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Problems that nurses confront in Primary Health Care in Kosovo in relation to diabetic patients at r

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Title: Problems that nurses confront in Primary Health Care in Kosovo in relation to diabetic patients at r


1
Problems that nurses confront in Primary Health
Care (in Kosovo) in relation to diabetic patients
at risk from developing foot ulcersMSc
Bukurije Cikaj
2
Introduction
  • It is well known that the prevalence of Diabetes
    Mellitus worldwide is increasing (Wild et al
    2004), so that long term diabetes related
    complications are likely to become more common.
  • In particular, diabetic foot ulcerations remain
    one of the most prevalent and serious
    complications associated in Diabetes Mellitus
    (Shojaie Fard et al 2007) and represents major
    medical, social and economic problems all over
    the world (Currie et al. 1998, Boulton et al
    2004, Boulton et al 2005).

3
Amputation
  • Every 30 second, somewhere in the world a leg is
    lost due to diabetes (Papanas et al 2006
    Jeffcoate and Bakker 2005).
  • Amputation is one of the most costly and feared
    surgical interventions resulting from diabetic
    limb disease (Krishnan et al 2008).
  • 85 of all amputations in people with diabetes
    are preceded by foot ulcers (Frykberg 2002)
  • An understanding of pathogenesis of diabetic foot
    ulcers with early recognition of the causes and
    prompt management of the ulcer - essential and
    saving from amputations (Merza and Tesfaye 2003).

4
  • Epidemiological data on the diabetic foot in
    developed countries does exist
  • Prevalence of foot complications are lacking
    among diabetic population from developing
    countries (Morbach et al 2003), as well as in
    Kosovo
  • Health System Information in Kosovo is not fully
    developed
  • 1.39 of diabetes people admitted in Intern
    Clinic of Prishtina, had gangrene digits (Koqinaj
    2001)
  • 57.30 of the minor or major amputations in
    Vascular Surgery Clinic of Prishtina were as a
    result of diabetes (University Clinic of
    Prishtina, 2004)
  • Of all amputees, 50 are patients with diabetes
    (Levin, 2002)

5
  • None of any clinical guidance on diabetes
    management, tools for identification of at risk
    foot and ulcer classification schemes are
    available or used in Kosovo
  • Diabetes patients at risk of developing foot
    ulcers in Kosovo are identified based on risk
    factors asked during the check ups
  • Nurses challenges related to diabetic foot care
    have received little attention on worldwide
    research

6
Aim
  • The aim of the research is to identify and
    explore Kosovan nursing challenges in relation to
    diabetic patients at risk from developing foot
    ulcers

7
Methodology
  • A qualitative exploratory research

8
Methods
  • Constant comparative method of Strauss and Corbin
    (1998) analytical framework

9
Ethics
  • Ethical approval granted by the Glasgow
    Caledonian University
  • In the absence of Kosovo Nursing Ethical
    Committee, permission by the Kosovo Ministry of
    Health was also granted.

10
Findings
  • Seven categories conducted
  • Education (nurse and patient education)
  • Environmental constraints
  • Collaboration between professionals on foot care
  • Absence of network in Health Care Settings
  • Identification of high risk patients
  • Diabetic foot complications and their
    consequences , and
  • Professional autonomy

11
  • Education (nurse and patient education)
  • Need for nurse education on diabetes foot care as
    well as patient education
  • No training in relation to diabetic foot care has
    been offered up to now for nurses working in
    Primary Health Care (PHC) in Kosovo, or to nurses
    who work close to diabetes patients
  • Every Health Professional to be included on
    patient education
  • Raising patients awareness through health
    education

12
  • 2. Environmental constraints
  • Low socio-economic standard
  • Poor management and treatment of foot ulcers in
    PHC
  • Absence of health insurance
  • Absence of professionals on foot care in PHC
  • Kosovo Ministry of Health has not yet established
    any strategy which supports the development of
    multidisciplinary foot clinics.

13
  • 3. Collaboration between professionals on foot
    care
  • Only Family Physicians available
  • Non collaboration with other health professionals
  • Occasional collaboration with Diabetologist/Vascul
    ar Surgeon
  • Needs for network improvement between health
    institutions

14
  • 4. Absence of network in Health Care Settings
  • Network setting does not exist in Kosovo health
    care
  • Well established network system in Health
    Settings could improved collaboration between
    health professionals and patients outcomes

15
  • 5. Identification of high risk patients
  • No protocols classification system implemented
  • Identification of problems instead of
    identification of high-risk patient
  • Absence of community care

16
  • 6. Diabetic foot complications and their
    consequences
  • Nurses in PHC working in Diabetes Consultation
    Room/Wound Care Room do not check patients feet
    annually
  • Not even the family physician checks the
    patients feet
  • Diabetes patients in Kosovo are not having
    appropriate care in PHC
  • Diabetes foot complications are underestimated by
    health care professionals.

