Role of Nurses in Managing Diabetes Among Adult Sample

INTRODUCTION

Diabetes Mellitus [DM] is characterised by inadequate control of blood glucose level, it is subclassified as Type 1, Type 2, gestational, neonatal and steroid-induced Diabetes. This is becoming a global public health complexity that requires significant attention and therefore, management of diabetes proves to be a crucial domain in healthcare settings (Cloete, 2021). Adopting nurse-led models ensures patient-centred care which is essential in diabetes care, these interventions support adult patients and significantly effective management of diabetes can be undertaken. The diabetes management within UK emphasises on multidisciplinary approach that entails with integration of varied care providers such as nurse, physician, podiatrists and dietitians (Mathew et al, 2022). However, the role of nurses is still unrecognised despite of assuring huge contribution. Nurses focuses on routine activities and manages insulin level of patients that ultimate contributes in diabetes management. The diabetes nurse educators [DNEs] assures effectual contribution in equipping patient with knowledge and confidence and aims to attain self-care goals related to diabetes management (Mathew et al, 2022). Thus, nurses playing important role as they act as a primary caregiver and implements consistent interaction with patients. The holistic care to patient has been ensured and along with physical health, emotional and mental well-being of patients is prioritised.

The current dissertation will be based on evaluating the role of nurses in managing diabetes related complications among adult patients in the UK. In-depth analysis will be done and accordingly role of nurses would be described. Furthermore, emphasis will be made on the complexities faced by nurses in the whole process and subsequently, accurate findings will be analysed.

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BACKGROUND

Diabetes proves to be topmost public health issue within UK that develops significant implication on healthcare system, families and patients. From the statistical estimation, it has been witnessed that approximately 4.9 million people in UK are suffering from diabetes and the numbers are consistently rising (Diabetes statistics UK, 2023). Increasing prevalence of diabetes is accompanied through varied complications that aligns with retinopathy, cardiovascular disease, neuropathy and nephropathy. Thus, these complications can further result is serious health complexities, reduction in quality of life [QoL] and increased in healthcare cost (Powell et al, 2021). Nurses are playing important role in managing diabetes complications especially in prevention and management of diabetes-related complications. There are varied responsibilities performed by nurses that ranges from self-management practices, educating patients, conducting regular health assessment, monitoring of blood glucose level and providing psychological support to patients. There is need to adopt multifaceted approach for tackling the complications of diabetes (Powell et al, 2021). By evaluating the role of nurses in this context best practices can be identified, patient outcomes could be enhanced and further areas can be analysed in which training and resources are essential.

From the studies it has been evidenced that diabetes education by nurses can result in the reduction of severe diabetic complication and further enhances the quality of life in patients. However, there are certain challenges experienced by nurses with respect to managing diabetes complication in adult patient (Forde et al, 2021). Workforce challenge proves to be the topmost challenge in this context, the nursing workforce suffering from varied issues such as extreme work pressure, staff shortage and increasing patient loads and this might create barrier in undertaking diabetic management procedure. Nurses interacts with patients and analyse their issues therefore; it is important to consider nurses needs as well so that significant outcomes can be gained and consistent support to patient can be ensured (Karam et al, 2021). Lack of training to nurses developed significant complications for them and further they are not able to deal with the serious issues which underpins the requirement of professionals. It is essential to organise training program so that consistent support can be ensured to nurses and they will further become able to learn new interventions and strategies and consequently, incorporate this in their diabetic management procedure.

Different socioeconomic factors such as health literacy level and psychological barriers complicates nurses’ ability in terms of managing individuals with diabetes. As a result, patient faces complexities in understanding diabetes management plan which impacts their health outcomes (Chan, 2021). Patient care is crucial process that requires significant attention and therefore, nurses implement consistent communication with the patients so that appropriate decision can be taken and care outcomes could be enhanced. However, there is need to create support for the nurses as well, they are the ones who perform consistent responsibilities and still they are not recognised (Chan, 2021). Educating patient, setting diet plan, observing blood glucose level and so on components are focused out by nurses. However, extreme pressure on them makes situation difficult and this impacts their care practices as well. The nurse led-education intervention proves to be highly effectual in developing awareness in the patient. Education is an important component which has been approached by the nurses and accordingly, they focus on developing awareness in the patient (Munshi et al, 2020). The contextual information has depicted that nurses are playing pivotal role in reducing the severe complication related to diabetes by educating patient and focusing on their consistent care. However, there are certain loopholes identified in this context and there is need to implement substantial focus on this area so that extent of issues faced by nurses can be reduced.

