Diabetes Management in Primary Care

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Ten nurses and 18 patients participated in this geographical arm of the study. The sampling frame for the wider study aimed for diversity in terms of age and ethnicity. Video and audio recording devices were placed in the consultation room for each participant consultation and removed at the conclusion of the consultation.

Treatment of Diabetes- Update and Physiologic Approach 3/29/17

This was a method used successfully in previous studies [ 31 ] and ensured data from each participant consultation could be obtained with minimal disruption to the work of the practice. Participants were reminded that they could stop the recording at any stage without having to give a reason. A researcher was not present in the consultation. Analysis followed an iterative qualitative process including content analysis, interactional analysis of consultations and interviews, and closer interactional and observational analysis of selected segments supported by field notes and associated medical records.

Analysis encompassed both micro-level analysis fine-grained linguistic and sequential analysis of individual interactions and texts and broader ethnographic descriptions of the institutional context of diabetes care and its communication patterns and systems. Following data collection LM , each recording was viewed and the content summarised in a detailed written log by an independent nurse researcher SV. Research assistants transcribed the interactions. In addition, data for each patient was labelled, anonymised and collated into an inventory which included length of recordings for each interaction RT.

An overall picture of the cohort of patients was gained by plotting the number and length of consultations each patient had during the 6-month study period LM and RT. This provided context for analysis of the nurse-patient consultations. More in depth content and interactional analysis started with data sessions where a multidisciplinary team with backgrounds in general medical practice TD, TK , nursing LM, SV, NS, BD , interactional sociolinguistics MS , information management RT , psychology DR public health LG and sociology KD , viewed consultations and noted anything at all that stood out as unexpected, curious or interesting.

  • Nurse-patient communication in primary care diabetes management: an exploratory study;
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Initially these sessions provided opportunity for closely observing the nature of routine practice and for open-ended, unconstrained enquiry. Different analytic methodologies were used as follows. Document analysis and content analysis assisted in identifying particular communication themes and patterns that facilitate or hinder communication processes. This linguistic and ethnographic analysis was integrated with analysis of the interactions from a clinical perspective [ 33 ]. The research team remarked on how long some of the consultations were and on the large amount of information being offered both verbally and in written form.

An update on type 2 diabetes management in primary care

These initial impressions prompted more in depth data analysis of the context and possible explanations for participants expressing a sense of being overwhelmed. Quantitative data was checked, e. This iterative process involved closing in on small segments and then drawing back to explore contextual data to help understand the nature of communication in those instances. An overview of the contact each patient had with health professionals in the 6-month study period showed that patients spent more time with nurses than with any other health professional. Of the 18 patients in this study, and in the 6 month study period, 11 had one consultation with a nurse alone and 6 had 2 consultations with a nurse alone.

There were 11 consultations with a nurse where the GP joined in for part of it. Note that consultation lengths have been aggregated by health professional and do not reflect the order of consultation. Initial consultations with nurses were longer than with other health professionals involved in diabetes management average length 52 minutes, range 8—95 minutes compared with an average 21 minutes with a GP, range 8—35 minutes.

These figures take into account only those interactions actually recorded - our study may not have captured all the interactions these patients had in the 6 month time frame. For 7 patients the initial consultation with their GP was not recorded.

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The time spent with nurses, either alone over minutes in total or together with another health professional almost minutes in total was significantly higher than for any other health professional. The clinical content of nurse-patient consultations was wide-ranging as might be expected at the outset of a chronic illness such as diabetes. There are some physical examinations e. A typical list of topics covered includes: diet, exercise, weight, eye-screening, depression, blood sugar monitoring, dental hygiene, cardiovascular risk, skin care and sexual health.

As well as these physical topics, the data shows that nurses take care to address social issues and services and attend to interpersonal relational work. This is illustrated in the following typical excerpts taken from interviews. Both nurses quoted below describe the same dilemma and illustrate their conscientious attitude. Nurses were well aware of the dilemma they faced in wanting to impart as much information as possible while remaining sensitive to what patients could deal with at a given time, as in the following examples.

Excerpt 4 Nurse: She seemed to take on board what I said and um yeah very hard to know how much to give her though and whether you give her the right stuff. The data strongly suggests that this large volume of information may be difficult for patients to take in initially.

Patients expressed some surprise and bewilderment after initial consultations, as in the example below. GP: mm mm yeah did [Nurse] go through that little book with the pictures with you about [diabetes]. On viewing each consultation and looking for the clinical content singly and across the 6 month time period for each patient, it quickly became apparent that most nurses explicitly referred to or had adopted and internalised the national guidelines [ 2 , 7 ] for diabetes management in some way.

