Diabetes specialist nurses' perceptions of their multifaceted role

Original article

EDN Summer 2012 Vol. 9 No. 2 Copyright © 2012 FEND. Published by John Wiley & Sons 39

IntroductionThe diabetes specialist nurse (DSN)in primary care has an importantrole in supporting patients in theirindividual disease management andhas a key position in diabetespatient education to strengthenpatients’ self-management and pre-vent complications.1–3 According to the International DiabetesFederation, DSNs are expected to:take a comprehensive view of the patient, promoting a healthylifestyle and supporting patients’self-management;3,4 be involved inthe management of diabetes healthcare; support the education ofpatients, families, and health careprofessionals;5,6 and make careplans for the patient with other professionals on the diabetes careteam.7 A large cross-national study8

found that both physicians’ and specialist nurses’ support ofnational prevention goals werequite high; however, this study

showed that health professionals inthe Scandinavian countries hadamong the lowest rates in endorsingnational goals. Hörnsten et al.9described Swedish DSNs’ encoun-ters with patients in diabetes care asconflicted and characterised by difficulties in integrating medicalgoals with patients’ life experiences.

In Europe, almost all DSNs work in primary or secondary carewithin community health authorities.The DSN’s title differs between coun-tries – e.g. diabetes educator, diabetesspecialist nurse, or diabetes nurse –as do DSNs’ duties, responsibilities,and weekly case loads.2,5,6,10–13 MostSwedish DSNs in primary care pass apostgraduate examination as districtnurse and have a formal qualificationin diabetes care.14 Swedish DSNswork mainly in primary care settingsrun by county councils or communi-ties. In Sweden, most work part-timeas DSNs, combining their responsi-bility for diabetes care with other

duties such as providing telephoneadvice, home care, and clinical nursing. Swedish DSNs also haveindependent prescribing rights, similar to those of community nursesin the UK, for a limited list of medicines.15,16

A recent review17 of the clinicaleffect and cost-effectiveness of DSNsin the UK emphasised the impor-tance of DSNs to the future of dia-betes care. James et al.17 argued thatthe role of the DSN is becoming frag-mented and more research is neededamong community DSNs. Hörnstenet al.9 argued that DSNs need toreflect upon their professional role inthe clinical encounter with patients,because different understandingsand attitudes influence how DSNsdeliver care and what they choose tofocus on in their work, e.g. providinginformation, emotional support, orcollaboration.18

An increasing number ofpatients with type 2 diabetes will

Diabetes specialist nurses’ perceptions of their multifaceted role

SummaryThe aim of this study was to explore diabetes specialist nurses’ (DSNs’) perceptions oftheir professional role in diabetes care.

Exploratory interviews were used to elicit DSNs’ perceptions of their professional role.Twenty-nine DSNs working in 23 primary health care centres in northern Sweden wereinterviewed in focus groups. Data were analysed using qualitative content analysis.

The DSNs described their profession as encompassing five major roles: ‘expert’,‘fosterer’, ‘executive’, ‘leader’, and ‘role model’. Challenges interpreted as roleambiguities included feeling uninformed, fragmented, resigned, pressed for time, and self-reproachful.

The profession of DSN was interpreted as multifaceted, with various roles and roleambiguities. Patient-centred care and empowerment, which are recommended indiabetes care, can be difficult to achieve when DSNs experience role ambiguity.

Lack of clarity about role demands and difficulty in reconciling different roles mayhave a negative impact on DSNs’ attitudes in clinical encounters and could inhibit patient-centred care. The development of the DSN profession requires improvedawareness of the DSN’s professional role in the clinical encounter, not only to improve the care of patients with diabetes, but also to retain these professionals.

