An Evaluation of Patient Education Practice by Nurses in the Community Sector: Perspectives from a Diabetic Healthcare Centre in the Kingdom of Saudi Arabia- Western Region
An Evaluation of Patient Education Practice by Nurses in the Community Sector: Perspectives from a Diabetic Healthcare Centre in the Kingdom of Saudi Arabia- Western Region
3.3. Sampling Technique and Sample Selection. 8
3.4. Study Participants and Research Setting. 8
3.5. Data Collection Techniques. 8
3.5. Ethical Considerations. 9
4.1. Contributions and Implications of the Study. 9
4.2. Limitations of the Study and Anticipated Problems. 10
1. INTRODUCTION
Diabetes mellitus is a chronic and progressive condition that affects almost every aspect of life of an individual who is diagnosed with. According to the figures made available by the World Health Organization (WHO, 2014), the number of people worldwide diagnosed with diabetes increased from 108 million in 1980 to 422 million in 2014. This is alarming considering the fact that diabetes can have a negative impact on almost all the essential parts of the body, such as the kidneys, the heart and others. It can also lead to vision loss, nerve damage and leg amputation. Apart from causing physical damage, diabetes is also said to cause economic loss to people with diabetes and their families, as well as health systems.
In its toolkit to help people prevent diabetes, the International Diabetes Federation (IDF, 2010) stresses that following a healthy diet, engaging in regular physical activity and maintaining a healthy body weight are essential in preventing the onset of diabetes in adults. However, many people fail to adopt these measures for various reasons. For years, several attempts have been made to help people with diabetes manage their condition better. These include providing patient education,improving self-management among patients, helping patients use the latest technology to monitor their condition and others (Diabetes UK, 2015; Powers et al., 2015; Sturt et al., 2005). However, in spite of these efforts, it is still unclear what kinds of resources can help patients better manage their condition. In fact, in its report the WHO (2016) concludes that there is no single solution to diabetes and that it is necessary for patients with diabetes to adopt coordinated, multi-component interventions if they want to improve their condition.
The situation of people living with type 2 Diabetes is worse among people living in developing countries such as the Kingdom of Saudi Arabia (KSA). For example, several studies (Al-Nozha et al., 2004; Al Quwaidhi, 2013) indicate that the prevalence of type 2 diabetes in Saudi Arabia is increasingly rapidly. It has also been found that KSA faces one of the highest rates of type 2 Diabetes in the world and is expected to be the seventh country in the world to have the highest number of people living with Type 2 Diabetes by the year 2030 (Bani, 2015). According to Almutairi (2015), culture and language differences serve as a major communication barrier between patients and healthcare workers in the KSA. According to the author, this barrier in turn hampers the ability of the healthcare workers to provide quality care to patients in the KSA.
According to studies (Atak et al., 2008; Karakurt&Kasikci, 2012; McGowan, 2011) the effects of provision of patient education are positive on people living with type 2 diabetes. The reasons for the positive effects are that patient education which the World Health Organization (WHO, 1998; pp. 29-57) defines as something that ‘enables people with chronic diseases to manage their illness and yields benefits in both health and financial terms’ can help patients with type 2 diabetes improve their self-care and help them manage their condition better. For this study, the definition of patient education provided by Oyetunde and Akinmeye(2015) will be used. In their study, Oyetunde and Akinmeye (2015, p. 505) define patient education as “activities performed by health care professionals, aiming at achieving better health outcomes for patients. This is achieved through the provision of information, knowledge and skills that are necessary for the management of their health and illness concerns”.
The continuing increase in the number of people with type 2 diabetes in the KSA and all its consequences such as coronary heart disease, impaired vision and others is what has motivated the current study. As noted above, patient education plays an important role in helping patients with type 2 diabetes manage their condition better. However, there are cultural and language barriers hamper the provision of quality care inthe KSA. Hence, in particular, the study proposed here argues that educating patients with diabetes can help them effectively manage their condition and that nurses’ play a critical role in providing this education. As a result, it is important to help healthcare workers in theKSA to improve their patient education practice. This is mainly because patient education can not only help those patients suffering from diabetes to manage their condition better, but can also lead to health promotion among others.
