Practice nurses have an increasingly important role in caring for people with type 2 diabetes (Kenealy et al, 2004; Wisher, 2004; Mold et al, 2008). Government policy and nursing literature emphasise the importance of empowering patients through support, education and good clinical care (Department of Health [DH], 2001; Robinson, 2005; Holdich, 2009).
According to Stewart et al (2006), diabetes outcomes can be improved by an increased involvement of the person with diabetes in decisions about their care. However, there may be constraints to working in a collaborative/participatory way with people with type 2 diabetes, such as limited time and working to meet targets. These factors, alongside nurse training and nurses’ attitudes, may impact on the delivery of nursing care (Stewart et al, 2006).
With the importance of user involvement being increasingly recognised over recent years (Cooper, 2005; Branfield and Beresford, 2006), the views of patients are extremely relevant to practice nurses involved in the management of type 2 diabetes, which is why patients’ perspectives were the focus of this qualitative study.
Aim
The aim of this study was to strengthen evidence and insights into patients’ perspectives of diabetes care by practice nurses, with particular reference to the possibilities of collaborative and participatory working.
Methods
The research was conducted as part of a Masters in Primary Care and was based on semi-structured interviews with people who have type 2 diabetes. A total of 11 people participated in this qualitative study; one was used for a pilot interview and 10 were included as actual interviews. Four women and seven men took part, from the diverse London borough of Ealing (where ethical approval was granted to include patients in the research). Seven participants were white British, two were Asian-Indian, one was white South African and one was white Irish. Convenience sampling was used for recruitment via GP surgeries and at a local diabetes education group. For ethical reasons none of the people who took part in the study were patients of the researcher (who was working as a practice nurse at the time of the project).
The interview schedule was devised following a review of the literature, consultation with patients and a pilot interview. Interviews took place between April and June 2009 and lasted a mean average of 25 minutes each. Participants chose the location: half were by telephone and half were face-to-face. With participants’ verbal and written consent, all interviews were audio recorded using a digital audio recorder and transcribed verbatim.
Data analysis
Data were analysed manually by the researcher using content analysis, which involved creating categories of data and developing rules for coding data into these categories (Nieswiadomy, 2008). Taylor-Powell and Renner’s (2003) framework was used to guide the analysis process:
- Familiarisation.
- Focus the analysis.
- Categorisation of information.
- Identification of patterns and connections.
- Interpretation.
An additional stage was incorporated into the analysis process, which involved an experienced service-user researcher appraising the data analysis.
Results
The length of time participants had been diagnosed with diabetes ranged from a few months to 20 years. Only three of the participants had attended a group diabetes education session. Most of the interviewees had seen their practice nurse once or twice in the last year about their diabetes, as well as a range of other healthcare professionals: GPs, hospital doctors, DSNs, ophthalmologists, dieticians, podiatrists and pharmacists. It was clear that practice nurses are one part of a multidisciplinary team in diabetes care.
How are decisions made about the treatment and management of participants’ diabetes?
Figure 1 illustrates who the participants perceived make the decisions about the treatment and management of their diabetes.
Six people listed the GP as deciding what treatment they take. However, it was recognised by some participants that professionals may work together in the decision-making process and most participants listed several healthcare workers. Two people clearly stated that they were involved in treatment decisions. For example, Mrs Y had switched hospitals because she was dissatisfied with the hospital she was initially attending.
Do participants have opportunity to be involved in decisions about the treatment and management of their diabetes?
Seven participants responded that they had little involvement in decisions about their diabetes, for example:
“None whatsoever, up until the practice nurse got hold of me.” (Mr W)
“I leave the doctor to the medical side of things really, because I’m only a layman.” (Mr G)
Three participants clearly stated that they are involved: one man said he makes “lots of decisions” about his diabetes and Mrs Y explained:
“First they wanted me to do the three injections a day and I said, ‘No. My lifestyle’s not for that, I’m never in [the house] to do that.’ And so this is why I take the glargine [insulin] once a day, and I’m quite happy and my numbers are quite controlled… I couldn’t be any more involved in the way decisions are made than this, because I am quite an outspoken person.” (Mrs Y)
In total, six people did give examples of ways in which they participate in decisions, as illustrated in Figure 2.