The outcomes of the research will benefit healthcare settings and consequently, they can implement initiatives with regards to enhancing nursing practices for managing diabetes complication in adult patients. In-depth evaluation will be undertaken and accordingly, authentic outcomes would be developed.

Aim

Aim- To evaluate the role of nurses in managing diabetes complications among adult patients in the UK.

Objectives

The three objectives are framed from the aim which supports in undertaking in-depth analysis by covering each of the domain.

1. To understand the role of nurses in managing diabetes complications
2. To assess the impact of nursing intervention on diabetes management outcomes.
3. To identify the barriers and facilitators influencing the role of nurses in diabetic care.

METHODOLOGY

Systematic literature review approach has been adopted in the research and accordingly evaluation was done (Liu, Shapira and Yue, 2021). The rationale behind selecting this approach aligns with allocation of data in systematic manner and summarising in context of particular topic. However, the contradictory point is that biasness during selection procedure might impact the quality of findings.

Database

As per the views of Khurshid et al, (2021) those search engines which are vital and reputable are important to approach for obtaining the valid and reliable research articles. Therefore, significant databases preferred in the current research. The reviewer has used three databases for retrieval of the articles.

Table 1-Databases

Database	Justification
CINAHL	This database encompasses with allied nursing and health literature. The peer reviewed and authentic articles are uploaded on CINHAL and therefore, analyst has used this.
BioMed	BioMed provides extensive information related to varied types of diseases, treatments, medicines and patient outcomes (Pascarella et al, 2021). Henceforth, researcher retrieved articles from this database and subsequently, wider literature reviewed.
PubMed	It delivers publicly available search interfaces for the NLM sources and Medline (Pascarella et al, 2021). Hence, it is considered as the premium source for nursing and biomedical literature.

Keywords

Keywords are explicated as the confrontations that are important to enter while searching for the articles. It is described as the foundation for obtaining appropriate and relevant information for addressing research questions (Aliannejadi et al, 2022). The major key words that have been used within the research are- Nurses, Diabetes, Adult, Patient, Management, Complications and Role. By using these domains relevant information allocated and accordingly outcomes were developed. Furthermore, researcher emphasised on using Boolean Operators; it is essential to use these domains specifically when the concepts align with varied search terms. “AND” & “OR” are the Boolean operators that has been used while retrieving articles and papers.

PICO

PICO framework is considered as that tool which is used in evidence-based researches for developing a clinical research question (Liu, Shapira and Yue, 2021). The researcher has used this framework for formulating question within current research context and subsequently, evidence-based research has been undertaken.

Table 2-PICO framework

Population	Intervention	Comparison	Outcome
Adult patients	Different role performed by nurses	Different complications in diabetes management	Enhancing patient outcomes.

Research Question

• What is the role of nurses in managing diabetes complication among adult patients within UK

Inclusion and exclusion criteria

Inclusion and exclusion criteria determine about the standard protocols and components which are needed to be included and excluded from the research (Tanima et al, 2023). The researcher has used this criterion for selecting significant articles that are relevant and authentic.

Table 3- Inclusion and Exclusion Criteria

Inclusion Criteria	Exclusion Criteria
Articles that are published after 2012 has been included in the research and accordingly, significant information allocated. Only primary-based studies were approached by researcher. Papers published in English language were used in the study. Studies focusing on diabetic care management and role of nurses were prioritised. International articles were approached while prioritising the UK context.	Those articles which are published before 2012 excluded from the research. Secondary-based research articles were not considered in the study. Articles which are other than English language excluded from the study. Papers that were focusing on other disease and not on diabetes were not involved in the research.

Search process

The initial search from the three database was undertaken and total 1208 articles were selected. After removing the duplicates there was 1200 articles and then records were screened and 1170 articles excluded as they were not meeting the criteria. The full text articles were reviewed that was 30 and then 23 articles were again excluded due to duplication. Lastly, 7 articles included in the study that were meeting the inclusion and exclusion criteria.

Critical appraisal

Critical appraisal refers to the analysis that enables analyst to identify whether the selected articles are adhering with the quality reviewing process or not (Dasgupta et al, 2024). For appraising the articles, researcher has used CASP framework and consequently, in-depth critical evaluation was undertaken (CASP, 2023). This critical tool proves to be highly effectual for assessing the quality of articles and therefore researcher incorporated this tool in current research.

