable Diseases (NCD) prevention and control is a new challenge for the Sri Lankan health system. The system has fewer options to offer in the present context. Although continued care and behavioual modification strategies are seen as the essence in prevention and control of NCD care, Sri Lankan healthcare delivery system is not designed to accommodate these goals. Hence, in response many initiatives were proposed and implemented by different stakeholders. The initiatives proposed ranged from a systems change to targeted interventions in human resource development. One of such initiatives is the NIROGI Lanka project established by Sri Lanka Medical Association under the Diabetes Prevention Task Force with the help of World Diabetes Foundation. The project trained selected nursing officers in hospitals as Diabetic Educator Nursing Officers (DENO) to implement educational activities in the hospital setting. In three years over three hundred DENOs were trained  from secondary and tertiary care hospitals. This training was done with the concurrence of the ministry of health and a directive was issued on how to utilize DENOs for educational activities. This is a special training programme and still not incorporated into the regular human resource development plan.
Objectives Awareness of the disease plays a major role in compliance of treatment and control of the disease. Adherence to treatment and lifestyle modification can delay the complication of diabetes. Tailor made education and regular follow up sessions can improve compliance to a greater extent. Traditionally physicians are entrusted to advise the patients. However, physicians in a busy clinic find it difficult to provide comprehensive education on diabetes to patients. Hence, there was a longstanding need to streamline the educational activities to improve treatment outcomes. DENO initiative was proposed as a supplementary activity to strengthen diabetic education in hospital settings.Being a new initiative to tackle the emerging epidemic of diabetes coordinated by a non state actor, the implementation agency, NIROGI Lanka project, does not have direct control of the DENOs working in the hospital. It relies on the Ministry of Health for this purpose. The project expects the Ministry of Health to take over the training and the implementation of this initiative after the completion of the project cycle. The health administration system in Sri Lanka is two tiered; small number of tertiary care hospitals administered by the central government and the rest by provincial health authorities. The majority of the DENOs work in secondary care hospitals in the periphery. Hence, the manner in which DENOs are utilized in hospitals after the training depends on the decisions taken by the provincial and hospital administration. DENO are a new category of health workers and the routine information system does not still report their performance in monthly or annual returns. This limits the usage of routine management information systems to assess the utilization of DENOs and their performance. In this circumstance an independent evaluation was proposed to provide inputs that would strengthen the DENO initiative. Hence, an evaluation was undertaken to assess the extent of utilization of DENOs for diabetic education in hospitals and the systems developed to optimize their services to the patients.
Methodology The evaluation was based on a conceptual framework that guided the whole research process. The conceptual framework was developed to articulate the underpinning programme theory of DENO initiative. It consisted of impact theory, service utilization plan, organizational plan and process theory. In order to understand the rationale behind the decisions undertaken to utilize DENOs for diabetic education, the actual service utilization plan and the organizational plan were tested against the articulated theory. The study employed a qualitative methodology to explore the research question. In-depth interviews and focus group discussions were the main techniques. In addition, observation of the work setting was done to verify actual practices. Interviews and discussions were held with the DENOs, clinicians involved in diabetic care, immediate supervising officers of DENO and hospital directors.DENOs of 28 hospitals from five provinces of the country participated in the study. Of those hospitals 19 were visited. Selected healthcare centers included teaching hospitals administered by central government, provincial hospitals, base hospitals and district hospitals that come under the provincial authorities. Five focus group discussions were held with the participation of 51 DENOs. In addition 25 in-depth interviews were done with DENOs. Seventeen medical administrators, 20 clinicians and 8 nursing administrators were also interviewed. Interviews with DENOs were done in local language. Most of the interviews with administrators were done in English. All the interviews were recorded and transcribed. Principal investigator conducted the interview with the help a research assistant. A flexible interview guide was used for both focus group discussions and in-depth interviews. During the field visits, working arrangements of DENOs were observed.Thematic analysis was done grounded on the data.Transcripts were coded manually. Codes were refined several times after revisiting the data. Articulated programme theory guided the analysis. Working arrangements of the DENOs were elicited and systems developed in the hospitals to utilize DENOs were constructed. Ethics approval for the study was obtained from the Faculty of Medicine, University of Colombo.