Two people expressed dissatisfaction with the amount of involvement they have in managing their diabetes. However, five people clearly expressed that they were satisfied with the involvement that they do have. Mr R explained that he is not involved in decisions about treatment because:
“I just take it blindly. I don’t have a habit of arguing. If the doctor thinks it’s good, it’s good.” (Mr R)
As Figure 2 illustrates, participants did not always seem to associate lifestyle decisions, such as diet and physical activity, as a way they might be involved in managing their diabetes.
Do participants want to be more involved in decisions about their care?
Some participants said they would like to be more involved in decisions about their diabetes. For example, Mr H expressed frustration at the lack of opportunity to talk to anybody about his diabetes or have more check-ups. Others explained that they did not want to be more involved in decisions about their care and were:
“… happy with the way things are going”. (Mr G)
Furthermore, three people in the study stated that they were already significantly participating in decisions.
Where do participants go for advice about their diabetes?
Table 1 illustrates that a range of health professionals and sources of advice were listed by participants. Six people listed the GP as someone they would go to for advice:
“I just rely on the doctor all the time.” (Mr G)
Only two people said they would go to the practice nurse for advice. For example, Mrs N described her nurse as: “the first port of call”.
Accessibility of the healthcare professional emerged as very important to five of the participants. Who they turn to for advice depended on how accessible that person is:
“I would ring up the diabetic [sic] nurse at the hospital and I would call straight there, because she talks to you straight away.” (Mrs Y)
“There’s a lady there that’s absolutely marvellous at the diabetes clinic, been at the centre as long as I have. She’s absolutely – I mean she goes way, way over the top to do things for me. And if you phone up – she even put me onto a consultant or whatever, anytime.” (Mr H)
Do participants speak to the practice nurse about their diabetes-related health worries?
Only two participants said they had discussed diabetes concerns with their practice nurse. Reasons for why the other participants had not discussed diabetes health worries with their practice nurse included:
“The nurse asks you how you’re feeling, like, and have you got any concerns or anything, but I don’t really.” (Mr G)
Some interviewees did not perceive the visit to the nurse as an opportunity for them to address any concerns they might have. For example, Mr PL explained that he had simply seen the practice nurse for his diabetes check-up and “…that’s all I went for, nothing else”.
Participants said that one reason they did not discuss health worries with the practice nurse was if he or she was difficult to contact.
What do patients perceive the role of the practice nurse to be in diabetes care?
As Table 2 illustrates, for six of the participants, the role of the practice nurse in diabetes care was mainly the physical check-up:
“She [the practice nurse] looks at my results and weight and blood pressure.” (Mr PK)
To make recommendations and give advice were also seen as part of the practice nurse’s role:
“It was her that told the doctor to put me on insulin. It was her who said ‘the tablets aren’t working’.” (Mr W)
Three participants suggested that the practice nurse has only a small role in diabetes management. Reasons for this were that her main duty in diabetes was simply to carry out the physical check-ups:
“I’m not sure that there’s actually anything, apart from doing the checks.” (Mr PK)
Another factor suggested as limiting the role the practice nurse has in diabetes was the infrequency of visits that some participants had to the practice nurse.
What do participants find helpful in their appointments with the practice nurse?
“She talks about diet and ways that I could help myself more.” (Mrs Y)
“The advice she gave … was a hundred times more helpful than the advice the doctor ever gave me. She knew her stuff … the practice nurse saved my foot.” (Mr W)
The physical check-up was cited as a major part of the practice nurse’s role by six people, but, as Figure 3 shows, only two participants actually cited it as helpful:
“I find out whether the blood’s altered. Also she weighs me and keeps an eye on my weight and then my feet.” (Mrs Y)
Mr PK suggested that the practice nurse:
“Should be more critical … if you’re beginning to run into problems … you want to know that your control is not good, what we can do about it.”
What do participants suggest could improve the experience of seeing their practice nurse?
Four people could not think of anything that would have improved on their experience of seeing the practice nurse. Several reasons were offered for this, for example:
“Because I know for a fact like that she reports back to him [the doctor] afterwards and she says ‘I think you should have a look at him’ or whatever like, and he might call me and make an appointment … But I’m quite happy with the way they’re going about it.” (Mr PK)
Two people said they would have liked to see the nurse more often:
“I just want to go more frequently … and just have a check-on, check-up. And just be told how things are coming along, you know.” (Mr H)
The need for support and information was cited as being important, especially following a diagnosis of diabetes:
“I think she could explain that this is how long it will take. Or, give you an indication this is not just for tonight or today, but this will take us maybe six months to a year to sort it out – to sort you out and get it into a situation where everything’s checked, so that you know what’s going on.” (Mrs S)
Discussion
During this study it was clear that diabetes care is multidisciplinary. Although the diabetes role of the practice nurse has increased (Mold et al, 2008), as Peters et al (2001) point out, it is just one aspect of practice nursing. Not all of the participants considered their practice nurse to have a significant function in diabetes care.