Thematic analysis

It refers to the process of analysing qualitative information while developing different themes that addresses research objectives (Aliannejadi et al, 2021). The reviewer has integrated thematic analysis and accordingly, data was analysed. It enabled researcher in terms of understanding the information in effectual manner and subsequently, themes have been developed. This led to support in gaining significant insights related to research area and qualitative synthesis has been done (Dasgupta et al, 2024). However, major challenge aligns with thematic analysis is flexibility, this makes it difficult for reader to understand the important domains of the research.

FINDINGS

Matrix table

Table 3-Matrix table

Authors, Year & country of study	Study Type & sample size	Major findings in relation to our research question	Critical strengths & weakness of the studies
De la Fuente et al, (2020)	Randomised Control Trial [RCT] 12-24 months period involving 69 participants from public health organisation	The findings of the article stated that education is the foremost element in managing diabetic complication. Thus, nurses are accountable for educating patient and further they focus on empowering service users by enhancing their knowledge. Thus, article emphasised on organising structured and individualised educational program for T2D patients.	The major strength witnessed in the article aligned with focusing on the most important parameter of nurse role and that was education. The RCT was undertaken in two arms; intervention and control groups that enhanced the efficacy of outcomes. However, weakness of the article is that author only focused on educational aspect, despite of collecting wider data from the participants (Bartlett et al, 2020).
Alshammari et al, (2021) UK	Descriptive Qualitative Approach Semi-structured interview 10 nurses from NHS UK were involved in the study.	The findings of the research developed significant insights and there are varied roles of the nurses witnessed, health education and health promotion, providing holistic care, prescribing, interprofessional roles, provides patient-centred care and enhances professional autonomy. However, there are certain challenges such as shortage of staff, lack of recognition, increased work pressure and financial conflict faced by nurses.	In current study the researcher has taken consent of participants as it is essential for performing ethical domains. However, there is no such weakness witnessed in the study as researcher focused on every element and presented authentic findings.
Macdonald et al, (2013)	Qualitative approach [Video Recording Consultation] 38 participants [10 nurses and 18 patients]	Nurses undertakes pivotal role in managing patients who are suffering from diabetes. This study focused on UK and New Zealand. In context of UK, it has been witnessed that nurses’ tackles patient and their family members but due to lack of resources in the setting varied complications has been faced by them. Whereas, in New Zealand lack of staff creates work pressure on nurses and they have look upon every requirement of patients.	The research was based on undertaking face to face interaction through video consultation. For analysing data thematic approach has been used which led to develop effective understanding (Lee and Lee, 2024). However, researcher was not able to manage the balance between two of these countries and there was lack of comparison undertaken.
Lumu et al, (2024)	Randomised Control Trial [RCT] for 6 months	Nurse- led management intervention results in reducing the risk of systolic blood pressure and Atherosclerotic Cardiovascular Disease in patients suffering from T2D.	The study has employed significant methodology for gaining authentic results and observation on the nurse-led intervention was undertaken. However, there was lack of critical analysis in relation to the findings which impacted the efficacy of outcomes.
Nikitara et al, (2021)	Qualitative Research checklist [Focus group and Semi-structured interviews] 24 participants	Findings indicated that nurses facing varied barriers in providing diabetes inpatient care and this creates drastic impact on patient outcomes. Lack of training, lack of support and staff shortage proves to be the drastic challenges.	The research adopted the two forms of qualitative research focus group and semi-structured interviews. This results in gaining wider data related to barriers faced by nurses. However, there was lack of information presented in context of ethical analysis.
Snell, Budge and Courtenay, (2022)	Survey 250 participants New Zealand (n = 111), and UK (n = 139).	Nurses undertakes the role of physician as well by prescribing medicines to diabetic patient in emergency situation.	The Monkey Questionnaire used by researcher for gaining the data and quantitative analysis was undertaken. The study used thematic approach for analysing the data. However, there was lack of information provided regarding the ethical consideration in the research and this can be considered as one of the foremost weaknesses within research.
Octari, Suryadi and Sawitri, (2020)	Survey 157 participants	Nurses plays vital role in enhancing the Quality of patients by guiding them about the important of healthy routine and health diet. This is supporting in reducing the complications related to diabetic care.	Non-probability sampling was involved in the study and this has reduced the biasness within study (Kamal, 2023).  However, limitation associates with lack of in-depth analysis within study.

