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Transcript of Diabetes_care_practice_nurse_roles_attitudes_and_concerns.pdf
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I S S U E S A N D I N N O V A T IO N S I N N U R S I N G P R A C T I C E
Diabetes care: practice nurse roles, attitudes and concerns
Tim Kenealy MBChB FRNZCGP
HRC Training Fellow, Department of General Practice and Primary Health Care, University of Auckland, Auckland,
New Zealand
Bruce Arroll BSc MBChB MHSc PhD FRNZCGP FAFPHM
Associate Professor, Department of General Practice and Primary Health Care, University of Auckland, Auckland,
New Zealand
Helen Kenealy BHB
Medical Student, University of Auckland, Auckland, New Zealand
Barbara Docherty RGON ADN
Director, Primary Health Care Nursing, Department of General Practice and Primary Health Care, University of Auckland,
Auckland, New Zealand
David Scott MBChB FRNZCGP
Diabetologist, Diabetes Project Trust, Auckland, New Zealand
Robert Scragg MBChB PhD FAFPHM
Senior Lecturer, Department of Community Health, University of Auckland, Auckland, New Zealand
David Simmons MD FRACP
Professor of Rural Health, Department of Rural Health, University of Melbourne, Shepparton, Victoria, Australia
Submitted for publication 18 March 2003
Accepted for publication 15 March 2004
Correspondence:
Tim Kenealy,
Department of General Practice and Primary
Health Care,
University of Auckland,
Private Bag 92019,
Auckland,
New Zealand.
E-mail: [email protected]
K E N E A L Y T . , A R R O L L B . , K E N E A L Y H . , D O C H E R T Y B . , S C O T T D . , S C R A G G R .K E N E A L Y T . , A R R O L L B . , K E N E A L Y H . , D O C H E R T Y B . , S C O T T D . , S C R A G G R .
& S I M M O N S D . ( 2 0 0 4 )& S I M M O N S D . ( 2 0 0 4 ) Journal of Advanced Nursing48(1), 6875
Diabetes care: practice nurse roles, attitudes and concerns
Background. Practice nurses (PNs) are the largest group of nurses providing pri-
mary care for patients with diabetes in New Zealand, and changes in the health
system are likely to have a substantial effect on their roles. To inform the devel-
opment of a new primary health care nursing structure and evaluate the new role
associated with this, it will be important to have data on current practice nurse
roles.
Aims. The aim of this paper is to report a study to compare the diabetes-related
work roles, training and attitudes of practice nurses in New Zealand surveyed in
1990 and 1999, to consider whether barriers to practice nurse diabetes care changed
through that decade, and whether ongoing barriers will be addressed by current
changes in primary care.
Methods. Questionnaires were mailed to all 146 PNs in South Auckland in 1990
and to all 180 in 1999, asking about personal and practice descriptions, practice
organization, time spent with patients with diabetes, screening practices,
68 2004 Blackwell Publishing Ltd
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components of care undertaken by practice nurses, difficulties and barriers to good
practice, training in diabetes and need for further education. The 1999 question-
naire also asked about nurse prescribing and influence on patient quality of life.
Results. More nurses surveyed in 1999 had postregistration diabetes training than
those in 1990, although most of those surveyed in both years wanted further
training. In 1999, nurses looked after more patients with diabetes, without spending
more time on diabetes care than nurses in 1990. Nevertheless, they reported in-
creased involvement in the more complex areas of diabetes care. Respondents in
1999 were no more likely than those in 1990 to adjust treatment, and gave a full
range of opinion for and against proposals to allow nurse prescribing. The relatively
low response rate to the 1990 survey may lead to an underestimate of changes
between 1990 and 1999.
Conclusions. Developments in New Zealand primary care are likely to increase the
role of primary health care nurses in diabetes. Research and evaluation is required to
ascertain whether this increasing role translates into improved outcomes for
patients.
Keywords: practice nurse, diabetes, role changes, education, nurse prescribing,
survey
Introduction
In New Zealand, important concurrent changes are taking
place in diabetes care, the role of practice nurses (PNs), and
the whole structure and delivery of primary health care.
Concern about an epidemic of diabetes in New Zealand
(Simmons 1996a, 1996b) prompted production of a national
strategy in 1997 (Ministry of Health 1997), which placed
primary health care at the centre of diabetes detection and
management. Despite the changes being created by reformers,
many at government level, there is no published description
of the diabetes care currently provided by PNs or other nurses
working in primary health care. This paper offers a baseline
description that will contribute to later efforts to evaluate the
impact of the reforms.
