How to write a nursing Literature Review and Critical Appraisal (Solved)

How to write a nursing Literature Review and Critical Appraisal (Solved)

Access to quality healthcare remains a challenge to most patients, especially those with chronic conditions like diabetes. In the current COVID-19 pandemic, diabetes affects coronavirus mortality with the process of recovery and treatment being affected by the pandemic (Nouhjah & Jahanfar, 2020). Apart from the pandemic, diabetes management is affected by various factors like culture, socioeconomic status, and healthcare system issues. Although most researchers have examined barriers to basic access to care, much less research has explored barriers in the healthcare system that lead to poor diabetes management. Good care, including early screening, diagnosis, and treatment of the disease is crucial to its management. Primary care clinics that represent areas with limited resources continue to face challenges with effectively managing diabetes patients. The focus of this chapter is to identify barriers in primary care clinics that make it difficult to provide effective care to individuals with diabetes.

Key Words: Diabetes, Diabetes management, Healthcare challenges, Primary care clinic

Research Summaries and Critical Appraisal

The global burden of diabetes has increased over the years and is expected to increase in the coming years (Blasco-Blasco et al., 2020). The increase in diabetes burden is attributed to many factors including globalization and poor management of the disease in its early stages. While most of the factors associated with the global increase in diabetes are individual-centered, the healthcare system is observed to play part in poor management of the disease. To address this challenge, research was conducted in the Latin America and Caribbean region to identify barriers to diabetes management. The study also aimed at getting the perspectives of patients and healthcare providers regarding the perceived barriers to effective management of diabetes (Blasco-Blasco et al., 2020). To understand the barriers to diabetes management, the researchers conducted a systematic review from MEDLINE, Web of Science, and SciELO.

The findings from the study identified both individual and system factors that hinder the effective treatment of diabetes. The study found that lack of resources and issues with healthcare access impaired diabetes management, especially in low-income areas. Secondly, it was observed that clinicians’ paternalistic attitudes and lack of proper attention to patients made it difficult to manage diabetes (Blasco-Blasco et al., 2020). In primary care clinics, it was observed that issues with resources made access to essential services difficult. The researchers concluded that successful diabetes management in Latin America and the Caribbean region is highly dependent on factors beyond the control of individual patients (Blasco-Blasco et al., 2020). successful treatment and control of diabetes will require the promotion of patient-centered care and addressing issues with healthcare access at the environmental level.

Diabetes is a chronic complex illness that requires continuous medical care with multifactorial risk-reduction measures. In the United States, diabetes is the seventh leading cause of death and many others live with complications that require close monitoring (Kutz et al., 2018). A research was conducted in the US to examine the effect of implementing a chronic care model to optimize primary care management of the disease. The researchers observed that only 39% of the patients seeking primary care services had their hemoglobin A1c levels in control (Kutz et al., 2018). Gaps were observed in the treatment of patients including measuring of blood pressure, regular patient examination, and provision of systematic ongoing care. The goal of the research was to implement a care bundle that could address system factors leading to poor management of diabetes.

During the research, a primary care clinic in Illinois was piloted and involved care delivery by 16 physicians to 1422 patients (Kutz et al., 2018). Strict adherence to the diabetes care bundle was implemented and involved an A1c test, monofilament foot examination, retinal eye examination, and blood pressure monitoring among many other interventions. The interventions in the study primarily focused on changes within the providers’ workflow and the results were impressive. The researchers observed that the main barrier in primary care delivery of diabetes care is the lack of standardization of accepted care practices (Kutz et al., 2018). Addressing barriers in primary care management of diabetes should focus on the role of healthcare providers in following recommended guidelines. The implementation of diabetes care bundles can be an important step toward addressing healthcare system barriers to diabetes treatment. Additionally, primary care centers were observed to have challenges with workflow and scheduling that slowed the effective delivery of services to patients.

General awareness about diabetes is important to patients and awareness about the disease is utterly crucial to healthcare providers for effective treatment. Treatment of diabetes does not only involve taking medications, but also have enough information about the disease process, prevention, and other management approaches. Hence it becomes important that the knowledge about diabetes care is regularly assessed among healthcare providers (Gharsangi et al., 2021). For instance, healthcare providers like nurses should have the right knowledge and attitude to deal with patients with chronic diseases. Despite this understanding, there is a gap in knowledge about diabetes that makes it difficult to provide required care to patients in primary care settings.

