Diabetes is the fifth leading cause of death in the world.¹ The rising cost and prevalence of chronic illnesses, such as diabetes, have led to healthcare systems examining ways to reorganise services with growing emphasis on the development of primary care services.² In Ireland, diabetes care is delivered in a variety of ways including traditional mixed care, hospital-led care, shared care arrangements and primary care-led management.

At general practice level, type 2 diabetes care is often ad-hoc, reflected in the absence of patient registries, irregular review and lack of guideline use among GPs.³ However, there are a number of initiatives in Ireland, whereby comprehensive systematic care for patients with diabetes is provided using a multidisciplinary structured approach. Recent audits in Ireland of some of these initiatives have shown that these patients can be successfully managed in primary care.^4-7

The HSE National Service Plan 2012 has provided a commitment for the rollout of a chronic disease management programme for diabetes during 2012 in primary care.⁸ In order to facilitate the forthcoming changes in diabetes care delivery, practice nurses will need to update and extend their knowledge and expertise in the management of type 2 diabetes. 

Background

There is a paucity of published Irish studies that investigate the role of the practice nurse in general and more specifically their role in diabetes care. However, the research that is available serves to highlight the changing role of the practice nurse in the past 10 years. A study by Harrington et al, investigating the practice nurse role, highlighted that dressings, removal of sutures and blood pressure measurements featured largely as part of the nurse’s role (97%) and over 90% of practice nurses were undertaking duties such as stock ordering and reception duties.⁹

In 2009, McCarthy et al identified the diverse, challenging and changing role of the practice nurse within the Irish healthcare system and recommended that the role of the practice nurse in primary care needs to be further developed towards specialist practice such as the management of chronic conditions including asthma, COPD, diabetes and cardiovascular disease.^{10 11}

Furthermore, McCarthy et al, in a more recent study on the perspectives of GPs and practice nurses on the future development of practice nursing in Ireland, reported that 85% of GPs and practice nurses surveyed noted diabetes as one of the main chronic disease conditions that require further education and training and that 95% of GPs were of the opinion that practice nurses should extend their role into chronic disease management.¹²

The changing role of chronic disease management in Ireland is placing greater emphasis on care delivery in primary care settings and by association, practice nurses. 

Over the years, practice nurses have undertaken education programmes in various chronic illnesses and there is a large amount of knowledge and expertise in the community which is not being used to its maximum potential.¹³ Nurses working in general practice in Ireland are an important part of the primary care workforce.

Moreover, the development of primary care teams, through the National Primary Care Strategy, has put a greater emphasis on the requirement to roll out a successful chronic disease management programme for diabetes to all GP practices which is finally a key deliverable of the National Diabetes Programme.⁸

In this regard, this paper presents research that investigates the current role, attitudes and concerns of practice nurses with respect to the management of patients with type 2 diabetes in the HSE Midland Area. The research also identifies the educational preparation and the professional development needs of the practice nurse within this specialist area.

Methodology

A descriptive quantitative design was used in this study and it was reviewed and approved by the Irish College of General Practitioners Research Ethics Committee. 

A postal questionnaire and information leaflet was circulated to all known practice nurses in the HSE Midland Area (n = 123) addressing practice demographics, practice nurse experience, current management of type 2 diabetes and education issues. 

Key findings

Practice nurse role 

The response rate was 49% (n = 60). Respondents were primarily from mixed or rural practices with a median of 4,500 (mean = 4,869; range = 250-15,000; SD = 3,316) patients registered per practice. Practice nurses reported working for an average of seven years at their current practice, which is encouraging from a continuity of care point of view for patients. 

The majority of practices had no full-time practice nurse (56.7%), with practice nurses reporting that they worked for a median of 23 hours per week (mean = 24,5 hours per week; range = 12-40; SD = 7.6). Management of type 2 diabetes is a large component of the practice nurse workload with 93% reporting involvement in diabetes care for a median of five hours (mean = 5.4; range 0-15; SD = 3.5) per week. The areas of care they were involved in are included in Table 1.

Educational requirements

Practice nurses recognise their educational requirements in diabetes management with 51.5% (n = 31) having completed an accredited diabetes nursing module which was found to be of great benefit (see Table 2). 

Eighty-nine per cent of respondents reported that they required further ongoing education in areas such as footcare, dietary and medication management. It was possible to improve diabetes education of patients in their practice according to 85% of practice nurses, but 75% highlighted a lack of protected time for diabetes patient education as a significant barrier to improving patient care.

Availability to attend education sessions can sometimes be problematic for busy practices and 16% of respondents indicated that they would not be allowed time off due to being too busy, job sharing, working part-time, would not get paid or were not allowed. For 19 practices where a community diabetes nurse specialist was not available to the practice, 68% reported that access to a community diabetes nurse specialist would support diabetes care in their practice. 