Purpose and Research Questions
Over the years, there have been dramatic changes in patient education practice. From disseminating pamphlets in clinics to providing educational programmes on specific health conditions, patient education techniques have changed rapidly. A number of studies, such as those of Coppola et al. (2015) and McGowan (2011) have suggested that patient education can greatly help in improving the compliance and self-care skills of diabetic patients and prevent future complications. There is no doubt that nurses have an important role to play in diabetes patient education. However, research (Findlay & McDowell, 2002; Davies & Buxton 2015; Mogre, et al. 2015; Cardwell, et al. 2016) has shown that nurses have a very low level of diabetes-related knowledge. This in turn greatly hampers their ability to provide relevant patient education and prevents them from effectively delivering quality care to their patients. Hence, considering the significance of nurses in providing patient education, it is of great importance to assess the challenges that they face in providing patient education to people suffering from diabetes and to identify resources that can help them – and other health educators – to provide such education effectively (Loveman, et al. 2008).
The main aim of the proposed study is to evaluate the knowledge level of nurses trained in the KSA pertaining to patient education for people with type 2 diabetes and determine the factors that act as barriers or hamper their ability to provide appropriate patient education. To achieve this aim, the knowledge of nurses in KSA pertaining to patient education concerning type 2 diabetes will be assessed using a multiple-choice questionnaire. In addition, nurses’ perception of their ability to provide patient education and any perceived difficulties they may have will also be explored through an open questionnaire. Finally, the study will highlight the implications of the study in terms how to support and improve nurses’knowledge and ability to provide effective and appropriate patient education to aid self-management/empower/enable patients with type 2 diabetes to manage their condition and reduce short and long term destructive consequences. In order to reach the purpose of the study, the following research questions will be examined.
- How do nurses in Saudi Arabia perceive the importance of patient education for patients with type 2 Diabetes?
- What are the factors that nurses in the KSA perceive as barriers when providing patient education to patients with type 2 Diabetes?
This proposal is organized as follows. Section 2 provides a summary review of the literature, defining patient education and assessing the role of nurses in this regard, as well as addressing factors that hamper nurses’ ability in providing patient education and the diabetes-related knowledge of nurses and its impact on patient education. It also considered measures taken to enhance nurses’ knowledge of type 2 diabetes. The main aim in conducting this review is to help identify factors that prevent and enhance the delivery of patient education by nurses related to type 2 diabetes. Section 3 addresses the research approach, design, and methodology that will be used to conduct this study, providing information on the sample (participants), data collection, ethical considerations and data analysis (quantitative and qualitative). The final section considers the implications and limitations of the study and outlines the timetable for the research.
2. LITERATURE REVIEW
Over the years, several attempts have been made to define patient education. For example, WHO (1998; pp. 29-57) defined patient education as something that ‘enables people with chronic diseases to manage their illness and yields benefits in both health and financial terms’. In some cases, patient education is defined as a patient’s right and a healthcare provider’s responsibility, specifically in educating patients about the prevention and management of any medical condition (WHO, 1998). Coppola, et al. (2015), summarizing the work of previous researchers on the importance of patient education in the management of type 2 diabetes, highlight that patient education is not only effective in improving clinical, lifestyle and psycho-social outcomes, but also helps in the treatment and prevention of the condition. Oyetunde and Akinmeye (2015) state that nurses are critical in the provision of patient education. In practice, teaching or educating patients about their specific health problems and care has been always considered one of the key functions of nurses.
For years, nurses have been found to help patients take control of their own health. However, over the years, a stream of research has emerged showing that nurses face several challenges or barriers which hamper their ability in providing patient education. For example, factors such as lack of time and knowledge, lack of training and lack of confidence have been found to hamper nurses’ competence in providing patient education. So far this is a little repetitive of the Introduction – add more depth
With regard to diabetes mellitus, a large number of studies assessing the diabetes-related knowledge of nurses have been conducted. The results of these studies indicate that nurses lack basic knowledge concerning diabetes (Cardwell, et al. 2016) and that their knowledge of the complications (Davies & Buxton, 2015) and associated factors and nutritional management of diabetes is poor (Ahmed, et al. 2012; Mogre, et al. 2015). This not only increases the incidence of type 2 diabetes, but also results in exacerbating the severity of the complications among patients with diabetes. This is mainly because lack of knowledge on the part of healthcare providers, such as nurses, serves as an obstacle to the effective management of hyperglycaemia in diabetic conditions (Davies & Buxton, 2015). However, it has to be noted that many of these studies have been conducted outside the Middle East. Little or no empirical research examining the knowledge of nurses’ pertaining to type2 diabetes in Middle Eastern countries such as theKSA has been conducted. Hence, the purview of this study will be to assess the knowledge of patient education pertaining to patients with type 2 diabetes of nurses educated in the KSA, as well as to highlight the barriers that affect nurses’ ability to provide patient education to people with type 2 diabetes.