Reflecting the findings of other authors (Kinmonth et al, 1989; Alzari et al, 2006), some participants spoke highly of their practice nurse’s involvement. However, it was also suggested that the practice nurse’s role was limited to physical checks. Pill et al (1999) highlighted that some practice nurses also see themselves primarily as monitors of physical measurements. While these checks are important (particularly in terms of disease prevention), they are only one part of diabetes management. It has been argued that the Quality and Outcomes Framework (QOF) has encouraged GP surgeries to improve the standard of diabetes care (Campbell et al, 2008) by introducing payments linked to indicators. However, the QOF may also increase pressure on practice nurses to focus on the clinical issues, rather than looking at the patient’s agenda and their concerns in relation to their diabetes (Campbell et al, 2008).
This is not a new issue. Pill et al’s (1999) qualitative study focused on practice nurses and the reasons why they might have difficulty working in a more collaborative way with patients. It emerged that factors such as lack of time and the need to perform the basic physical checks meant that practice nurses were not always able to encourage patient participation and involvement in the way they would like to.
The amount of input patients want to have in the management of their diabetes will vary. Not everyone wants to actively participate (Cheek, 2003). Some of the participants of this study suggested that they had limited involvement in their care, but were satisfied with this. While some people want to actively contribute to decisions, others may prefer to rely on the decision-making of the clinician.
Education for people with diabetes was found to be an important way of encouraging patients to be involved in their diabetes management. This included one-to-one education and structured group sessions. This is consistent with some of the literature, which argues that diabetes education programmes can empower people by teaching them to manage their own disease (Sale, 2004).
Accessibility to diabetes services emerged as a strong theme throughout the study findings, which is an essential aspect of care (DH, 2001). Previous studies have found that access to clinicians is important to people with diabetes (Lawton et al, 2005; Alzari et al, 2006) and this was reflected in this research. Participants who spoke highly of a healthcare professional mentioned that they were easy to contact.
Although patients’ perspectives of practice nurses were the focus of this study, it quickly became apparent that diabetes care is very much multidisciplinary.
It is impossible to talk to people about their views of diabetes care without other healthcare professionals being discussed. The participants who were interviewed described their care as a whole and it was clear that practice nurses are just one part of it.
Many of the emerging issues, such as accessibility, support and education are relevant to all healthcare professionals working with people who have type 2 diabetes.
Relevance to clinical practice
For healthcare professionals to work in a collaborative/participatory way with patients the following is recommended; this incorporates some of the ideas of Kirkland (2004) and Robertson (2005):
- Relate to patients and listen to their perspectives during consultations.
- Hold a focus group to find out what people with diabetes want from services.
- Conduct patient satisfaction surveys.
- Ongoing diabetes education (one-to-one and group education).
- Involve people with diabetes in education for healthcare professionals.
- Effective communication between the multidisciplinary team.
- Improve access to services, for example convenient appointment times and telephone access.
Strengths and weaknesses of the study
This was a small-scale qualitative study and the intention was not to make generalisations about the views of people with diabetes. However, some useful findings were generated, which have offered insight into patients’ perspectives.
Participants were made aware that the researcher was herself a practice nurse (at the time) and this could have impacted on the responses they gave. Therefore, it was emphasised that there were no right or wrong answers.
It was also explained that their responses would not be fed back to their own practice nurse.
Conclusion
Collaboration between patients and healthcare professionals is an essential part of diabetes care, yet the structure of services may inhibit collaborative working. People with type 2 diabetes need the opportunity to be involved at individual, local and national level to ensure their needs are properly met.
This project gave a small number of people the opportunity to express their views of diabetes care by practice nurses. Talking to patients about their experiences has been invaluable to the author in her own clinical practice and encouraged her to consider the way she works with patients. In her current role as a DSN she conducts a monthly satisfaction survey at the diabetes centre and runs the Diabetes Patients’ Focus Group. Only by talking to those people affected by conditions such as diabetes, can healthcare professionals really begin to understand what issues are important to service users; and how best to meet their needs.
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