Subject for Dissertation

SYNOPSIS FOR REGISTRATION OF

SUBJECT FOR DISSERTATION

SUBMITTED BY:

Mrs. BRONYA B

I M.Sc. NURSING

MEDICAL SURGICAL NURSING

(2012-2014 BATCH)

SHARABHESWARA COLLEGE OF NURSING

6TH WARD, GUGGARAHATTI, BANGALORE ROAD,

BELLARY – 583 102

SYNOPSIS FOR REGISTRATION OF SUBJECT FOR DISSERTATION

INTRODUCTION

The term diabetes mellitus (DM) describes a metabolic disorder of multiple etiological factors characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both1,2.

Diabetes is a global public health problem, a chronic disease and is now growing as an epidemic in both developed and developing countries3. Diabetic Mellitus is recognized as one of the leading cause of death and disability worldwide. The physical, social and economic factors involved in the management of diabetes are a continuous strain for health sector as well as to Government Agencies4.

One of the world's leading research and advisory firms focusing on pharmaceutical and healthcare issues finds that the prevalence of Diabetes in India is among the highest in the world with more than 28 million cases in 2007 and it will grow more rapidly in India than in any other developing or developed nation and World Health Organization also expected that approximately 366 million people in the world by the year 203011; 60 million cases by 201712 and 80 million cases by 2030 will be affected by Diabetic Mellitus in India alone5.

The peak incidence of Type I diabetes is at 10-12 years with a small male predominance. Nevertheless, elderly people can also have Type I diabetes and some children have Type II diabetes. The prevalence of diabetes is higher in men than women, but there are more women with diabetes than men. The urban population in developing countries is projected to double between 2000 and 2030. The most important demographic change to diabetes prevalence across the world appears to be the increase in the proportion of people with greater than or equal to 65 years of age6.

Knowledge about Diabetic Mellitus is a prerequisite for individuals and communities to take action for control the diabetes7.

6.0 BRIEF RESUME OF THE INTENDED WORK

6.1NEED FOR THE STUDY

People with diabetes are at increased risk of cardiovascular, peripheral vascular and cerebrovascular disease1,2. Many of these complications can be prevented with appropriate timely medical care8.The treatment for Diabetic Mellitus includes administration of Oral Hypoglycemic agents and inject able Insulin therapy along with life style modifications9.

Insulin therapy is a cornerstone of treatment in type I diabetes and, in many cases, also critical to the management of type 2 diabetes. Despite evidence documenting the benefits of insulin therapy in achieving glycemic control and reducing risk of long-term diabetes complications,1-4 insulin therapy remains under utilized,5, 6with only 29% of adults with diabetes using insulin world wide10.

This underuse reflects numerous barriers to treatment initiation as well as obstacles that hinder treatment adherence. Errors in insulin injection further curtail the ability of many patients to attain glycemic goals. According to two recent surveys, at least one third of patients fail to take their insulin as prescribed 8, and 20% of adults intentionally skip their doses11.

Furthermore, despite the essential role of insulin therapy in the management of type I diabetes, compromised adherence is also common among younger patients with this disease, with many failing to follow their treatment plans12.

Resistance to insulin therapy among both patients and providers is a major problem, as elucidated by the landmark Diabetes Attitudes, Wishes, and Needs (DAWN) Study13.

Often the reluctance among patients is psychological and founded on myths and misconceptions14.Providers’ attitudes and beliefs are also implicated in the clinical inertia that underpins insulin underutilization15.

The Diabetes Attitudes, Wishes, and Needs (DAWN) Study revealed that insulin therapy begins later in the United States than in most other countries due to the belief among many clinicians that insulin therapy should be delayed until absolutely necessary11.