3. RESEARCH AND METHODOLOGY
3.1. Research Purpose
Gray (2004) states that research can be divided into three groups in terms of purpose, namely descriptive, exploratory and explanatory. As discussed earlier, the main purpose of this study is to assess the knowledge of nurses in relation to patient education and identify the factors that serve as barriers to the provision of patient education. Keeping this in mind, this study is descriptive and exploratory in nature. This study is descriptive because it attempts to study an area with already existing information, or nurses’ knowledge of patient education and diabetes in general. As the study also seeks to explore the relationship between nurses’ knowledge concerning patient education and the barriers that hinder them from offering quality patient education, this study is, to some extent, also exploratory in nature. Hence, the research purpose of the studies can be divided as follows:
- Assess nurses’ knowledge with regards to patient education pertaining to Type 2 Diabetes
- Identify the barriers that nurses’ experience when providing patient education to patients with Type 2 Diabetes
3.2. Research Approach
There are three major approaches to research. Philosophically, these reflect a world view (empirical or naturalistic enquiry) and are more commonly referred to as quantitative, qualitative and mixed methods. Quantitative research draws on the collection of quantitative or numerical data; qualitative research employs the collection and analysis of qualitative, usually textual data; the mixed approach includes both quantitative and qualitative techniques (Creswell 2008). According to Creswell (2008), researchers predominantly refer to existing studies and then gather and analyse data. In a qualitative approach, researchers study a limited number of objects and do not aim to generalize the findings of the study.
According to Moule and Goodman (2008), the quantitative approach to conducting research in nursing is most suitable when testing knowledge. On the other hand, the qualitative approach is most suitable when gathering personal views and experiences of people. As the aim of this study will be to assess the knowledge of nurses in patient education, as well as to determine barriers that prevent nurses from providing patient education, it will use both quantitative and qualitative approaches, i.e. mixed methods. Wisdom, et al. (2012) point out that when carefully used and implemented the mixed methods research approach can help improve understanding of health services. The authors add that in this field, the mixed methods approach can assist in providing a relatively comprehensive picture of health care provision. Another major reason for using the mixed methods approach is that this methodology when applied in nursing research can greatly help strengthen the depth and breadth of understanding of a particular nursing phenomenon (Doorenbos, 2014).The quantitative approach used in this study will help in the assessment of the knowledge of nurses concerning patient education with regard to type 2 diabetes, whereas the qualitative dimension will help determine the views of the nurses in terms of the barriers they encounter when providing patient education.
3.3. Sampling Technique and Sample Selection
Oppong (2013, pp. 203) defines sampling as ‘a process of selecting subjects to take part in a research investigation on the ground that they provide information considered relevant to the research problem’. According to Oppong (2013), there are three types of sampling technique that researchers can use in qualitative research. These include: a) convenience sampling, b) judgment or purposive sampling and c) theoretical sampling. Convenience sampling is one of the most widely used sampling techniques. This is mainly because it involves low cost, time and effort. However, this type of sampling technique, when used without a well thought-out procedure, can lead to the risk of gathering poor quality data and to poor research outcomes. On the other hand, the judgment or purposive sampling technique is used when a researcher wants to obtain data from participants who are experts and knowledgeable about the issue under investigation (Oppong, 2013). In the theoretical sampling technique, the researcher tries to devise explanatory theories that emerge from a specific line of information, i.e. the researcher tries to test an already configured theory using a new sample (Oppong, 2013).In this study, the judgment or purposive sampling technique will be used as the main aim of this study is to assess the knowledge of nurses concerning patient education with regard to type 2 diabetes. Thus, the main rationale for using this type of sampling method is that it will enable assessment of the knowledge of those experts (nurses) who deliver patient education to people with type2 diabetes.
3.4. Study Participants and Research Setting
The study will involve a minimum of 40 participants (nurses), working as diabetic educators at a diabetic healthcare centre in the KSA (Western Region).
3.5. Data Collection Techniques
A survey will be conducted using a questionnaire to gather data from the participants. The questionnaire was devised from a number of studies that dealt with the issues in administering patient education. The questionnaire will also be pilot tested and validated from a group of expert nurses to evaluate its validity and reliability. As this study will use a mixed methods approach, the questionnaire will consist of both closed and open-ended questions: closed questions are most suitable for obtaining data that need to be quantified, whereas open-ended questions are most appropriate in gaining data for qualitative study. In this study, knowledge of the participants with regard to patient education will be assessed using Likert scale items, i.e. quantitative data. In contrast, the open-ended items will collect qualitative data to address themes concerning the barriers that nurses face when providing patient education. The following are some questions that will be asked of the participants with regard to obtaining qualitative data:
- What do you understand by ‘patient education’?