Primary health care in New Zealand is currently delivered
principally by general practices consisting of PNs, general
medical practitioners (GPs) and support staff. There was at
least one PN in 94% of general practices in 1999 (Kenealy
et al. 2002a, 2002c). General practice provides sole medical
care for over 60% of all patients with diabetes across all
ethnic groups (Simmons et al. 1994). Care of a person withdiabetes is commonly divided between a PN and GP,
although the roles overlap considerably and the division of
labour varies between practices. Nevertheless, a new payment
to primary health care providers for a diabetes annual review
is likely to encourage devolvement of diabetes care from GPs
to PNs (Health Funding Authority 2000).
General practices have typically been owned and run by
GPs. Since 1970, the government has subsidised PN salaries
in general practice to provide GPs with nursing assistance.
The PN work role is, therefore, typically moulded around
that of the GP, and the patients who attend the GP on a given
day. This has resulted in few nursing decisions being made
by nurses for nurses and has ultimately hindered progress in
professional development for PNs at a national level or in
advanced nursing practice. PN roles, training and compe-
tency vary considerably and there is no benchmark to assess
the competence of any PN in providing diabetes care.
Health reforms since 2001 have signalled a major role for
primary health care (PHC) nurses (King 2001). This has
resulted in a national education framework for primary
health care nursing that is presently moving through the
endorsement requirements of the Nursing Council of New
Zealand. The framework includes a new nurse practitioner
pathway at clinical masters level, which will allow nurse
prescribing. All nurses working in primary health care,
including PNs, will work under the auspices of primary
health care nursing at a postgraduate level and have
associated competencies that will be required for annual
practising certificates. The requirement for postgraduate
training in future contracts for PNs nursing services willensure advanced nursing roles in disease management,
including diabetes.
A new government primary health care strategy is using
funding to direct general practices to become part of new
primary health organizations that are funded by capitation
(payment to the organization) rather than fee-for-service
(payment to the doctor) (King 2001). This reorganization
also seems likely to support the developing role of a qualified
Issues and innovations in nursing practice Nurse roles, attitudes and concerns in diabetes care
2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(1), 6875 69
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PHC nurse, who may run diabetes mini-clinics (which are still
unusual in New Zealand) and may, increasingly, take on the
role of diabetes case-manager. Many of these changes would
make primary health care in New Zealand more like that in
the United Kingdom (UK).
In this paper, along with a description of current PN
diabetes care, we describe changes that have taken place since
1990, when a survey was undertaken as part of a major study
of diabetes in South Auckland (Wilson et al.1994, Simmons
et al. 2000). To evaluate the new PHC nurse role it is
important to consider published data on current PN roles and
historical changes in this role.
The study
Aims
The aims of the study were:
to describe the diabetes-related work roles, training andattitudes of PNs in New Zealand, comparing 1990 with
1999; and
to consider whether barriers to PN diabetes care changed
through that decade, and whether ongoing barriers may be
addressed by current changes in primary care.
Design
A longitudinal survey design was used, with questionnaires
being distributed to all South Auckland PNs in 1990 and
1999.
Setting
South Auckland had a population of 341,721 according to
the 1996 census, with 53% being European, 17% New
Zealand Maori, 16% Pacific Polynesian, 8% Asian and 6%
other and unknown ethnicities (Statistics New Zealand
1997). The population in the area increased by 23% between
the 1991 and 2001 censuses (http://www.statistics.govt.nz).
The area includes some of the most economically deprived
people in New Zealand and is relatively under-served by
health care providers.
Participants
All PNs working in South Auckland at the time of the surveys
were considered eligible for the studies. In 1990, a list of PNs
working in South Auckland was compiled from Auckland
Area Health Board records and updated by telephoning each
practice. A total of 146 PNs were identified. In 1999, a list of
all PNs working in South Auckland was obtained from a
commercial mail-list company and also supplemented by
telephoning each practice. A total of 213 PNs were initially
identified, of whom 33 proved ineligible (six retired, 27 left the
practice), leaving 180 PNs eligible. The commercial list
contained only 775% of those on the final list. The question-
naires were posted in November 1999 and responses were not
anonymous. Non-responders were phoned after 2 weeks,
followed by a second mail-out and a final phone call.
Questionnaires
The 1990 questionnaire consisted of a total of 104 closed and
open questions. In 1999, it was shortened and updated to
address current interests. The 1999 questionnaire contained a
total of 76 closed and open questions, including 66 previously
asked. Both questionnaires enquired about personal and
practice descriptions, practice organization, time spent with
patients with diabetes, screening practices, components ofcare undertaken by PNs, difficulties in and barriers to good
practice, training in diabetes and need for further education.