The present section will constitute important arguments comprised with research area, key findings from the articles will be conveyed via undertaking thematic format. The in-depth analysis encompasses with the seven papers [De la Fuente et al, 2020, Alshammari et al, 2021, Macdonald et al, 2013, Lumu et al, 2024, Nikitara et al, 2021, Snell, Budge and Courtenay, 2022 and Octari, Suryadi and Sawitri, 2020] summary of the findings will be presented along with emphasising on the important elements that addresses research question and clarifies about the role of nurses. Furthermore, influence of nurse-led interventions will be shown and barriers experienced by nurses in diabetic care would be analysed.

Theme 1- Role of nurses in managing diabetes complications

The present theme will emphasise on signifying about the role of nurses in diabetic care, from the analysis of different studies key pointers identified that led to develop significant insights regarding the role of nurses. The Randomised Control Trial [RCT] by De la Fuente et al, (2020) revealed that nurses playing important role in educating patients, diabetes proves to be a long-term-disease that requires consistent management. In order to improve the condition of patient it is essential that patient should be educated and empowered. In accordance with NICE guidelines, education must be at the forefront of any intervention and care plan specially in the case of long-term complications such as diabetes (NICE, 2023). Education is delineated as topmost factor within social determinant of health [SDOH] and therefore, it requires to be prioritised and nurses are guided to educate and empower patient regarding diabetes management. The study undertaken a RCT which disclosed that when nurses educate patient then it results in enhancing patient outcomes and further increases their morals. The findings of the De la Fuente et al, (2020) were similar with results of Lumu et al, (2024). The study by Lumu et al, (2024) articulated that empowering patient is the ultimate agenda of healthcare professionals and nurses focuses on this domain. They consistently interact with patients and analyse their issues and develops a mutual trust and afterwards, they educate patient regarding the consequences of diabetes if healthy lifestyle has not been maintained. The paper stated that complication is diabetic management is mainly due to lack of awareness in the patient and this led to create drastic situation.

Therefore, patients are advised to adopt healthy lifestyle and specifically they need to focus on their diet and physical exercise. Nurses further focuses on making diet plans for patient by taking guidance from the dietitian and senior healthcare professionals guides in another context. This is depicting about the multidisciplinary approach incorporated in diabetic care. Similar context identified in the qualitative study of Alshammari et al, (2021); management of diabetes in UK concerned with undertaking multidisciplinary approach that integrates different care providers such as physician, nurses, dietitians, podiatrists and other healthcare professionals. Nurses who are working in NHS trust undertakes their role in effective manner. However, their roles have been often influenced due to other colleagues when they are work in multidisciplinary team. The research by Alshammari et al, (2021) developed significant insights in current research context. This study was based on 10 female participants who had nursing experience of 38 years. Different roles were identified that have been performed by them while tackling diabetic patient. Health education and health management is the topmost role identified in nursing care and same aspects were witnessed in the study of De la Fuente et al, (2020). Nurses reported that they communicate health promotion message with the patient and inform them about the consequences. Further, interaction with their family members of patient has been implemented and they are also guided about the ways in which patient outcomes could be enhanced.

However, Alshammari et al, (2021) stated that, patient often find difficulty in understanding the professional language at that time nurses uses easy language that can be easily understood by service users. Thus, nurses are accountable for creating ease for the patient and accordingly, appropriate support has been ensured to patients. Moreover, it has been identified that nurses assure holistic care to patient, it is an important component in diabetic care specially for adult patient. They suffer from varied emotional trauma and therefore, it is important to look upon emotional and mental well-being of patient. In such situation, nurses use nurse-patient communication concept and subsequently, interaction with the patient has been implemented and their issues are identified. This enables nurses to develop effectual interaction with service user and their emotional issues can be managed accordingly (Alshammari et al, 2021). Hence, there is no doubt in stating that nurses focus on the individual needs of patient and accordingly, decisions are taken by them. There are diverse needs of patient that requires to be addressed, it is considered with financial and cultural components as well. Nurses further supports them in this area by communicating their issues with appropriate healthcare professional who can look upon these issues.