Eur Diabetes Nursing 2012; 9(2): 39–44

Key wordsdiabetes specialist nurse; patient-centred care; professional role; role ambiguity

Eva Boström, RN, PhD Student1

Ulf Isaksson, MHN, PhD, Post-doctoralResearch Fellow, Senior Lecturer1

Berit Lundman, RN, PhD, ProfessorEmerita1

Annika Egan Sjölander, PhD, SeniorLecturer2

Åsa Hörnsten, RN, PhD, AssociateProfessor1

1Department of Nursing, Umeå University,Sweden2Department of Culture and Media Studies,Umeå University, Sweden

Correspondence to: Eva Boström, PhDStudent, Department of Nursing, UmeåUniversity, SE-901 87 Umeå, Sweden; email: [email protected]

Received: 7 October 2011Accepted in revised form:16 March 2012

Original articleDiabetes specialist nurses’ perceptions of their multifaceted role

40 EDN Summer 2012 Vol. 9 No. 2 Copyright © 2012 FEND. Published by John Wiley & Sons

strain the current health care system, and improvements in theefficiency and quality of care arerequired. DSNs may be a resourcein this development;19 however,their role is in a state of change, andthey have new responsibilities andan increased need of new knowl-edge.20 In order that the DSNs canimprove the clinical encounterswith patients and, additionally, sothat the profession can be devel-oped and strengthened, it is neces-sary to clarify how the DSNs perceive their professional role.

The aim of this study was toexplore DSNs’ perceptions of theirprofessional role in diabetes care.

MethodDesign and setting The study used a descriptiveexploratory approach based onfocus group interviews at 23 pri-mary health care centres in north-ern Sweden. During data collection,the primary health care centreswere responsible for general care in specific geographic catchmentareas governed by county councils.The health care centres were staffedby GPs and primary health carenurses, some of whom were DSNsresponsible for diabetes clinic care.Nurse aids, social workers and psychologists were also available atmost of the health care centres.

Participants The study included 29 participants(27 women, two men), all regis-tered DSNs, with an average age of51 years. They had 15–41 years ofwork experience as nurses and 2–19years of work experience as DSNs.All except two were also educatedas district nurses, and all had further education in diabetes care.The participants, who freely volun-teered in focus group interviews,worked at any of the primary healthcare centres in the county counciljurisdiction, and all were informed

about the study by letter, by tele-phone, or in person.

Data collectionFocus group interviews are frequently used in qualitativehealth research. This interviewmethod is used to collect dataregarding people’s views and atti-tudes about specific topics, and toallow participants to clarify theirexperiences and problems throughgroup discussion.21

The participants in our studyformed five focus groups of three toeight participants each. The inter-views were conducted during 2009.Two members of the research teamwere present during the sessionsand acted as either interviewer or moderator.

Each interview lasted 50–90 min-utes (median 67) and was voice-recorded. The interviews were semi-structured and included some maintopics about the DSNs’ role in dia-betes care, perceived expectations,and thoughts about patient-centredcare. The initial questions were:‘Please, can you describe your maintasks as a DSN?’; ‘Can you describeyour own part in diabetes care?’; ‘Isthere anything significant aboutbeing a DSN?’; ‘How do you lookupon yourself as a DSN?’; and‘What expectations do you thinkothers have of you?’ Following thesequestions, we asked the participantswhether they wanted to add any-thing more. The interviews endedwhen the participants had nothingmore to add. The voice-recordedfocus group interviews were tran-scribed verbatim.

Data analysisThe text was analysed using the qual-itative content analysis described by Graneheim and Lundman.22

Qualitative content analysis is amethod for analysing communica-tion in a systematic manner.23 Theanalysis is a process of interpretation

that focuses on similarities and differences between different partsof the text and results in the organi-sation of the data into categories or themes.22

The analysis was performed inseveral steps. First, the interviewswere read through to gain a sense ofthe whole. Second, the text wasdivided into meaning units corre-sponding to the aim of the study,and the units were condensed with their core meanings retained.Third, the condensed meaningunits were coded, compared forsimilarities and differences, andgrouped into sub-themes. Finally,from the sub-themes we interpretedthreads of underlying meaning andidentified five main themes corre-sponding to DSNs’ professional rolein diabetic care. Throughout theanalysis, the research group dis-cussed the codes, sub-themes, andthemes until agreement about suitable labelling was reached.22

Ethical considerationsConfidentiality and de-identifiedpresentations of participants’ quota-tions were assured. The study wasapproved by the Regional EthicalReview Board in Umeå (Dno 00-323M, Dno 06-126M).

