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NIROGI Lanka - Phase 1

National Initiative to Reinforce and Organize General diabetes care In Sri Lanka

COMPONENT 1 - Diabetes Educator Nursing Officers (DENO)

Objective:
To develop a national program for capacity building in diabetes care by establishing a pioneer cohort of ‘diabetes nurse educators’ (DENO) in hospitals in Sri Lanka

Justification:
Registered nurses attached to the state curative health sector play a pivotal role in caring for patients with DM in the outpatient and in-door settings in Sri Lanka, thus are identified as the best target group to receive specific training in diabetes care; where the capacity building of these nurses will directly impact the quality of diabetes care in Sri Lanka. Nurses have been previously empowered to carry out specific tasks such as infection control in hospitals, which have proven to be successful. It was envisaged that the proposed training would proceed in line with such task-based training that also has a well-established in-built monitoring process in place.

Project area:
Hospitals drawn from districts in seven provinces (Western, Southern, Central, North Western, Sabaragamuwa, Uva and North Central)

Beneficiaries:
  • Nurses attached to state teaching, provincial and base hospitals who are expected to work in diabetic and general medical clinics and wards on staggered basis
  • Private sector nurses who play a role as Nurse aids and unregistered nurses
  • Health Educator Nursing Officers (HENO)
  • Patients seeking follow-up care for diabetes in state and private sector hospitals
Expected outcomes:
Capacity building of human and technical resources for diabetes specific care services in the state and semi-government health care sectors
  • Nurses attached to state teaching, provincial and base hospitals who are expected to work in diabetic and general medical clinics and wards on staggered basis
  • To develop training modules for future training of DENOs
  • To establish a pioneer cohort of ‘Diabetes Educator Nursing Officers’ (DENO) trained to provide better diabetes care for patients in Sri Lanka initially in the state health sector to be expanded later to PHC both in public and private sectors through the College of General Practitioners of Sri Lanka
Methods adopted:
This was a novel concept for Sri Lanka to have nursing officers trained throughout the country as ‘diabetes educators’ to improve the quality of hospital-based diabetes care.

  • Prior to training, a clear job description was detailed for the trained staff such as assisting the doctors caring for diabetics by providing in-depth health education on diet and lifestyle modification, encouraging self-care and self-injection of insulin, enhancing self-monitoring, ensuring regular follow up and target organ damage in specified clinics and work towards improving patient care at primary and tertiary care; thus ensuring secondary and tertiary prevention with health promotion of the family of affected subjects.
  • The training of nurses was based on training modules which were developed in-house using the IDF modules as the basic framework. Experts in medical education and behavioural change communication were also part of a wider team that developed 12 modules for the training course.
    • Overview and pathophysiology
    • Prevention of diabetes
    • Psychological Issues related to diabetes
    • Nutrition in diabetes
    • Non-pharmacological management
    • Pharmacological management
    • Diabetic foot and Diabetes and the Surgical Patient
    • Other Diabetic complications
    • Gestational Diabetes
    • Case studies
    • Diabetic emergencies in Adults
    • Childhood diabetes and Diabetic Emergencies in Children


  • New modules apart from IDF modules were developed for GDM and CVD management, with clear grids made for each module on the expected learning outcomes linked to the job description developed for the DENOs. The lesson plans were developed by the Post Basic Nurses Training School headed by its principal and nurse tutors. Once developed, approval was obtained from the relevant stakeholders.
  • The training consisted of lectures and practical sessions, and was initiated through the existing post basic nurses training programme under the supervision of the DDGHS- Education, Training and Research in affiliation with the post basic school of nursing and the National Institute of Health Sciences, Kalutara. Training was conducted in a step wise manner for batches of 50 full time staff nurses selected by priority given to those assisting in the management of diabetics in the state curative health sector viz. specialized diabetic clinics and general medical clinics/wards located at NHSL, De Soysa Maternity Hospital, Castle Street hospital for Women, Lady Ridgeway Hospital for Children, Colombo South Teaching Hospital and Colombo North Teaching Hospital. This ensured appropriate distribution of work hours by the trained staff to function under the supervision of medical staff.
  • The basic training period was two weeks followed by a refresher course of 2 days after 6-12 months. Pre-tests and post tests were developed for the first training course. Every refresher course gave an opportunity for DENOs to display their skills and review their achievements. Important issues that affected their optimal job activities were also identified and suggestions to improve were conveyed to hospital administrators.
  • The trained staff was supervised closely by the nursing sisters /matrons and their competencies monitored annually by the training institute. Written feedback was obtained from consultants and administrators to review. In addition, regular administrative meetings were held throughout the project period in preparation of and immediately following each training session with the hospital administrators, matrons and physicians to review the training programme and discuss the administrative issues.
  • The training programme was later extended to nurses in PHC both in public and private sectors. Private sector nurses were selected from the PHC institutions recommended by the College of General Practitioners. Health Educator Nursing Officers (HENOs) of the state sector were trained in conjunction with the Health Education Bureau.
  • For maintaining the enthusiasm of all trained nurses, they were given an opportunity and a platform to demonstrate their achievements, and to advocate for diabetes care outside the clinical settings by engaging them in collaborative activities conducted by the NIROGI Lanka project.
Impact assessment and evaluation:
  • Provision of diabetes care by the Diabetes Educator Nurses was evaluated by assessing the knowledge, skills and attitudes of the trained staff at baseline and after completion of the refresher course
  • Diabetic educator nurses were requested to maintain a diary of diabetes cases of interest and that will be assessed biannually
  • Satisfaction of the patients and their families on the care provided was evaluated using a qualitative questionnaire.
  • Feedback from the matrons and the consultants in charge of the respective units was observed bi-annually.
Key achievements:
  • A total of 279 nursing officers from 124 government hospitals were trained as DENOs using the training modules.
  • A total of 64 Diabetic Educators (DE) were trained from 34 private sector hospitals. For this purpose, the DENO format was modified following stakeholder consultation and adapted to private sector nurses who play a role as nurse aids and unregistered nurses.
  • A total of 74 Health Educator Nursing Officers (HENOs) from the state sector were trained in conjunction with the Health Education Bureau. For this purpose, the course material was adapted to incorporate health promotion and education on diet and life style.