The insulin therapy requires coordination and understanding of both the individual with diabetes and those responsible for diabetic care. There is no definite insulin dose that works well for every individual, the dosage of insulin changes based on patient's blood glucose levels and the type of insulin used. Therefore, insulin treatment must be individualized to fit the life style of the individual and metabolism of individual with diabetes. The changes and modifications are made as needed throughout the life of individual with diabetes 15. Information and Education gives consequent improvements in knowledge, attitudes and skills which leads to better control of the disease and is widely accepted to be an integral part of comprehensive diabetes care7. Patient education has been proven to be an effective method in management of prevailing health problem16.

More emphasis should be given to the standardization and improvement of Insulin Self Administration technique, focusing on proper teaching of those techniques, the people to become more aware of their responsibility and make fewer mistakes during Insulin administration17. Since, the treatment of diabetes continues for lifetime, there is a need to monitor the knowledge, understanding and competency level of clients in relation to their disease process and its management18. Research Studies have conducted in different parts of the world showed the evidence of inadequate knowledge and poor practice level on Insulin Self Administration among Diabetic Mellitus patients19-20. It was proved that there is an increasing amount of evidence that the patient education is the most effective way to lessen the complications of diabetes and its better management21. Investigator of earlier studies was perceived that knowledge of diabetics on self care management needed to be strengthened.

With this view, the present study will carried out to assess the knowledge levels of diabetic patients on diabetes and Insulin Self Administration; to evaluate their practice skills of Insulin Self Administration; to determine the association of knowledge and practice with selected demographic variables; to scrutinize the most common incorrect and correct procedures in the Insulin Self Administration technique and to establish the professional responsibility in providing instructions on how to self administer insulin.

6.2REVIEW OF LITERATURE

A non experimental descriptive study was conducted for sixtydiabetic patients to assess the knowledge and practice regarding Insulin Self Administration with selected demographic variables. Semi structured interview schedule was used. The results of the study revealed that the patients on insulin did not have adequate knowledge, practice and skill on Insulin Self Administration and there was a positive correlation between knowledge and practice of Insulin Self Administration and concluded that the education is likely to be effective when the characteristics of the patients in terms of their knowledge, attitude and practices about self care management are known. Therefore, it is of paramount importance, that people with diabetes mellitus should be provided with ongoing high quality need based education to be delivered by skilled health care provider22.

A descriptive study was conducted for 526 to assess knowledge of people with diabetes use correct injection techniques. A semi structured questionnaire was used to collect the data and results revealed that use of correct insulin injection therapy is a vital part of nurses' role and concluded that nurses should enhance the professional responsibility to teach technique for patients with diabetic for their better gycemic control and emphasises the importance of ongoing patient education and regular reviews of knowledge and technique23.

A study was conducted to for 200 diabetic patients on the practices of insulin self-injection techniques. The results highlight in particular the importance of patient education and concluded that patients were having poor knowledge on insulin administration technique24.

A cross-sectional study was conducted for 169 patients were selected by simple random sampling to describe the most common correct and incorrect self administration techniques for insulin using disposable syringes by patients cared for by the 37 Family Health Strategy, the results identified that errors in all the steps recommended by the American Diabetes Association and Brazilian Diabetes Association for the safe administration of insulin, from hand washing to compression on the injection site. The study recommended the development of interventions focused on education of patients regarding insulin injection25.

A study was conducted to investigate the acquisition of skill in the self-administration of insulin (by insulin pens) among 79 diabetes outpatients. The degree of skill acquisition by patients with poor glycemic was significantly lower than that by those with good control and patients who had continuously used insulin pens over a 3-year period had higher rates of incorrect usage. In addition, the patients who kept the needle of the insulin pen pointing downwards for a certain period of time was significantly lower than that for those who held the needle downwards for less than this period of time. These results indicated that the precise acquisition of skill in the self-administration of insulin is necessary to achieve good glycemic control and that keeping the needle pointing downwards for a sufficient period of time is the most important factor in the self-administration procedure and study suggested that medical staff should keep a check on the skill of patients in the self-administration of insulin and repeatedly provide instruction on this to patients26.