ResultsThe DSNs’ perceptions of their pro-fessional role are presented in fivethemes labelled: ‘striving to be anexpert’, ‘striving to be a fosterer’,‘striving to be a leader’, ‘striving tobe an executive’, and ‘striving to bea role model’. Themes and sub-themes are described and pre-sented together with associatedchallenges. Each theme is an inter-pretation of the meaning of theDSNs’ perceptions of the profes-sional role. Sub-themes in bold textheadings express characteristics ofthe various roles. Significant quota-tions from the original text illus-trate the analysis.



Striving to be an expert This theme included two sub-themes: being the teacher andbeing the specialist. DSNs empha-sised the importance of their skills,but perceived these skills as difficultto achieve. They were not in a posi-tion to prioritise their own furthereducation, nor did they have timeto improve their skills; hence, theyalso felt uninformed.

Being the teacher. The DSNsdescribed how they educatedpatients about their new situation,informing them about the disease, possible complications andtest results, while recommendingchanges in diet and increased exer-cise. ‘We can provide the patients witheducation about complications, andwhat they can do. If we can get them tounderstand, they have an opportunity toinfluence the course of their disease.’

The DSNs expressed how impor-tant it was that they achieved newknowledge themselves. However,they described often feeling unin-formed or insufficiently skilledbecause they lacked time for contin-uing education. ‘… [you] will neverget fully trained, since there’s alwayssomething new to learn.’

Being the specialist. The DSNsdescribed themselves as specialists,with the broadest and most impor-tant knowledge of diabetes and theability to apply that knowledge criti-cally using advanced skill sets. Theydescribed themselves as decisive,flexible, capable and qualified intheir work performance, managingmost aspects of diabetes care inde-pendently. However, it could be difficult being the specialist whensome patients had more knowledgeand experience of diabetes than theDSNs themselves. ‘The difference frombefore is that patients have so much moreknowledge. They have become some sortof experts on their own.’ The DSNsdescribed being a specialist as

including a comprehensive viewand seeing the patients as individu-als. However, they said that lack oftime made it difficult to maintaintheir grasp of each patient’s needs.‘It takes time to see the whole personbehind the disease; something we lack…’

Striving to be a fosterer This theme included three sub-themes: being the counsellor, beingthe monitor, and being the supervi-sor. The DSNs emphasised preven-tion, assessment and decisiveness as important in this role, whileacknowledging that it also impliedthem being doubtful and suspiciousof their patients.

Being the counsellor. The DSNsdescribed prevention work andmotivational interviews in theirwork to support patients’ self-management. ‘If you find and pick up a small grain of gold in them [the patients], then you can motivate and support them.’ The DSNsput great effort into trying toenhance patients’ motivation tomake lifestyle changes. However,they expressed doubts aboutpatients who did not manage self-care or did not have the will tomake lifestyle changes, and said thatmotivational work was time consum-ing. ‘It demands so much more timewhen you work more motivationally with the patients … about them takingresponsibility around their own diet and exercise…’

Being the monitor. The DSNs wouldhave liked more control over thepatients and their disease progres-sion and more insight into patients’self-care in daily life. ‘But sometimeswe want to be able to look through thekeyhole to see what they have eaten…Sometimes you think: God, if you onlycould be at their home and see what actu-ally is happening.’ The DSNs some-times felt the need to be suspiciousabout what patients told them, since

they did not always consider theirpatients trustworthy. ‘It is not alwaysthe truth that patients tell us about theirfood habits ... they tell us what they thinkwe want to hear.’

Being the supervisor. The DSNssometimes found it appropriate topush patients to achieve treatmentgoals. It could also be appropriateto reduce pressure on patients whowere too hard on themselves, and itwas difficult to know whether orwhen frightening or confronting apatient was justified. ‘It is hard toknow how to balance threatening andscaring, or how you say it…’ The DSNsexpressed their frustration with howdifficult it could be to work withpatients who were unwilling tomake lifestyle changes, and saidthey sometimes felt resigned totheir limited influence on suchpatients’ health. ‘Yes, they expect youwill make them healthy so they feel good,but I cannot exercise for them or locktheir refrigerator.’