They generally used an electronic protocol or checklist, derived from the national guidelines, to structure the consultation. Checklists helped nurses and patients by making sure essential clinical and well-being issues were addressed in a consistent way and by normalising or sensitively broaching delicate issues like mental health, as in this example, 43 minutes into the consultation:. Note that the tut in Excerpt 6 signifies a non-specific verbal hesitancy like a click of the tongue.

It is one interactional indicator that this is a delicate issue. The nurse began by framing depression as just one of a number of topics which would be routinely discussed. She stopped short of baldly naming depression then rephrased it. The use of the passive voice there has been a connection made distanced the nurse from suggesting that this patient had depression. In this way, the nurse skilfully left the topic open for the patient to take up. While there was no further discussion of mental health in this consultation, the patient himself raised it in a subsequent consultation with the same nurse.

However, a degree of interactional discomfort arising from the use of checklists was also observed in many consultations. They were observed to constrain interactional flow at times and to override immediate concerns and usual interactional processes or responsiveness. In the following example, the nurse and patient had been exploring the topic of depression in some depth, when the nurse brought the discussion to an end by moving on to a completely unrelated topic, teeth, which was the next item of the electronic protocol.

In the following example, as the nurse moved through a series of checks, the patient introduced a concern outside the usual scope of diabetes checks:. Excerpt 8 Patient: now is there any chance of…with the next blood test one should because of my age should have the um prostate blood test as well…. Nurse: [starting to examine feet, no eye contact with PT] oh yeah well we can ask [doctor] if he can do that [matter of fact tone]. The communicative strategy used by the nurse in the example above might be interpreted in a number of ways. One interpretation is that the nurse proceeds with her checklist paying minimal attention to the different concern raised by the patient and that the patient might find that reaction disconcerting.

Another more positive interpretation is that the physical touch and averted gaze provided by the nurse gave the patient a very welcome opportunity to raise a delicate issue and her matter-of-fact tone normalised the issue. In this recorded interaction the nurse in fact returned to the concern later in the consultation and noted it for follow up. These brief examples from the interactional analysis of the consultations in our sample illustrate how the use of checklists and protocols could both help and hinder the flow of nurse-patient consultations.

There was also evidence that nurses in this study were aware of the dilemma that these posed namely that while they facilitated coverage of all key topics, they could also make the interaction less natural. This point is exemplified by the following excerpt taken from an interview with the nurse after she had viewed clips of her recorded consultations. Our data suggests that when checklists and protocols are used more flexibly or with discretion, nurses are freed to practice in a more autonomous manner that is contingent on and sensitive to the local context of the discussion.

For example, in the following excerpt the nurse explained in her interview that she abbreviated her planned discussion when she noted the patient losing concentration.

This appeared to be designed to enable the nurse to assess how the patient was reacting to the information and how she might direct her efforts in future for this patient. When the patient simply acknowledged her summary, she prompted for a further response.

Excerpt 10 Nurse: so er it is important that we um tut that we monitor all of those things with you. Nurses were clear about the purpose of their consultations in prospectively managing long-term conditions such as diabetes and were equally clear that they generally adopted a checklist-driven approach.

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There was evidence from field notes and interviews that there is still some way to go to match expectations between parties in nurse-patient consultations see examples below. Additionally patients have different needs in terms of pace and amount of information and the data showed that this was not always easy to assess at the outset, and may not be easily accommodated in a checklist-driven consultation.

In the following example the patient was describing a desire for a gradual and methodical step process:. In the following excerpt a patient expressed frustration at her inability to participate in the consultation as much as she would have wanted, and at a lack of acknowledgement of her prior knowledge and actions. Nurses reported sensing these mismatches but also commented that knowing how to change their approach was a challenge, as evidenced in the following examples taken from a nurse interview.

However, it was apparent in many consultations that this stated awareness did not lead to a shift away from the checklist to engaging in a conversation that listened to the patient and focused on their most important concerns. Another important observation was that patient perceptions can change over time. One of the strengths of the study design was the tracking over a 6 month time period which provided an opportunity to ask patients to reflect back on their initial consultation.

In the following example, a patient recognised benefits which were not obvious to him at the outset:. World Health Organization; Action plan for the prevention and control of noncommunicable diseases in South-East Asia, Diabetes in Asia: epidemiology, risk factors, and pathophysiology. Non-communicable diseases in the Asia-Pacific region: prevalence, risk factors and community-based prevention.

Diabetes Management Programs at Middlesex Health // Middlesex Health

The Diabcare-Asia study--outcomes on control and complications in type 1 and type 2 diabetic patients. Curr Med Res Opin. The status of diabetes control in Asia--a cross-sectional survey of 24 patients with diabetes mellitus in Diabet Med.

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Diabetes Management in Primary Care Diabetes Management in Primary Care
Diabetes Management in Primary Care Diabetes Management in Primary Care
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