Exploring the relevance of the DSN role to the Greek healthcare setting

The role of the DSN has been clearly established in the UK and plays a vital role in the provision of diabetes care (Humphris et al, 1999; McGee and Castledine, 1999; Llahana et al, 2001a; Llahana, 2002).

Diabetes specialist nursing has not yet been implemented in Greece, although in the last year a great effort has been made to introduce the DSN role into the healthcare sector. The care of people with diabetes in Greece is currently carried out by general nurses whose qualifications and responsibilities are varied. Diabetes care is mainly provided in the hospital setting, which also provides primary care services. Even though Greece has the second highest prevalence of type 2 diabetes in Europe (International Diabetes Federation, 2000), there is no literature that documents the provision of diabetes care and the role of the nurse working in this area. Moreover, there is very limited literature in Greek relating to this role (Lemonidou, 1999; Llahana and Gerogianni, 2003).

Aims of the study
The study was cross-cultural between Greece and the UK and was undertaken in two stages. The first stage took place in the UK and explored the DSN role performance and factors that influence its development (Llahana et al, 2001a; Llahana et al, 2001b; Llahana, 2002; Llahana et al, 2003).

Based on the results of the first stage and the unavailability of evidence-based information in the area of diabetes in Greece, stage two aimed to:

• Provide information regarding the practice, responsibilities and qualifications of nurses working in diabetes care in Greece.
• Explore opinions of healthcare professionals and people with diabetes about the feasibility of implementing the role of the DSN in Greece, guided by the UK model of the DSN role (Llahana, 2002).

Design and methods of the study in Greece
The focus group interview was considered to be the most appropriate qualitative method, as the main objective was to obtain a diversity of beliefs and opinions regarding the feasibility of implementing the DSN role in a new setting. The following agenda of questions was designed to elicit information from the focus group sessions according to the objectives of this study:

1. What are the responsibilities and practice of nurses working in diabetes care in Greece?
2. How do health professionals and patients perceive the role of the DSN?
3. What are the advantages of implementing the DSN role in Greece?
4. What constraints and obstacles, if any, exist in the implementation of the DSN role in the Greek healthcare system?
5. What pathway should be followed for the successful implementation of the diabetes nursing speciality in the Greek healthcare system?

This article presents the results from question 2 and discusses the respondents’ perceptions about the DSN role in relation to its relevance to the Greek healthcare system.

Sample
Physician diabetologists and nurses working in seven diabetes centres in Athens and people with diabetes were involved in the study. Managers of the diabetes centres were asked for permission to conduct the focus group interviews and to provide a study sample, which was 37 participants: 19 physicians, 14 nurses, and 4 patients with diabetes (Table 1).

Introducing the research topic
Prior to selecting a sample, the researcher met with the majority of the physicians and nurses working in the centres selected for the study. It was found that only a very limited number of them were familiar with the DSN role. For this reason, the researcher organised a seminar day for all participants, to provide them with information regarding the DSN role characteristics and its constituting components and activities.

Data collection and analysis
Five focus group interviews were conducted with an overall number of 19 respondents (Table 1).

The discussion in the focus groups was guided by the agenda of questions described earlier. Questions were asked in a questioning route as suggested by Krueger and Casey (2000) in order to provide a conversational tone to the interviews. The researcher obtained the participants’ agreement to tape-record the interviews and each session lasted for approximately 1 h.

As the study emphasised interaction between participants, data were analysed at both a group and an individual level, using the guidelines of Reiskin (1992), McDaniel and Bach (1996), and Kitzinger and Barbour (1999):

• The tape-recorded interviews were transcribed verbatim after the session in combination with the additional field notes of the moderator.
• Sections that were relevant to the research questions were identified and a coding system for major topics and ideas was developed. Following this, each transcript was read independently and organised into categories which were examined for themes, patterns, similar words and context.
• At the final stage, analysis involved drawing together and comparing discussion of similar themes. The relationship of these to the variation between individuals and groups was then examined.

Results and discussion
Respondents in the focus groups were asked to comment on the DSN role and its relevance to the Greek healthcare setting. The following five role components were explored:

• Expert practice
• Education
• Consultation
• Research
• Management/leadership

Activities constituting these components, as found from stage one of the study (Llahana, 2002) have been discussed in detail previously (Llahana et al, 2001a).