The study reflected that consistent support from nurses and enhanced the health outcomes of T2D patients. However, in the study of De la Fuente et al, (2020) there were certain challenges highlighted that comprised with ineffective care towards patient. Nurses often feel stress due to extreme work pressure and this ultimately results their interaction with the patients. Thus, this lead to create negative impact on the patient outcomes. The nurses are overburdened with the responsibilities and lack of supports towards them makes the situation complicated and patient outcomes are impacted on negative note (De la Fuente et al, 2020). The research has subjected stress as major component in terms of challenges that makes diabetes management complicated. In accordance with NICE, nurse manager is accountable for supporting nurse practitioners and senior nurses when they are stressed (NICE, 2023). The consistent communication requires to be implemented with them so that timely actions can be taken. However, from the findings it has been analysed that there is lack of support provided to nurse and it is important to develop substantial focus on this area so that effectual decisions can be undertaken.

Nurses performs important role in providing medication related advice to the diabetic patients. This role is comprised with adjustment and prescription of insulin dosage that is important for managing insulin level (Alshammari et al, 2021)) However, this role led to increase the work pressure on nurses while working in diabetic care. Many patients require urgent treatment and, in such situation, nurses refer them and prescribes the medicines as well, it is significantly done for reducing the severe risk for patient (Alshammari et al, 2021). Thus, it can be said that nurses are playing essential role in the management of diabetes complication among adult patient. They are looking upon physically, mental, cultural, emotional and multiple requirements of the patient with the aim of ensuring holistic care to them.

Theme 2- Analysing the influence of nursing intervention on diabetes management outcomes

In the study of Lumu et al, (2024) it has been witnessed that nurse-led management interventions support patient in terms of dealing with diabetes. The study has focused on Nurse-led diabetes self-management education [DSME]; it proves to be a significant strategy that helps in the management of diabetes mellitus [DM] as it improves self-care practices and knowledge that enable patient to take appropriate actions. On the other hand, Snell, Budge and Courtenay (2022) stated that nurses only focus on educating patients and all the interventions are complying with educating service users. However, limited actions are taken in this area there is need to adopt wider approaches that consistently empowers patient and reduces the extreme burden on nurses. The research by Octari, Suryadi and Sawitri (2020) revealed that it is highly essential to guide patient about healthy diet and healthy routine as it supports in creating a healthy lifestyle pattern which is utmost in diabetic care. Hence, it can be said that nurse-led interventions positively influencing patient outcomes by developing awareness in them.

Alshammari et al, (2021) elucidated that nurse maintains autonomy while educating patient and interacting with their family members. This has been significantly done for involving patient and their family members in decision making process. Patient-centred care is another nursing intervention used for providing care to diabetic patient. It refers to that care approach which puts patient at the forefront of care services. Hence, by adopting patient-centred care approach requirement of the patients are analysed and accordingly appropriate decisions have been taken which enhances patient outcomes. Thus, it can be said that, nursing intervention in diabetic care are mainly comprised with looking upon patient requirement and empowering them through education (Octari, Suryadi and Sawitri, 2020). Thus, there is no doubt in stating that it is important to understand patient issues as each individual has unique requirement. Nurses focuses on this aspect that results in assuring significant support to service users and further enhances their care outcomes.

Theme 3- Barriers and facilitators that are influencing nurse role within diabetic care

Macdonald et al, (2013) articulated that nurse faces varied issues while providing diabetic care, staff shortage at the setting developing consistent pressure on the nurses and further increasing stress for them. The study revealed that, nurses perform the role of physician and GP as well by prescribing medicines to the service users. Lack of resources has made it difficult for nurses to provide quality care to patient. In multidisciplinary teams, major role has been performed by nurses still they do not get recognition, they are accountable for providing holistic care to patient and subsequently, they focus on each of the domain so that patient can receive holistic care. Despite making significant contribution nurses are not getting recognition that crates demotivation in them. The qualitative research by Nikitara et al, (2021) articulated that nurse manager must communicate with nurses and their issues should be analysed so that appropriate actions can be taken and support can be assured to nurses.

Alshammari et al, (2021) stated that, Diabetes Specialist Nurses [DSNs] provides training to nurse practitioners and enhances their knowledge regarding diabetes management and this is developing consistent support for the nurses at the setting. However, the identified barriers are more in comparison to facilitators and this is signifying about the gaps within setting. There is need to analyse the issues faced by nurses and consequently, communication requires to be undertaken with them so that their complexities can be solved (Alshammari et al, 2021). Nurses ensuring significant contribution in tackling diabetic patients and complications and therefore, higher administration should focus on the drastic challenges faced by nurses and accordingly, appropriate actions are required to be undertaken.