- How do you go about educating patients who have type 2 diabetes?
- Do you use any assessment or framework to guide you when educating the patients?
- Please describe the self-management advice that you give to patients with type2 diabetes? How effective do you think this is and how do you determine this?
- Are there any particular barriers that you feel you encounter when providing patient education to patients with type 2 diabetes?
- In your opinion are there any improvements that could be made in providing education to patients with type 2 diabetes?
As far as obtaining data for the quantitative part of the study is concerned, the participants will be asked for their views concerning the provision of education to patients with type 2 diabetes. A competency based strategy will be used to measure the knowledge and practice of patient education among the nurses sampled. For example, a list of key competencies considered important for patient education such as the importance of ‘continuing patient education concerning type 2 diabetes’, ‘the need for special training’, will be used to assess the competency of the nurses. The nurses would then be asked about the factors that serve as barriers to providing patient education such as ‘lack of referrals from physicians’, ‘lack of interest from patients ‘and ‘lack of knowledge on the part of providers ‘and others. These responses will be measured using a Likert scale. The questionnaire will be available via the World Wide Web. How exactly – closed access survey tool?
Quality Standards
To increase the validity of the study, a triangulation method will be used. Since this study consists of mixed-method approach, a methodological triangulation technique will be used to enhance the credibility of the study.
3.5. Ethical Considerations
The Middlesex University Research Ethics Review Form will be completed and permission for the research will be obtained from the Middlesex University Ethics Committee. Ethical approval will also be gained from the diabetic healthcare centre in Saudi Arabia.
3.6. Data Analysis
The quantitative data obtained will be analysed using the Statistical Package for the Social Sciences (SPSS) software. What specifically will be looked for ie correlations/t-tests/descriptivesetc The qualitative data obtained will be analysed using content analysis to derive themes, helping express the ideas of the nurses with regard to the barriers they encounter when delivering patient education to people suffering from type 2 diabetes. This type of qualitative data analysis technique is effective in this field because it allows nurses not only to critique the findings obtained from the data, but also consider how the knowledge obtained can be made applicable to nursing (LoBiondo-Wood & Haber, 2014).
4. CONTRIBUTIONS AND IMPLICATIONS, LIMITATIONS AND TIMETABLE
4.1. Contributions and Implications of the Study
As this study will assess the knowledge of nurses with regard to providing patient education to people with type 2 diabetes and will examine barriers that nurses face when delivering patient education, it aims to make a useful contribution to the literature, practice and policy making in terms of enhancing the provision of patient education to diabetic patients, especially in the KSA, in various ways. First, by assessing existing knowledge, it will help identify the level and accuracy of knwoeldge?whether or not there is a need to enhance the knowledge of nurses, especially those working in the KSA, with regard to patient education. Second, this study will seek to identify whether or not there are any attitudinal?l perceptual? socioeconomic, cultural and political barriers that hamper nurses’ ability to provide patient education. It will also highlight ways these barriers can be eliminated by identifying the resources that could help them enhance their practice in relation to patient education concerning people with type 2 diabetes. Finally, as this study seeks to provide useful insights for the wider healthcare community in terms of enhancing patient education with a view to managing type 2 diabetes, it will also contribute to enhancing the outcomes for patients living with type 2 diabetes.
Therefore, this study has implications for theory, practice and policy making, including suggestions for the healthcare community, incorporating not only nurses and other healthcare practitioners, but also healthcare authorities, in terms of enhancing nurses’ knowledge of patient education and identifying and rectifying the challenges that currently hinder nurses from delivering effective patient education to people with type 2 diabetes.
4.2. Limitations of the Study and Anticipated Problems
As in any research, this study will have its limitations, particularly arising from the use of the mixed methods approach. For example, Wisdom, et al. (2012) and Guba (1989) state that when using mixed methods, it is important to adhere to the standards of each method, which is a challenge as the criteria for quantitative and qualitative approaches differ. Moreover, the sample size used in this study will be too small to generalize the findings of the study also, getting a substantial response to the questionnaire which is notoriously difficult, especially among populations such as nurses, who are extremely busy; as Wisdom, et al. (2012) point out, quantitative analyses require much larger sample sizes to attain any statistical significance. Hence, the assessment of nurses’ knowledge concerning patient education conducted in this study may lack adequate statistical power and it may be difficult to generalize the findings of this study beyond the specific sample, let alone to other healthcare settings.
4.3. Timetable
| Activity | Calendar |
| Questionnaire administration | over 2 weeks |
| The literature review | over 6 weeks |
| Data analysis and editing of the survey tool | 3 weeks |
| Completion of full study | 20 weeks |
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