Addressing barriers to diabetes care and self-care in general practice: A new framework for practice nurses

There has been extensive research identifying barriers to diabetes care and self-management (Simmons et al, 1998; Conrood, 2001; Glasgow et al, 2001; Tripp-Reimer et al, 2001; Zgibor and Songer, 2001; Nam et al, 2011). A recent randomised controlled trial,  which looked at identifying and addressing barriers to diabetes management among older adults in the US, demonstrated improvements in HbA_1c and self-care (Munshi et al, 2013). At the centre of this approach is the person with diabetes, their life context and recognition that diabetes control is not just about medication and the usual topics discussed in consultations. In short, many aspects of a person’s life can provide obstacles to good diabetes self-care. Although difficult to define, patient-centred care has been described as consisting of three elements: communication, continuity of care and concordance (Stewart, 2001; Irwin and Richardson, 2006) and many health professionals would agree these are integral to providing a quality service. The trend in the UK to strive towards health outcome targets (Oldani, 2010) can make patient-centred care difficult to deliver in primary care. However, given the complexities of diabetes, it is vital that diabetes healthcare professionals are supported to consider the person’s life and barriers to self-management. 

This article describes a programme carried out in general practices in Cambridgeshire, which was designed to facilitate the process of identifying and tackling barriers to diabetes care. It also describes issues that emerged during its delivery to general practices.

Method
In 2008 a Cambridgeshire practice, which had recently taken an interest in developing its diabetes service, agreed to develop and pilot a new approach to identifying barriers to diabetes care. A questionnaire was developed to systematically identify barriers to care and answers to the questions were linked to categories identified in previous research, including educational, psychological, physical and social barriers (Simmons, 1998; 2001). Strategies were then developed to address the responses based on the local context. The resulting process of identifying barriers and then linking to potential solutions became known as the “Barriers Framework” (see Table 1).

The questionnaire was sent to all people with diabetes at the practice prior to annual review, to help identify barriers. The questionnaire asked about the difficulties experienced, including whether and why they were worried about their diabetes, how they would improve local diabetes services and what they believed prevented themselves or others from improving their diabetes (Simmons, 1998). Based on the answers to this questionnaire, the lead practice nurse compiled local resources such as leaflets, websites and phone numbers in a resource folder. The questionnaire and clinical results were then used alongside the resource folder to create person-specific management plans.

The lead nurse in this pilot was then invited to join the local diabetes integrated care team (Hollern and Simmons, 2011) and share the approach developed in her practice with the 17 other practices served by the team. It was envisaged this would help develop community links, raise awareness of the new integrated care team and offer resources to practices wishing to update their diabetes knowledge and reappraise their consultation styles. In rolling out the Barriers Framework, the lead nurse started to arrange meetings with other practice nurses in the area responsible for diabetes reviews and also other relevant practice staff.

Data collection and analysis
The lead nurse took written notes at 73 visits to 17 Cambridgeshire practices between November 2009 and March 2011. Visits were arranged to discuss implementation of the Barriers Framework and promote the integrated care team. A social scientist was employed to evaluate the broader integrated care initiative and interviewed the lead nurse to discuss the context of the notes taken. The social scientist also conducted observations of the approach having been implemented in one practice and not yet in another. 

This research was undertaken as part of a larger study of integrated diabetes care and, as such, semi-structured interviews were also conducted with the integrated care staff. The written notes, interview and observation notes were then manually analysed and themes were coded to identify the components of the programme delivered and recurrent issues generated during implementation.

Description of the approach
The Barriers Framework was presented as a new method of conducting annual reviews, targeting people with poor glycaemic control (HbA_1c ≥75 mmol/mol [9%]) and focused on treating the person in a holistic manner, rather than purely based on clinical outcomes. The practice was encouraged to send people with diabetes a brief questionnaire about barriers to care (Simmons, 1998) prior to annual review. Each nurse was encouraged to consider responses as psychological, social, environmental, financial and educational factors that could be associated with poor glycaemic control. A resource folder was provided to each practice nurse, to help overcome these barriers. For example, if language barriers were identified, contact details for interpreting services and multilingual documents were readily available in the resource folder.  

During the practice visits, the lead nurse used case studies drawing on her own use of the Barriers Framework to demonstrate how it could be used to develop care plans. As these sessions unfolded, discussions at each practice identified further education and training that practices nurses felt they needed. This often related to medication and foot care. The visits also included detailed discussion of the referral pathways (Table 2), with emphasis on using the structured diabetes patient education courses provided locally and also the use of the integrated care team to reduce burden when dealing with particularly challenging barriers. 

Key issues
Flexibility
When describing implementation, the lead nurse noted that it was important for her to be flexible and work with the requirements of each practice. This was apparent in the written notes, which report that half the practices found the postal nature of the questionnaire burdensome. The rationale for pre-sending the questionnaire was to reduce the influence of the nurse on each person’s answers. However, practices often asked people with diabetes to complete it as they waited, or fill it out during their consultation. In a number of instances, people with low levels of literacy or who spoke little English were assisted by the nurses who either went through the questionnaire with them or arranged for translations to be made. Such adaptation of the guidelines was common in other areas too, such as the collection of the suggested baseline clinical measures. 