CONCLUSION AND RECOMMENDATIONS

Conclusion

Conclusively, research has articulated that nurses are playing pivotal role managing diabetic complications for patient. Consistent efforts have been made by them while adhering with patient-centred care which proves to be significant in enhancing patient outcomes. Findings of the research revealed that, education is an important element when it comes to tackling diabetes complication and nurses focusing on this aspect consistently. They are empowering patient by leading educational programs and accordingly, importance of diet plans and routine exercise has been communicated with patient. The contextual information from the research revealed that, patent empowerment and patient education are considered as topmost role of nurses while tackling diabetes complication. Furthermore, nurses are providing holistic care to patient by focusing on their emotional, mental, cultural, physical and financial requirements. Nurse-patient communication has been implemented in the setting and subsequently, nurses communicated with patient and solves their issues. Substantially, a therapeutic alliance implemented by the nurses. However, despite ensuring consistent contribution, nurses are not appreciated and this creates sense of demotivation in them.

Moreover, extreme pressure on nurse and continuous workload develops stress for them and impacts care practices. Nurses often undertakes the role of physician and GPs in emergency situation by prescribing medicines to patient. Hence, there is no doubt in specifying that nurses are making consistent efforts with the aim of enhancing patient outcomes. They are educating service users along with prioritising the needs patients. Henceforth, there is need to provide support to nurses so their stress and work pressure can be reduced. On moral and ethical basis, it is highly important to consider the requirements of healthcare providers such as nurses.

Limitation

The limitations are associated with risk of biasness, the researcher has followed systematic review approach for conducting the literature and this is concerned with potential risk of biasness. The clinical and statistical imprecision and heterogeneity can lead to varied errors that ultimately impacts research outcomes. However, reviewer has assured focus on this area and accordingly, articles were selected after undertaking a significant search strategy. This led to reduce the risk of biasness within research.

Recommendations

Stress management techniques

These techniques provide chances to nurses in terms of relieving mental and physical symptoms. The research has shown that nurses are extremely overburden and this is impacting their practices at the setting. Therefore, it is important to introduce stress management approaches to nurses that enable them to strengthen their Emotional Intelligence Capabilities and increases resilience capabilities (ElSayed et al, 2023). Consistent stress can reduce the retention of nurses in the hospital and therefore, it is important to imply focus on this area and stress management techniques should be undertaken.

Collaboration

The collaboration with the nurses’ results in reducing their work pressure, it is important to take action in this area and therefore, task allocation should be done in appropriate manner. The multidisciplinary approach is specifically for implementing collaboration so that effectual care delivery can be provided to patient (Karam et al, 2021). The collaboration among the staff members results in developing a supportive environment at the setting and it further provides opportunity to team members in terms of solving their issues in frequent manner. Thus, by focusing on this area appropriate support can be ensured to nurses and accordingly their issues could be solved.

Continuous professional development

There is need to organise training at the setting for providing consistent professional development opportunities to nurses (Martínez et al, 2021). Diabetes is a long-term condition that associates with severe complications and therefore, it is important to educate nurses regarding this aspect. Also, training programs lead to create sense of satisfaction in the nurses as they get opportunity to enhance their practices (Ernawati et al, 2021). Furthermore, this results in providing career opportunities to the nurses and enhances their motivation level. Hence, as per the needs and requirements of nurses, training at the setting should be organised and appropriate opportunity must be given to the nurses for gaining personal and professional development.

Recognition

The recognition of nurses proves to be important as they play pivotal role in patient safety. Leadership influence the role of nurse in the setting, despite facing varied hurdles nurses focuses on patient health (Porter et al, 2023). It is the accountability of nurse leaders and managers that they should look upon this context and accordingly, nurses must be appreciated. Thus, this results in motivating nurses and further enhances their performance and therefore, specific emphasis should be made on this area.

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Online

CASP, 2023. Online. Available through: < https://casp-uk.net/casp-tools-checklists/ >

Diabetes statistics UK, 2023. Online. Available through: < https://assets.publishing.service.gov.uk/media/5a82c07340f0b6230269c82d/Diabetesprevalencemodelbriefing.pdf >

NICE, 2023. Online. Available through: < https://www.nice.org.uk/ >