A cross-sectional study was conducted for 269 patients to compare two groups of patients with diabetes mellitus treated under the Family Health Strategy, with insulin self-administration versus non-self-administration, by simple random sampling out of 37 Family Health Strategy units in the urban area of a municipality in the State of Minas Gerais, Brazil. The self-administration group consisted of 169 individuals (62.8%), as compared to 100 (37.2%) in the non-self-administration group. Comparing the two groups, schooling was statistically significant, 45% of those who did not self-administer reported absence of physical or cognitive difficulties that might prevent them from conducting the procedure, demonstrating the potential for adherence, 90% reported needing assistance in the insulin administration process at home and of these 75% reported receiving assistance from family members27.

An analytical study was conducted on issues of insulin self injection in elderly in Japan. The study evaluated the procedure in 194 outpatients, using a checklist. The study results showed that errors in insulin self-injection were found in about 145 patients that is nearly 66%. There were more errors in the elderly group (aged >65 years) than in the adult group (aged <65 years). The researcher concluded that it is necessary to perform periodical confirmation of insulin self-injection at all ages28.

A descriptive study was conducted for 113 patients with diabetics regarding use of disposal syringes in the administration of insulin at home with a aim to learn the utilization and reutilization of disposable syringes for administration of insulin at home, the results showed that 98.2% of patients used disposable syringes and 94.6% reused the disposable syringe. The study suggested that unhealthy practice had to be changed by giving education to prevent complication related to insulin wrong administration29.

An exploratory study to determine the prevalence of psychological insulin resistance among type I diabetic patients in USA. A total of 100 samples were selected randomly. The results showed that 33% of patients with type II diabetes mellitus were unwilling to take insulin due to misconceptions. The researchers identified several misconceptions regarding insulin therapy and suggest targets for educational interventions30.

A Chennai urban rural epidemiology study was conducted on awareness and knowledge of diabetes in Chennai. A structured Questionnaire administered to 26,001 individuals, and the result shows that only 75% (19642/26001) of the whole population reported that they know about a condition called diabetes, nearly 25% of the Chennai population was unaware of the condition called diabetes. 602% of all participants and 76.7% of the self reported diabetic subjects know that the prevalence of diabetes was increasing in India. Only 22.27% of the whole population and 41.0% of the Known diabetic subjects were aware that Diabetes could be prevented. Awareness and knowledge regarding diabetes is still grossly inadequate in India. Massive diabetes education programmers are urgently needed both Urban and rural India31.

6.3STATEMENT OF THE PROBLEM

“STUDY TO ASSESS THE EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE AND PRACTICE REGARDING INSULIN SELF ADMINISTRATION AMONG CLIENTS WITH TYPE I DIABETIC MELLITUS IN SELECTED HOSPITAL AT BELLARY.”

6.4OBJECTIVES OF THE STUDY

1. To assess the existing knowledge of clients with Type I Diabetic Mellitus regarding Insulin Self Administration by administering knowledge questionnaire.
2. To assess the practice of clients with Type I Diabetic Mellitus regarding Insulin Self Administration by administering observation check list.
3. To evaluate the effectiveness of structured teaching programme by determining the difference between the mean pretest and post test scores regarding knowledge and practice of clients with Type I Diabetic Mellitus regarding Insulin Self Administration.
4. To correlate the improvement knowledge and practice of clients with Type I Diabetic Mellitus regarding Insulin Self Administration in selected hospital.
5. To find an association between posttest knowledge and practice score with selected demographic variables.

6.5OPERATIONAL DEFINITIONS

ASSESS: Assess refers to statistical measurement on knowledge regarding Insulin Self Administration among clients with Type I Diabetic Mellitus regarding by using self administered questionnaire.

EFFECTIVENESS: In the present study Effectiveness refers to gain in knowledge and practice as determined by significant difference in pre and post test knowledge and practice score.

STRUCTURED TEACHING PROGRAMME: In the present study Structured Teaching Programme refers to a systematically organized plan of teaching on knowledge and practice regarding Insulin Self Administration among clients with Type I Diabetic Mellitus regarding in selected hospital.

