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Managing care in the community for patients with type 2 diabetes

Diabetes, particularly type 2, is a major and growing health problem, yet it is a condition that is managed to a very large extent in primary care by practice nurses. Given this burden of care, we sought to explore the perceptions of nurses, both practice nurses, and specialist diabetes nurses who are predominantly based in secondary care, regarding their current and future role in the management and care of people with type 2 diabetes.

Abstract

VOL: 99, ISSUE: 15, PAGE NO: 59

Jean Peters PhD, MPH, HonMFPHM, is senior lecturer in public health at the School of Health and Related Research, University of Sheffield

Aileen McIntosh MBBS, FFPHM, FRCGP, is senior researcher;Allen Hutchinson MSc, MPhil, BA, is professor and deputy dean, both at the School of Health and Related Research, University of Sheffield

Diabetes, particularly type 2, is a major and growing health problem, yet it is a condition that is managed to a very large extent in primary care by practice nurses. Given this burden of care, we sought to explore the perceptions of nurses, both practice nurses, and specialist diabetes nurses who are predominantly based in secondary care, regarding their current and future role in the management and care of people with type 2 diabetes.

Method Using a modified Delphi study (Jones and Hunter, 1995), randomly selected samples of practice nurses and diabetes specialist nurses were sent a questionnaire inviting their views on a series of broad statements about:
- Safe nursing;

- Effective nursing;

- The contribution of practice nurses and diabetes specialist nurses to the care of diabetic patients;

- Evidence-based factors that enhanced or inhibited care;

- Continuing professional development;

- Continuing changes in the NHS;

- Changes needed to improve care;

- The best thing about the care they provided.

The sample size used was estimated with the intention of obtaining about 100 responses. The statements were developed on the basis of a literature review and advice from an expert panel. Full details of the methodology are published elsewhere (Peters et al, 2001). The responses received were coded against a thematic framework (Miles and Huberman, 1994), collated and sent back to the responders to elicit levels of agreement.

Results From questionnaires sent to 160 practice nurses and 255 diabetes specialist nurses, 97 practice nurses and 69 specialist nurses responded with comments raging from single-word answers to detailed information and opinion. From the thematic analysis, 47 themes emerged which could subsequently be described under seven broad headings:
- Practice/clinical activity;

- Responsibility for care (clinical responsibility);

- Communication;

- Knowledge;

- Education/experience of the nurse;

- Rewards for the practitioner;

- The role of the patient;

Most of the themes raised were common to both nursing groups, but six of the themes were raised only by practice nurses and three themes only by specialist nurses.

The second round of the Delphi study - eliciting consensus for the themes identified and issues raised - produced strong agreement (>80 per cent) from both groups for the majority of the items (85 per cent). Areas in which agreement was not as strong related to factors identified in the first round as those that would inhibit care, such as: a lack of communication between professionals; not having professional responsibility; a lack of teamwork; limited resources; lack of education and training; lack of financial recognition; increased numbers of patients; poor patient access to nurses/services; and patients being unwilling to change their lifestyles.

There were also some areas in which responses from the two nursing groups differed. Ninety per cent of the diabetes specialist nurses agreed that with changes in the NHS, nurse prescribing was an important role in the care of people with diabetes, but the practice nurses were less convinced, only 71 per cent agreed with this.

Conversely, 90 per cent of practice nurses were very much in agreement that changes in the NHS would result in more responsibility and 97 per cent thought there would be a shift from secondary to primary care as part of their role in managing the care of patients with diabetes. However, for these two items, fewer of the specialist nurses were convinced that it would lead to more responsibility for them (81 per cent) or that there would be a shift to primary care (78 per cent).

The issue of limited resources was raised both as an inhibiting factor to future care and as an issue associated with the changes in the NHS. In each case, the specialist nurses were more in agreement that limited resources would be an issue in carrying out the nursing role for people with type 2 diabetes in the community.

Discussion It is encouraging for patient care that the two nurse groups, with their different perspectives and different roles in the care of people with type 2 diabetes, are in such agreement on what is perceived to be important for the care of such patients. Conversely, it is likely to be the differences in the two roles, with practice nurses being generalists, and specialist nurses, by implication from their title, being specialists, which provide an explanation for those differences that were seen between the two groups. However, it will be important for the future nursing management and care of people with type 2 diabetes that areas of discordance in the community are further explored and reasons for the discordance understood if the National Service Framework for Diabetes (Department of Health, 2001) is to be delivered.

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