  • Competitions were held around ‘World Diabetes Day’ to recognise good performance as teams e.g. Jaffna, Ragama and Panadura in 2011 were very innovative and wide based in their activities that were recognised. Their outputs included street drama, diabetes walks, video, art competitions, staff screening, peer training and general health education.



  • The concept of holding a ‘DENO day’ was conceived upon the visit of a Nurse Educator trainer from Tasmania. The first DENO day proved to be successful with 100% attendance and excellent enthusiasm, during which the DENOs were given the opportunity to showcase their achievements and make recommendations. Thereafter, two follow up DENO days were held, the latter coinciding with the site visit of Mrs. Hanne Strangaard (WDF representative) in September 2012. These were organized in concurrence with the Ministry of Health officials and Nursing School Principal and Tutors.
  • Stakeholder meetings were held to discuss the practical issues faced by DENOs, physicians and administrators to enhance cordial relationships between them to further improve the efficacy of work done by DENOs.
  • Published patient hand book for insulin injection by Prof Kusum de Abrew



  • Published ‘Diabetes and your Child’ book by Prof Shamya de Silva.



  • Developed ‘Personal Health Record’ for NIROGI clinics



  • Developed flash cards for DENOs.




Lessons learnt:
  • The modular based training was effective and appropriate for local settings, which comprised the main and refresher courses with regular reviews and feedback obtained from those trained.
  • Training mainly focussed on: - a multidisciplinary approach to diabetes control with behavioural change communication included in each module - a family approach for managing chronic NCDs in the curative settings - importance of primary care and outreach services to be coordinated by nurses
  • This component helped in developing a dedicated team approach towards focussed quality diabetic care through health education whilst addressing those with CVD risk (hypertension, obesity, high lipids and CVD). This in turn motivated health care workers to improve quality of care in the curative state sector, with a more focussed approach to tackle the increasing burden of diabetes and CVD.



  • The nurses proved to be useful allies in the recording of data for surveillance.
  • The nurses helped to address the deficient areas in diabetes care, in particular better patient compliance, motivation towards self-care, early detection of complications and outreach services for the relevant catchment areas by population screening, awareness campaigns and risk reduction efforts in the regions of Sri Lanka – all of which ensured equitable distribution targeting of the poorer sectors of society.
  • The college of GPs was proved to be good ally and needs special recognition.
  • Screening and commemorating WDD - the role of all categories of staff





  • Trained staff should be given adequate opportunities to demonstrate their achievements, and to advocate for diabetes care outside the clinical settings.
  • The project has been well accepted by the hierarchy as an important component to NCD curative and preventive care.
Technical group:
  • Dr Kayathri Periasamy (Consultant Diabetologist, Healthy Life Clinic) - Coordinator
  • Prof Chandrika Wijeyaratne (Professor in Reproductive Medicine, University of Colombo)
  • Dr HRU Indrasiri (Dep. Director General of Health Services - Education, Training and Research, Ministry of Health)
  • Prof Antoinette Perera (Consultant Family Physician, University of Sri Jayewardenepura)
  • Prof Shamya de Silva (Professor in Paediatrics, University of Colombo)
  • Dr Priyankara Jayawardena (Consultant Physician, Castle Street Hospital for Women)