Expert practitioner
Respondents perceived this sub-role as an important aspect of the DSN role. All of the groups emphasised the importance of providing support to patients and their families over the telephone. They reported that in Greece patients have no access to specialised support in case of emergency at times other than the morning shift. For this reason they believed that a 24 h help line is crucial.

One important activity which nurses do not undertake in Greece is home visits. Respondents reported that the provision of this service is essential in the absence of hospital-community coordination, and could be undertaken by a hospital-based DSN. One nurse had previously undertaken home visits, but had to stop them due to time constraints and the increase in patient caseload:

‘This activity was a very important aspect of my role. You enter the patient’s home and you see how he lives, how he behaves, you come close to him…He talks to you about his problems, his family affairs; you see his living environment.’ (Nurse A, focus group 1)

On the other hand, almost all physicians opposed the idea of the DSN undertaking advanced specialised care activities. They considered that a nurse could not acquire the appropriate knowledge to carry out activities such as prescribing diabetes-related medications, ordering laboratory tests and providing specialised care to patients with complex physical problems. They believed that such activities ‘…presuppose certain medical knowledge, which can only be acquired by attending medical school’. Similarly, many nurses did not believe they would be able to reach such an advanced level of practice to function autonomously:

‘I can tell the doctor my opinion, but I cannot make the final decision because I do not have this knowledge…’ (Nurse A, focus group 2)

‘The DSN can certainly have the first contact with the patient, but she should then transfer the information to the doctor.’ (Physician B, focus group 2)

‘Yes, exactly! And I believe the same applies to prescribing diabetes medications… you do not put your signature just like that if you do not have the appropriate knowledge.’ (Nurse B, focus group2)

Educator
The importance of the DSN functioning as an educator was highlighted by all of the respondents in the study; this sub-role was perceived as the main aspect of the DSN role. Respondents emphasised the role of the nurse in the education of patients and their families, particularly in group teaching.

Respondents perceived the involvement of the DSN in informing the public about diabetes as being a vital way to solve the problem of stigmatisation that patients with diabetes face in Greece. Diabetes education for school staff and pupils was also highlighted. However, one paediatric nurse who provided education to schools reported that this could often be difficult to achieve:

‘Many parents do not allow me to inform the school staff that this child has diabetes…they do not want others to know that their child is diabetic. Not only does this place me in a great dilemma, but also children often end up in hospital.’ (Nurse A, focus group 4)

Respondents’ opinions varied about the provision of education to medical staff by the DSN. Although more than half of the respondents believed that a DSN can educate physicians about diabetes issues, many others did not. Two physicians reported that the DSN should only be able to provide education to physicians on technical matters, for example, injection techniques and use of insulin pens. One commented:

‘A nurse, no matter how educated she is, cannot provide education to physicians… Only the medical staff provide education to the nursing staff, not the other way around.’ (Physician B, focus group 1)

Similarly, two nurses felt that ‘…a doctor would never accept my opinion!’ They believed that the medically dominated health system that exists at present in many hospitals expects the nurse to be at a ‘lower level than the doctor’. Patients also agreed with this:

‘It is a question of mentality that, in Greece, the nurse still has a different image than that of the nurse abroad. I do not think that a doctor would accept to be educated by a nurse, even if she is a specialist in her field.’ (Patient B, focus group 1)

Consultant
Respondents considered that nurses should act as consultants only to enable patients and their families to cope with the immediate crisis of diagnosis and long-term adjustments in lifestyle. The need for this was particularly highlighted by patients, who felt more comfortable approaching the nurse than any other member of the healthcare team.

Respondents perceived that an important aspect of the DSN role in consultation was in relation to the organisation of care, i.e. setting standards, development and implementation of policies, protocols and care pathways. However, they believed that the present structure of the healthcare system in Greece does not provide nurses with the authority to undertake such activities. The following comments were made:

‘Concerning the facts in Greece, these all [consultation activities] sound a bit funny. Here we are unable to communicate properly within the same hospital, let alone in a region or even more in the whole country!’ (Physician A, focus group 1)

‘DSNs could really have a valuable say on what is happening, but under the present situation, nobody would listen to what they say. Their advice would have no value if they do not have the authority…’ (Physician A, focus group 3)