17
  • 7. Professional autonomy
  • Absence of competencies
  • Nurses are seen as Physicians assistants
  • Basic nursing education was based on Secondary
    Vocational School
  • This could have been as a result of the political
    situation for ages in Kosovo
  • From 2003, Nursing and Midwifery Bachelor degree

18
Conclusion
  • Situation for Kosovo nurses is hopeless and is
    beyond their control
  • In the developed countries the role of the nurse
    has changed and expanded in recent years
  • The role of the nurse in Kosovo has still
    remained the same
  • All major centres in UK have at least two
    diabetes specialised nurses (Rayman 2000)
  • In Kosovo there is no any diabetes-specialised
    nurse, there is just one Podiatrist and only few
    Diabetologist/Endocrinologists (Statistical
    Office of Kosovo 2003).

19
Recommandations
  • Education/training of nurses on foot care
  • Establishment of nursing library
  • Professional identity and highly educated
    nurses-diabetes specialized nurses
  • Multidisciplinary clinics on foot care
  • Establishment of a Network System in Kosovo
    Health Care
  • Better collaboration and communication between
    health professionals
  • Establishing Nursing Research and a Nursing
    Research Ethic Committee, following the standard
    methodological research
  • Master and Doctorate Level in nursing could lead
    to the establishment of a Nursing Research itself

20
  • Although in developed countries diabetes
    specialized nurses are becoming increasingly
    involved in the care of those with foot problems,
    some part of the world are far behind and facing
    with many challenges.

21
  • References
  • Boulton, A. J. M., Vileikyte, L.,
    Ragnarson-Tennvall, G. Apelqvist, J. (2005)
    The global burden of diabetic foot disease,
    LANCET, Vol, 366, no. 9498, pp. 1719-1724
  • Boulton, A. J. M. (2004) The diabetic foot from
    art to science. The 18th Camillo Golgi lecture,
    Diabetologia, Vol. 47, no. 8, pp. 1343-1353
  • Currie, C. J., Morgan, C. L. Peters, J. B.
    (1998) The epidemiology and cost of inpatient
    care for peripheral vascular disease, infection,
    neuropathy and ulceration in diabetes, Diabetes
    Care, Vol. 21, no. 1, pp. 42-48
  • Frykberg, G. R. (2002) Diabetic foot ulcers
    Pathogenesis and management, American Family
    Physician, Vol. 66, no. 9, pp. 1655-1662
  • Jeffcoate, W. Bakker, K. (2005) World Diabetes
    Day footing the bill, LANCET, Vol. 365, no.
    9470, pp. 1527-1527
  • Koçinaj, M. (2001) Socio-medical aspect of
    diabetes disease in Prishtina region during the
    period 1995-1999. Prishine, Kosovo (unpublished
    study).
  • Krishnan, S., Nash, F., Baker, N., Fowler, D.
    Rayman, G. (2008) Reduction in diabetic
    amputation over 11 years in a defined U.K.
    population. Benefits of multidisciplinary team
    work and continuous prospective audit, Diabetes
    Care, Vol. 31, no. 1, pp. 99-101
  • Levin, M. E. (2002) Management of the diabetic
    foot preventing amputation, Southern Medical
    Journal, Vol. 95, no. 1, pp. 10-20
  • Merza, Z. Tesfaye, S. (2003) Risk factors for
    diabetic foot ulceration The Foot, Vol. 13, no.
    1, pp. 125-129
  • Morbach, S., Lutalet, J. K., Viswanathan, V.,
    Mollenberg, J., Ochs, H. R., Rajashekar, S.,
    Ramachandran, A Abbast, Z. G. (2003) Regional
    differences in risk factors and clinical
    presentation of diabetic foot lesions, Diabetes
    Medicine, Vol. 21, no. 1, pp. 91-95
  • Papanas, N., Maltezos, E. and Edmonds, M. (2006)
    St. Vincent declaration after 15 years or who
    cleft the devils foot?, Vasa, Vol.35, pp. 3-4,
    In Papanas, N. and Maltezos, E. (2007) Growth
    factors in the treatment of diabetic foot ulcers
    New technologies, any promises?, Lower Extremity
    Wound, Vol. 6, no.1, pp. 37-53
  • Rayman, G., Krishnam, S. T. M., Wareham, A.,
    Rayman, A. Baker, N. R. (2004) Are we
    underestimating diabetes-related lower-extremity
    amputation rates?, Diabetes Care, Vol. 27, no.
    8, pp. 1892-1896
  • Shojaie Fard, A., Esmaelzadeh, M. Larijani, B.
    (2007) Assessment and treatment of diabetic foot
    ulcer, International Journal of Clinical
    Practice, Vol. 61, no. 11, pp. 1931-1938
  • Strauss, A., Corbin, J. (1998) Basics of
    qualitative research Technique and Procedures
    for developing Grounded theory. 2nd ed., Sage
    Publication Thousand Oaks, CA
  • University Clinic of Prishtina (2004) Vascular
    Surgery Unit Data, Prishtinë (unpublished data)
  • Wild, S., Roglic, G., Green, A., Sicree, R.
    King, H. (2004) Global prevalence of diabetes
    estimates for 2000 and projections for 2030,
    Diabetes Care, Vol. 27, no. 5, pp. 1047-1053

22
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