Management of Diabetes among other non-communicable diseases has recently drawn substantial attention due to its associated complications and socio-economic impact.
Lack of knowledge among health care providers has been found to be one of the major obstacles in the management of hyperglycemia [13, 14]. Among health care providers, our trainee residents and nurses possess a significant role in provision of care to these patients. Before developing a teaching material for educational activities for health professionals, a comprehensive assessment of health professional’s current knowledge must be done. The present study assessed whether our trainee residents and nurses are well-equipped in terms of their knowledge to manage patients with diabetes. Identification of the gaps in the knowledge would help us in highlighting these areas more specifically in future educational programs with an ultimate aim of improving diabetes care delivery in Pakistan.
According to this current study, the overall mean score of the participants was found to be quite low which points towards the inadequacy of diabetes training. The results were even lower to the study, from which the tool was acquired (61%) [11] and other study done in UK [14]. In contrast, the results were better than one of the recent study done in Switzerland (43 ± 22) [12] but the difference could be attributed to the use of a slightly advanced questionnaire. The results were also low in comparison to the previous study investigating the diabetes related knowledge among family physicians in Pakistan (62%) [10]. These results are distressingly low keeping in view the exceedingly high number of diabetics in our country. Since the burden of non-communicable diseases like diabetes not only depends on preventive measures but also on the optimal care provided to existing cases.
The expected increment of knowledge from first to second year of IMR truly reflects impact of good quality postgraduate training. But subsequent lack of improvement consistent with findings from another study [15] points towards the lack of knowledge among senior medicine house staff. Interestingly, one of the intervention studies revealed that even with education the knowledge plateaus at a senior level [16]. In comparison, FMR & SR didn’t show any significant augmentation in their knowledge with their level of experience pointing towards need to add more diabetic sessions and lectures in their curriculum. These findings demonstrate that educational intervention should focus all PGY levels with greater emphasis on reinforcement of the same knowledge through lectures and tutorials. Furthermore, the gap in diabetes related knowledge among SR found in our study and two other previous studies [11, 12] is a source of concern since diabetic patients are extremely prone to adverse outcome of surgery if not managed optimally. Moreover, majority of the patients admitted under surgical care have underlying diabetes and evidence suggest that good glycemic control reduces the rate of blood transfusion, the need for dialysis, critical illness polyneuropathy, blood stream infections and hospital stay [17]. One could strongly argue that frequent consultation with diabetologists could resolve this issue. However, reluctance of health care providers to follow the recommendations of endocrine service was one of the most frequent barriers acknowledged in a study to control hyperglycemia in hospitalized patients due to various misconceptions [14]. Hence, to prevail over this clinical inertia, residents including SR need to have basic knowledge concerning management of hyperglycemia. Insulin is identified as one of the highest risk medications, globally and with an advent of new insulin analogues it is observed that most of the trainee residents and nurses are not very well acquainted with these new insulin formulations, so the chances of errors are amplified. Our study clearly proved this and demonstrated that majority of the participants especially nurses were not aware of the time action profile of these new insulin analogues.
The most serious problem recognized in this study was inadequate knowledge of RN regarding management of diabetes. Previous studies have also revealed the deficiency in their knowledge with scores of 41-72% [9, 11, 12, 18, 19] but our results are quite inferior to the results of above mentioned studies. Nurses play a major role in the treatment of diabetic patients and should be well equipped to perform recommended standards of care. A Cochrane review revealed that trained nurses can indeed replace physicians in various aspects of diabetes management [20].
Limitations
One of the limitations of our study might be small sample size of the participants belonging to FMR attributable to paucity of family practice training institutes in our setting. Worldwide, the care of diabetic patients has been moving from specialist to family/general physicians [21] pointing towards the need of more training programs for family medicine specialty in our setting. Undoubtedly family practitioners play fundamental role in promotion of health care and many countries depend on them for provision of affordable care to their patients. This limitation therefore highlights lack of family practice training programs in Pakistan which should be dealt to promote primary health care system in the country.
Another limitation could be the format of questionnaire since open ended questions can create difficulty for test takers and results in larger item non-response [22]. In contrast the chances of bias because of leading questions are reduced in assessment using open ended questionnaire since there are no clues in the questions for the participants.
Although the study tool was not validated on our population, however we performed content validity and agreement between subjects by doing Cronbach α which showed better internal consistency.
On the other hand, the multicenter nature is the major strength of our study maximizing the generalizability of the results. Moderately decent response rate of the participants despite of the use of open ended questionnaire also points towards the fact that trainee residents and nurses are also keen to learn the management of this important disease entity.