It was also felt that the DSN could have a valuable role in the organisation of patient support groups. Some respondents reported that they had organised support groups, but these lacked consistent planning and coordination. Moreover, as this was not included in their job description, their input into these was purely voluntary. One respondent commented:

‘Many people want to help, but there is no-one to coordinate them. Whereas if you set a plan, nationally, someone responsible for this activity, things would look much more promising. This is why I believe that the presence of the DSN would offer a lot in this direction!’ (Nurse B, focus group 4)

Researcher
Respondents perceived the involvement of the nurse in research activities in the clinical area as a ‘luxury’. Although two nurse respondents were involved in research, this was a component of their academic educational programme (MSc, Doctorate). The identified reasons for this were lack of research skills of nurses, time constraints, and ‘the fact that the nurse is not viewed as an equal member of the healthcare team’. Many respondents believed that, even if the DSN role were implemented in Greece, the only way for DSNs to be involved in research would be in cooperation with the University of Nursing. However, they stressed that ‘…there are so many things that the DSN will have to do that research will seem unreachable’.

Physicians in one focus group believed that nursing education cannot provide the appropriate skills for undertaking research studies, which they construed as purely clinical research:

‘Fine! Research is also what you do [addressing the researcher], but in Greece, in the clinical area, the meaning of research is completely different. It refers to clinical studies, and this is what we expect when we say research. I do not think that a nurse has the background to undertake such activities.’ (Physician B, focus group 1)

Manager/leader
Respondents reported that the only activity in the manager/leader sub-role relevant to the Greek setting would be DSN participation in identifying gaps in diabetes care services; the remaining activities were viewed as irrelevant. Respondents believed that this component could not be incorporated in the role of the DSN in Greece. They noted that the structure and organisation of the healthcare system does not provide the nurse with the authority to ‘make her voice heard’. This is illustrated in the following interaction:

‘The advice of the DSN would be valuable if accepted, because they are the professionals who really know the needs of this field. They should be able to say, for example: “We have come across this problem. You should provide funds for home visits, which is very important.”’ (Physician A, focus group 3)

‘Yes, I agree! The same applies to the input of hiring nursing staff in the diabetes centre, because the DSN is the most appropriate person to assess this. While if we need a new nurse, they will employ the first one from the waiting-for-employment list. This is unfortunately how the administration system works here!’ (Nurse B, focus group 3)

Implications for nursing practice
Although it is difficult to make direct cross-cultural comparisons between the UK and Greece, it is evident that the successful implementation of the DSN role in the UK was a long and painstaking process. Respondents in the focus groups perceived the implementation of the DSN role in Greece as necessary, but saw DSNs acting mainly as educators. Therefore, as the teaching role of the DSN is widely accepted, this may well be an initial step in implementation of the DSN role in Greece.

In the medically dominated system that currently exists in Greece it is unrealistic to expect DSNs to undertake a multifaceted role from the outset. Nevertheless, future DSNs should aim to expand their role progressively and incorporate all of the other components of the DSN role into their practice.

Findings of this study revealed that physicians did not agree with the idea of DSNs practising autonomously and without medical supervision. This could hinder the implementation of the role as they may view DSNs as intruding on their professional ground. It is hoped that this may be attributed to the lack of familiarity with the role. Increased efforts should be made by future DSNs to clarify that the role is not aimed at substituting the role of physicians. The two roles complement each other for improving standards of care for people with diabetes.

The role should be legally formalised in order to provide the DSN with the authority to practice autonomously. It is crucial for the Ministry of Health, the University of Nursing, and Nursing Administration to collaborate in setting common objectives for the DSN role in order for it to be successfully implemented.

Conclusion
This study was the first step in introducing the DSN role in Greece. It has raised the awareness of healthcare professionals and patients regarding this role by providing evidence from its implementation in the UK. Respondents agreed that DSNs play a vital role in the provision of diabetes care. However, implementation of the DSN role was perceived as a difficult process in light of the existing circumstances in Greece. Respondents believed that the medically dominated healthcare system and its present structure would not allow nurses to practice independently and at such an advanced level. The non- acceptance of the multifaceted role of the DSN can also be attributed to the lack of familiarity with the role. For this reason, efforts should be made to provide healthcare professionals and people with diabetes with more information and evidence on the DSN role. As this was an introductory study, further studies are required to provide a comprehensive exploration of this area.