In 1999, additional questions were asked about PN attitudes
to nurse prescribing and their expectations of influencing
patient quality and quantity of life. We can provide copies of
the questionnaires on request. Techniques used to improve
response rate in both 1990 and 1999 included multiple
contacts, different methods of contact, attention to presen-
tation of the questionnaire and the offer to enter respondents
into a prize draw (Sibbald et al. 1994, Deehan et al. 1997,
Young & Ward 1999).
Ethical considerations
Both studies received approval from the appropriate ethics
committees. Responses were anonymous, but questionnaires
were tagged with a temporary identification code to track
non-responders, who were followed-up by letter and then by
telephone. Consent to participate was implied by return of a
completed questionnaire.
Data analysis
SPSS 11.0 software was used to analyse the data. All results
reported refer to respondents only. Only data from questions
that were unchanged from 1990 to 1999 were directly
compared. Means were compared by t-test. Equal variance
was assumed when comparing years since graduation of PNs
in 1990 and 1999, but was not assumed for all other
comparisons. Proportions were compared using Pearsons
chi-square test, and the MannWhitney U-test was used to
T. Kenealyet al.
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compare scale rankings. Statistical significance was set at
P 005 and all tests were two-tailed.
Results
In 1990, responses were received from 86 PNs in 51 practices
and in 1999 from 155 PNs in 77 practices, giving response
rates of 59% and 86%, respectively (v2 3096, d.f. 1,
P < 00001). Table 1 describes the nurses and the general
practices in which they worked. Practice sizes increased from
1990 to 1999, as judged by the number of GPs per practice.
Similarly, the total number of PNs per practice grew, due to
an increase in the number working part-time, although the
mean number of hours worked was essentially unchanged.
PNs surveyed in 1999 had more years of experience since
registration or graduation and had worked longer in their
current practice than those in 1990.
In 1990, 148% of PNs had postregistration education in
diabetes compared with 471% in 1999 (v
2
23929, d.f. 1,
P < 00001), although it is notable that nearly all nurses in
both years wanted more education. Of the 59 PNs in 1999
who gave a description of their education, 49 said that they
had attended diabetes education sessions run by staff
working in outpatient clinics at local hospitals. In 1999,
73 PNs reported past experience in diabetes care, including
53 while working on medical wards, 22 on surgical wards,
seven as district nurses and five in care of older people.
It was not possible to count the exact number of organi-
zations or providers of education, but it was clear that there
was a wide range of educators and minimal co-ordination
between them, with subsequent fragmentation of diabetes
education.
Those PNs surveyed in 1999 who had any postregistration
diabetes education were compared with those who had not. It
was found that they had more years of postregistration
experience [241 (SESE 124) vs. 194 (SESE 120),t2683, d.f. 151,
P 0008]; were more likely to regularly spend time with
established patients (76% vs. 59%, v2 4914, d.f. 1,P0027);
were more likely to feel that their workload allowed for
positive health promotion (79% vs. 58% P 0007); and
were more likely to be involved in foot care (61% vs. 40%,
v2 7339, d.f. 1,P 0021). Nevertheless, they were also more
likely to perceive financial, educational and other barriers to
regular patient attendance and achieving good diabetes
control (78% vs. 60%, v2 5339, d.f. 1,P 0021), and to say
that they experienced difficulties in educating some groups
of patients (78% vs. 60%, v2 5134, d.f. 1, P 0023).
However, there were no statistically significant differences
in hours involved in diabetes care per week, methods used
for diabetes screening, and likelihood of being involved in
education about diet, weight, hypoglycaemia, blood testing,sick days, insulin injections, adjusting treatment or taking
blood pressure. Similar analyses comparing part-time and
full-time PNs showed no significant differences.
Table 2 shows that about one-third of PNs in both 1990
and 1999 prompted their GPs to screen for diabetes. Of the
respondents to the 1999 survey who did not prompt, 14 6%
commented that they did not need to, 101% did it
themselves and 124% said they would do it for high risk
patients. PNs were asked an open-ended question about
which patient groups warrant screening for diabetes. Sug-
gestions from the nurses surveyed in 1999 were Pacific
Island people (471%), Maoris (297%), obese or over-
weight people (196%), those with a family history of
Table 1 Practice nurses and their practices, comparing 1990 with 1999
1990 (n 86) 1999 (n 155) Statistics
Years since graduation t2283, d.f. 235,P 0 023
Range 140 143
Mean (SESE ) 185 (097) 216 (087)
Years as a nurse, mean (SESE ) n 136 (079) 74 Not asked
Years as a practice nurse, mean (SESE ) n Not asked 81 (052) 153
Postregistration diabetes education, % (n) 14
8 (81) 47
1 (153) v2
23
929, d.f. 1, P