Practice nurse attitudes to care and diabetes patients

The element to which practice nurses are satisfied with the work they do with patients with type 2 diabetes was probed by asking them to describe the patient that gives them a sense of achievement and also the most frustration. 

It was very clear that patients who absorb the education they receive, making the requisite lifestyle changes and adhering with their medications give the greatest sense of achievement to practice nurses. Practice nurses are extremely frustrated with patients who are non-compliant, have no interest in their health and those that will not make the requisite lifestyle changes. Patients that don’t attend for regular review, who have a poor attitude and those who are overweight and will not address their weight were also a source of frustration.

Poor patient motivation, particularly in the area of lifestyle change, was seen as a major barrier to achieving good glycaemic control in addition to poor medication compliance and poor understanding of the condition. Practice nurses, however, believed that they could favourably influence the length of, and the quality of life of their patients with diabetes.

Discussion

Practice nurse role

Practice nurses reported working in their current practice for an average of seven years and this is beneficial for the patients from the point of view of  continuity of care, not only for patients with diabetes, but for all patients. 

Continuity of care is ensured through regular, active and sustained follow-up.¹⁴ Continuity of care with a primary care provider has been shown to be associated with improved glucose control and significant decreases in HbA1c among patients with type 2 diabetes.¹⁵

This current study emphasises the importance of providing adequate support and resources for practice nurses in managing patients with diabetes in primary care, which is also supported by an older UK study by Stearn and Sullivan showing that by having the practice nurse involved in diabetes care there was an improvement in glycaemic control and improved documentation of risk factors.¹⁶

Results from this current study discovered practice nurse involvement in all aspects of type 2 diabetes care. The increased involvement of the practice nurse in the more complex aspects of diabetes care such as hypoglycaemia management or insulin therapy, signals again the need for further education and support. 

These results are consistent with previous research explored by Kenealy et al, in particular that practice nurses requested additional diabetes education.¹⁷  Similarly, McCarthy et al in their most recent study, highlighted that a large proportion of GPs and practice nurses noted diabetes as one of the major chronic diseases that necessitated further training and education.¹²

Community diabetes nurse specialist

The majority of practice nurses acknowledged that the availability of a community diabetes nurse specialist would support diabetes care in their practice, mainly with regard to provision of education and assistance in setting up a specialist diabetes clinic in the practice. This is a point also supported in research by MacKinnon et al, which reported that there is a function for the diabetes specialist nurse to support and update primary care nurses through education and training.¹⁸

Education issues

When reviewing education of practice nurses and their role development, the challenge that exists is to complement the professional interest of the practice nurse with the needs of the practice, the patients and also with a view of national policy. 

With regards to diabetes care, the evidence from literature shows that nurses are frequently involved in education, individualised care, promotion of self-care, psychological support and more recently insulin initiation and medicine adjustment. However, it is unclear whether the educational needs of nurses caring for patients with diabetes are being met.¹⁹

The results from this study show that the majority of respondents expressed a need for further education with regard to diabetes management, which is positive in terms of role development but highlights a gap in ongoing education for practice nurses. 

While many practice nurses noted a need to update their education regarding new medications or insulin initiation, very few mentioned a requirement for training in the area of counselling skills on lifestyle issues, motivational interviewing and behavioural change. 

This is interesting as many practice nurses found that the barriers to achieving improved glycaemic control were lifestyle-related, which have been shown to respond to brief intervention, motivational interviewing and behavioural change techniques.

With regard to previous education, 54% of respondents indicated that they had completed a diabetes education module and found that it was of benefit to them in their nursing practice. Similar findings were noted by Kenealy et al where 45% of practice nurses had undergone post registration diabetes education.¹⁷

The results from this survey also raise concerns regarding professional support for practice nurses to attend or to undertake further study in diabetes care, which may explain why less than half of respondents have attended an accredited module; findings similar to McCarthy et al, where concerns about the lack of financial, and in some cases, professional support to undertake further education were raised by practice nurses.¹⁰

Practice nurse attitudes to type 2 care

While national policy is potentially promoting the practice nurse as being the main person to deliver diabetes care in the community in conjunction with the GP, it needs to be noted that the main role of the practice nurse is as a generalist and consequently their time spent caring for patients with diabetes may only form a small part of their daily workload – approximately one hour per day according to this study. 

Furthermore, the patient’s diabetes review with the practice nurse can take place in the limited time span of a 15-20 minute check-up appointment. 