Education
It was also noted that discussions around the Barriers Framework encouraged the practice nurses to begin identifying gaps in their education. The lead nurse became a reference point and advocate for nurses wanting more information. As a result of requests for education around foot problems, training from the integrated care team’s podiatrist was routinely offered to practices. The lead nurse also kept the other nurses informed of local courses, online resources and other educational opportunities. Practice nurses were able to reflect on the multi-dimensionality of diabetes and seek training where their information was lacking.

Holism
The lead nurse frequently described the Barriers Framework as returning to a “holistic” consultation style, allowing for broader health and wellbeing issues to be raised and addressed within the diabetes consultation. One practice nurse using the framework reported that she was enjoying her job again, after feeling pressured to “get the numbers down” at the expense on focusing on caring for the person with diabetes. The lead nurse described the approach as being more consistent with an “old school” style of nursing, suggesting targets were a competing agenda for nurses.

Structural
The framework was considered especially useful by the nurse participants, as one remarked it allowed them the opportunity to review the responsibilities around annual reviews. By breaking down individual tasks associated with an annual review, nurses became clearer about its structure and importance. A significant consequence of this was that the lead nurse was able to promote longer annual review appointments, or to identify appropriate tasks that could be shared with healthcare assistants.

Built on trust
Another recurring issue was that the Barriers Framework highlighted the importance of trust between individuals and the team, both internally within practices and also between primary care and the integrated care team. Within the practices, staff noted the different relationships the practice team had with people with diabetes and the importance of these relationships. Similarly, the nurses suggested that if the integrated care team was to succeed, trust would have to play a central role. Related to this, the lead nurse noted the importance of communicating with the practice nurses and how this enabled them to develop stronger relationships.

Change, extra work and constraints
Whilst the reception of the framework was mostly positive, some participating nurses and GPs voiced frustration at changing their routines. For example, one GP reported that they already provided a good enough service to people with diabetes. Others explained they felt overworked and frustrated and therefore were reluctant to take on extra work. Such statements highlight problems associated with changing processes, especially when accompanied by other time pressures.

Discussion
We have presented the components of the Barriers Framework and described how the approach was received by participating nurses. Of particular interest is the questionnaire, as from a research perspective, it demonstrates the difficulties of using paper-based data collection tools. There was resistance to using a postal questionnaire (requiring additional administrative effort), but less resistance to asking the questions in a consultation, as this was deemed more time efficient and person focused. The importance of time constraints over the potential influence of the nurse on answers is not surprising. However, it is worth noting that the person with diabetes may have provided different questionnaire responses as a result. 

The Barriers Framework promoted intervention components such as multifaceted professional interventions, patient education and enhanced nurse role (Renders et al, 2001); however, a significant degree of flexibility was required to make these acceptable to nurses. Whilst it was designed to work as a comprehensive package, the option of only adopting those aspects that complement existing practices seemed to be part of its appeal. The ability of the lead nurse to deliver a multi-component programme such as this is vital, especially the ability to recognise the variable dynamics in practices and being able to tailor appropriate solutions. Equally, practices need to be willing to recognise the limitations of their current procedures and adapt locally available resources to their needs and the requirements of people with diabetes.

There was a sense amongst some nurses that using the Barriers Framework allowed them to return to a more holistic style of nursing, rather than the drive towards targets. This is promising, considering previous research regarding the concerns nurses have had (including loss of job satisfaction) over the impact of Quality and Outcomes Framework targets (McDonald et al, 2007). In 2009, McDonald et al described the changing role of the nurse as more “professional”, with a focus on technical knowledge; however, MacDonald et al also stated that less emphasis is placed on experiential learning, judgement and holism. Furthermore, they also suggested that computerised templates and new target-focused culture was seen by many nurses as changing the consultation process in a way which threatened the delivery of person-centred care (McDonald et al, 2009). Rather than purely a data collection tool, the questionnaire in the Barriers Framework could be used by nurses to prompt discussion around the daily life of the person with diabetes and allowed nurses to identify areas of change alongside the individual. The approach certainly resonates with a less target-oriented style of nursing, but equally addresses the lifestyle factors that are so important for diabetes control and therefore addresses targets that practices strive to meet. 

Unfortunately, no evaluation of the programme’s efficacy has been conducted. Implementation was not systematically measured and adoption evidence is limited. Teams rolling out new health initiatives often face such difficulties. The Barriers Framework demonstrated the importance of maintaining a flexible attitude towards implementation; however, this may have been at the detriment of a more robust evaluation. As this programme was rolled out alongside promoting the integrated care team, it would also be difficult to extrapolate the effectiveness of this programme in isolation. Yet, what we have been able to show is how some elements of the Barriers Framework were adapted and responses to its introduction. We also acknowledge the omission of exploring “facilitators” to self-care but would like to address this in future work.

Conclusion
The individual components of the Barriers Framework were reassessing annual review structure, use of a questionnaire, case study discussion, education and training, referral pathways, use of integrated care team and management plans for people with diabetes. Practices showed variable interest in the approach, largely due to time constraints. For those practice nurses that engaged most, the programme presented an alternative method for approaching annual reviews at a time of increased pressure to achieve Quality and Outcomes Framework (QOF) targets. Although numerous issues arose in implementation, a high degree of flexibility ensured that it was amenable and applicable for participating nurses.

This paper presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the  NHS, the NIHR or Department of Health.