A research was conducted in India to examine gaps in knowledge of diabetes care among nurses and recommend necessary education to healthcare providers. The cross-sectional descriptive study examined nurses working in various departments. A total of 102 healthcare providers were examined in the areas of knowledge regarding the etiology of diabetes, symptoms of the disease, complications, insulin role in diabetes, and general management of the disease (Gharsangi et al., 2021). Upon completion of the study, it was observed that most nurses lacked knowledge about the pathology of diabetes which contributed to poor management of the disease. There were also concerns about knowledge of symptoms of hypoglycemia leaving questions about the management of patients during a crisis (Gharsangi et al., 2021). There was a gap between knowledge and practice that should be addressed with a well-organized approach to ensure effective treatment of diabetes in primary care centers.

Barriers to diabetes management in primary care affect the quality of services administered to patients and overall outcomes upon treatment. Despite many primary care facilities providing service to over 80% of patients requiring glycemic control, only one-third achieve the required HbA1c levels (Somanawat et al., 2020). Primary care units compared to community hospitals are most affected by this problem because of various factors. A study was conducted in Thailand to determine challenges to the delivery of diabetes care in a sub-district health promotion hospital. Using a mixed-methods approach, the researchers used a semi-structured interview to assess the current care process, a descriptive study to evaluate the quality of care, and a focus group to identify challenges underlying diabetic care delivered in the facility.

Upon completion of the research, challenges like lack of adequate technological support, budget issues, policy challenges, and the lack of essential drugs were identified. Additionally, there were few providers specialized in providing care to diabetes patients making it difficult to achieve the required results (Somanawat et al., 2020). Diabetes care should involve collaboration between various healthcare providers including financial support from the lead governments. In another recent study that examined challenges to primary care delivery of diabetes care during the COVID-19 pandemic, similar results were reported. Focusing on reports from underdeveloped countries and low-income areas, the researchers observed that financial constraints made it difficult to achieve set targets. Because of the restrictions during the pandemic, it was observed that most primary care facilities lacked adequate technological advancement to implement telehealth services (Nouhjah & Jahanfar et al., 2020). Poor communication with patients is a challenge in these facilities with most patients, especially the elderly lacking adequate knowledge and skills on the use of telehealth.

The literature summary provided draws attention to the different factors that are barriers to primary care management of diabetes. All the articles discussed highlight challenges with finance that limit the availability of essential resources for diabetes care. For instance, the lack of adequate capital for primary care centers limits the utilization of technology that is required to manage chronic conditions today. With many healthcare centers being affected by the COVID-19 pandemic, the availability of capital can enhance the utilization of technology and ensure drugs are easily available. The second theme that is common in these reviews is the knowledge and attitude of healthcare providers towards diabetes. There is a gap in the healthcare providers’ knowledge regarding diabetes management and paternalistic attitudes by these providers limit diabetes care (Blasco-Blasco et al., 2020, Gharsangi et al., 2021). Apart from these factors, there is sufficient evidence that primary care centers have not utilized standard care approaches to diabetes management (Kutz et al., 2018). There is a need for the education of staff, particularly nurses on the use of diabetes care bundles and other essential components of care for diabetes patients.

The strengths of the literature review lie in the utilization of quality studies conducted using different research methodologies. For example, the literature review utilized findings from systematic reviews, mixed methods research, pilot study, and cross-sectional descriptive study. Another strength is that most articles focused their research on barriers in primary care centers from different countries. The research findings discussed indicate that primary care clinics across developed and developing countries face almost the same challenges that need to be addressed universally to optimize diabetes care. A few weaknesses can be noted in the articles discussed in the literature review summary. For example, some of the studies collected data from urban primary care facilities making the findings not applicable to other settings (Blasco-Blasco et al., 2020, Nouhjah & Jahanfar, 2020). Additionally, some articles have findings from research conducted in one primary care health system and the results cannot be generalized.


Blasco-Blasco, M., Puig-García, M., Piay, N., Lumbreras, B., Hernández-Aguado, I., & Parker, L. A. (2020). Barriers and facilitators to successful management of type 2 diabetes mellitus in Latin America and the Caribbean: A systematic review. PloS One15(9), e0237542.

Gharsangi, K., Himral, P., & Bhawani, R. (2021). Knowledge, attitude and practices regarding diabetes and its complications among health care workers in Medical College of North India. International Journal of Collaborative Research on Internal Medicine & Public Health13(6), 1-7.

Kutz, T. L., Roszhart, J. M., Hale, M., Dolan, V., Suchomski, G., & Jaeger, C. (2018). Improving comprehensive care for patients with diabetes. BMJ Open Quality7(4), e000101.

Nouhjah, S., & Jahanfar, S. (2020). Challenges of diabetes care management in developing countries with a high incidence of COVID-19: A brief report. Diabetes & Metabolic Syndrome14(5), 731–732.

Somanawat, J., Saramunee, K., & Chanasopon, S. (2020). Process, quality and challenges of diabetes care in primary care: A study of district health network in Thailand. Primary Health Care Research & Development21 (e46), 1-9.

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