KNOWLEDGE: In the present study Knowledge refers to level of understanding of clients with Type I Diabetic Mellitus regarding Insulin Self Administration in selected hospital.

PRACTICE: In the present study practice refers to the performance of any act in the care of the ill or injured.

TYPE I DIABETIC MELLITUS: In the present study Type I Diabetic Mellitus refers to the a metabolic disorder of multiple etiological factors characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both.

INSULIN SELF ADMINISTRATION: In the present study Insulin Self Administration refers to the steps of injecting insulin subcutaneously by the type I diabetes mellitus clients by themselves.

6.6HYPOTHESIS

H01:There is no association difference between pre test and post test knowledge and practice among clients with Type I Diabetic Mellitus regarding Insulin Self Administration in selected hospital.

H02: There is no significant relationship between knowledge and practice among clients with Type I Diabetic Mellitus regarding Insulin Self Administration in selected hospital.

H03:There is no significant association between the post test knowledge and practice score with selected demographic variables.

6.7 VARIABLES IN THE STUDY

INDEPENDENT VARIABLE: Structured teaching programme

DEPENDENT VARIABLE: knowledge and practice regarding Insulin Self Administration among clients with Type I Diabetic Mellitus in selected hospital.

DEMOGRAPHIC VARIBLES: Age, sex, qualification, religion, occupation, income, type of family, family history of diabetic mellitus, duration of illness, duration of insulin therapy, previous exposure to insulin self administration training.

7. MATERIALS AND METHODS

1. Clients with Type I Diabetic Mellitus in selected hospital.
2. Those clients who are willing to participate in the study.

7.2.1 TOOL FOR DATA COLLECTION

Section-1: Will contain demographic variables.

Section-2: Will contain structured self administered questionnaire and observation check list to assess the knowledge and practice regarding insulin self administration respectively.

7.2.2 METHOD OF DATA COLLECTION

Pre-test knowledge and practice will be assessed by using structured self administered questionnaire and observation check list respectively it will be followed by a structured teaching program and a post test will be conducted at the end of seven days by administering the same questionnaire and observation check list respectively.

7.2.3 METHOD OF DATA ANALYSIS

The investigator will analyze the data obtained, by using the descriptive and inferential statistics.

The plan of data analysis as follows:

• Organize the data in a master sheet or computer.
• Descriptive statistics: Mean, Mode, Median, percentage and standard deviation will be used for assessing the demographic characteristics.
• Inferential statistics: Student‘t’ test will be used to find out the significance.

7.3DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTIONS TO BE CONDUCTED ON OTHER HUMAN OR ANIMALS? SO PLEASE DESCRIBE BRIEFLY.

No.

7.4 HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM INSTITUTION?

• The ethical clearance is obtained from the research committee of Sharabheswara college of Nursing.
• Written permission will be obtained from the concerned authorities of selected hospital.
• Written consent will be obtained from the each of the participants.

1. LIST OF REFERENCES

1. World Health Organization. Definition, diagnosis and Classification of diabetes mellitus and its Complications: Report of a WHO Consolation. Geneva: World Health Organiztion; 1999.
2. Shu AD, Myers MG, Shoelson SE. Pharmacology of endocrine pancreas. In: Golan DE, Tashjian Jr AH, Armstrong EJ, Armstrong AW, editors. Principles of pharmacology the pathophysiologic basis of drug therapy. 2nd ed. New Delhi: Wolters Kluwer (India); 2008.
3. Zimmet. P Z. Diabetes epidemiology as a tool to trigger diabetes research and care. Diabetologia. 1999; 42:499-5.18.
4. Neelammakol, Manisha. Diabetes an emerging health problem in India. Health action. 2008. Nov 4; 6 (10):4, 5, 14, 16.
5. Prevalence of diabetes.

Available URL: cited on 2009 Nov 04.