During this time blood glucose level, weight and blood pressure are recorded, information about medications updated and footcare screening performed, while at the same time the practice nurse tries to promote behavioural change and motivate the patient to change his/her lifestyle. 

While all of these skills are carried out in a supportive, empathetic and comprehensive manner, it is not surprising that this survey supports previous research that suggests that nurses lack time and skills to promote lifestyle changes and risk reduction.^20,21

Conclusion

This study has highlighted the role of the practice nurse in the management of type 2 diabetes in the Midlands. Overall, practice nurses are satisfied with the work that they do and are of the opinion that they have a major role to play in the length of and also the quality of life of patients with diabetes. 

Concerns were noted regarding the management of type 2 diabetes care, in particular the further education needs of practice nurses in regard to lifestyle counselling of patients. Practice nurses feel that improvements could be made with type 2 diabetes care if there was an increase in dedicated time to educate patients upon review.  

The findings from this study emphasise the importance of providing adequate support for the practice nurse. The availability of a community diabetes nurse specialist was acknowledged as one such positive support for practice nurses. These and other themes will be further explored in the focus group component of this study.

Mairead Mannion is a community diabetes nurse specialist in the HSE Midland area and Paul Marsden is a researcher with the Department of Public Health, HSE Dublin Mid-Leinster, Tullamore

References

Roglic G, Unwin N, Bennett P et al. The burden of mortality attributable to diabetes. Diabetes Care 2005; 28(9): 2130-2135

Nocon A, Rhodes PJ, Wright JP et al. Specialist general practitioners and diabetes clinics in primary care: a qualitative and descriptive evaluation. Diabet Med 2004; 21(1): 32-38

McHugh S, O’Keeffe J, Fitzpatrick A et al. Diabetes care in Ireland: A survey of general practitioners. Prim Care Diabetes 2009; 3(4): 225-231

Murphy K, McHugh S, O’Keeffe J, Moran J. Diabetes Interest Group Audit Report, December 2007 - May 2008. June 2008

Jennings S, Whitford DL, Carey D, Smith SM. Structuring diabetes care in general practices: many improvements, remaining challenges. Ir J Med Sci 2009; 175(4):42-47

Marsden P, Brennan C, McHugh S, Harkins V. Audit report of the HSE Midland Diabetes Structured Care Programme. Department of Public Health, Health Service Executive Dublin Mid-Leinster, 2010

McHugh S, Marsden P, Brennan C et al. Counting on commitment; the quality of primary care-led diabetes management in a system with minimal incentives. BMC Health Services Research 2011; 11: 348

Health Service Executive Corporate Planning and Corporate Performance Directorate. National Service Plan 2012

Harrington P, Williams N, Conroy R, Shannon W. Employing a practice nurse – role and training implications in an Irish context. Ir J Med Sci 1994; 163(8): 384-387 

McCarthy G, Cornally N, Courtney M. The changing role of the practice nurse, Nursing in General Practice, 2009; 2(6): 38-44

McCarthy G, Cornally N, Courtney M. Role, clinical competence and the professional development of practice nurses in Ireland. Practice Nursing 2011; 22: 323-329

McCarthy G, Cornally N, Moran J, Courtney M. Practice nurses and general practitioners: perspectives on the role and future development of practice nursing in Ireland. J Clin Nursing 2012; 21: 2286-2295

Taylor R. Managing Chronic Illness in the Community. Nursing in General Practice 2009; 2(1)

Vonkorff M, Gruman J, Schaefer J et al. Collaborative management of chronic illness. Annals of Internal Medicine 2007; 127: 1097-1102

Parchman ML, Pugh JA, Noël PH, Larme AC. Continuity of care, self management behaviours, and glucose control in patients with type 2 diabetes. Med Care 2002; 40(2):137-144

Stearn R, Sullivan FM. Should practice nurses be involved in diabetic care. Br J Nurs 1993; 2(19):952-956

Kenealy T, Arroll B, Kenealy H et al. Diabetes care: practice nurses roles, attitudes and concerns. J Adv Nurs 2004; 48(1): 68-75

MacKinnon M, Wilson RM, Hardisty Ca, Ward DJ. Novel role for specialist nurses in managing diabetes in the community. BMJ 1989; 299(6698):552-554

Carey N, Courtenay M. A review of the activity and effects of nurse-led care in diabetes. J Clin Nursing 2007; 16(11c): 296-304

Casey D. Nurses’ perceptions, understanding and experiences of health promotion. J Clin Nursing 2007; 16(6): 1039-1049

Jansink R, Braspenning J, Van der Weijden T et al. Primary care nurses struggle with lifestyle counselling in diabetes care: a qualitative analysis. BMC Fam Pract 2010; 11: 41