Results DENO training is a new opportunity and majority of administrators at hospitals were not aware of the nature of the training in order to guide the selection process or to use them effectively. Selecting nursing officers for training programmes is a routine and immediate procedure. Only few nursing officers volunteered to attend the training programme and the rest were forced to attend. A formal application process was present in only three teaching hospitals. There was no advance planning for utilizing DENO in most hospitals. After the trainees were sent back to their original units most administrators find it difficult to release the DENO for their expected work due to severe a nurse shortage. This shortage is approaching a critical level in many hospitals where maintaining day to day service is threatened.Even after three years the circular issued on DENO utilization has not reached most of the hospitals. Hence, different hospitals resort to varying working arrangement. In the 28 hospitals, 10 types of working arrangements were identified. In summary, only 10 out of 51 DENOs were released for full time work on diabetic education under the supervision of a medical officer. Nine others released for diabetic education had to attend to routine work in the clinic setting. This effectively reduced the time spent on education. The remainder of DENOs  were still attached to their original work stations contrary to the directive. They had limited opportunity to take part in the diabetic educating activities. Those attached to wards and theaters lost opportunities to contribute to diabetic education due to heavy work loads.Although DENOs function under many constrains, they have invented several methods to attract and educate patients. Some of their suggestions were taken by the administration while others were not. Sending birthday cards to diabetic patients along with a reminder to attend a follow up screening for complications was a successful. This provides a platform to screen patients yearly with minimum effort. They also undertook the responsibility of drawing blood for tests in medical clinic. Hence, all the patients directed for the tests have to meet the DENO for an education session before attending the clinic. Exercise sessions and promotion of traditional food among clinic attendees were other novel methods undertaken.
Conclusion All healthcare staff need to be made aware of the importance of diabetic education and the role of DENOs for effective secondary prevention. Further, it is necessary to identify possible working models to deliver diabetic education according to the current resource level with provisions to upgrade service in an incremental manner. This would help maintain the service of diabetic education in a sustainable manner.The diabetic clinics need to be reorganized to minimize waiting time. Extended waiting time for services becomes an obstacle to retain the patient's attention during education sessions. Introducing an appointment system based on time blocks can minimize waiting time and overcrowding of clinics. Few hospitals have introduced this system with success.Unrealistic expectations of some DENOs themselves have negatively contributed to the programme. Due to over enthusiasm, some DENOs expect more independence and more resources to deliver their services. Although this would be the ideal model, such expectations may not be realistic within the present healthcare system. This has led to frustration, disappointment and conflicts. Hence, DENO training should include inputs on adaption to local context, team work, diplomacy and negotiation skills.Following the training neither the NIROGI project or the ministry was able to establish a focal point for DENOs to communicate when they needed technical or administrative support. Hence, DENOs have resorted to ad-hoc measures at individual level. There is an urgent need to institute a mechanism to coordinate DENO functions within the existing system. The Ministry of Health needs to take the responsibility of maintaining and upgrading the DENO initiative if it is to sustain.

Diabetes is a chronic disease, hence it is necessary to provide regular inputs to patients and opportunity for them to discuss their issues. Patients who are less compliant, ignorant and difficult to change are the very group missing from care at present. In consideration of the current workload of DENOs the follow-up system for health education need to be tailor-made according to the resource level of the institution. Although the directive on DENO duty mentions an information system, a systematic method is still not in place. An information system that can be used for planning and resource allocation needs to be established. However, even in the context of these shortcomings, when opportunity is given DENO can contribute effectively to the secondary prevention of diabetes.

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