Striving to be a leader This theme included two sub-themes: being the authority andbeing the coordinator. The DSNsemphasised their major responsi -bility and capacity to coordinate diabetes care, but they also felt quitealone, subordinated, and sometimesunappreciated by other professions.

Being the authority. The DSNsdescribed how they took responsi -bility for coordinating diabetes careamong their colleagues, physiciansand patients. They described them-selves as reliable in complicated situations and important decisions.‘If it weren’t for us DSNs, there wouldn’t be any diabetes care at all. A famousphysician in diabetes once said that, after the discovery of insulin, it is the establishment of the DSN that has beenmost important in diabetes treatment.’However, the DSNs also felt subordi-nated to physicians and frustrated by



their mandatory consultation whenunexpected problems emerged. Onthe other hand, DSNs also describedoften feeling overwhelmed byresponsibility, lonely in their work,and pressured by lack of time.Furthermore, they said they lackedsupport and appreciation from managers and other professionalsand felt that their specialised area of diabetes was seen as low priority. ‘It isreally hard to provide good diabetes carewhen you also have to manage all theother work stations. We always have to do this in between everything else, whentime permits.’

Being the coordinator. The DSNsdescribed how they organised andplanned diabetes care and coordi-nated care between themselves,physicians and other professionals.They emphasised that they had ashared mission in diabetes care, collaborating with other profession-als towards the same goals, but theyalso described how troublesome itwas to work with physicians who did not take responsibility. ‘You canunderstand each other much better if youhave exactly the same treatment goals.’ Itwas a challenge to remain organisedwithout becoming exhausted. Beingthe one others came to for solutionswas perceived as positive but also astiring. ‘Colleagues and others can comeand ask about this and that, and I’msupposed to be like a cog in the wheel andsolve their problems.’

Striving to be an executiveThis theme included two sub-themes: being the bureaucrat andbeing the administrator. Striving tobe executives, DSNs were hands-onnurses doing practical tasks accord-ing to current rules, but they alsofelt ambivalent and fragmented byperforming several different tasks.

Being the bureaucrat. The DSNsworked according to policy docu-ments, guidelines and quality

registers, e.g. the National DiabetesRegister (NDR). They structuredannual meetings with patients fol-lowing the NDR guidelines, such asdiscussing test results, and said itwas a secure way of knowing theywere performing the right tasks.‘I start from the NDR point of view,knowing that I’m doing the right thing.It’s a sort of checklist and results in sucha structured conversation.’ However,changes in the guidelines in dia-betes care could make DSNs feelambivalent and fragmented. Doubtsabout which guidelines were themost reliable or how to proceed onoccasions when guidelines offeredno solution to a problem madeDSNs uncomfortable and insecureabout clinical encounters. ‘It is verydifficult to give advice about diet todaybecause there are so many new influencesand therefore it is not easy to say, “Thisis the way it should be”.’

Being the administrator. DSNs saidthat giving practical service topatients and physicians was impor-tant in providing effective diabetescare, and they described how theycarried out work tasks based uponpatients’ wishes and needs andphysicians’ medical prescriptions.‘We are so used to work such as findingand preparing things. Sometimes it’s allI do: getting things ready for others.’The DSNs also described beingpressed for time because they weretorn between several different tasksand they expressed that other worktasks, e.g. home visits, telephoneadvice and clinical nursing, madethem fragmented in their work performance. ‘It’s like a cold shower;you never have time to get acquaintedwith anything since there is so muchother work – you become fragmented.’

Striving to be a role modelThis theme incorporated three sub-themes: being healthy, being avail-able, and being engaged. Being agood example, easily contacted

when needed, and committed topatients were perceived as desirablequalities in a DSN. However, DSNs’feelings of inability to live up to thissomewhat wishful image of them-selves could lead to self-reproachand self-doubt.

Being healthy. The DSNs describedthemselves as being interested inhealthy living (healthy food andproper exercise) and as livinghealthy lives themselves. ‘We arehealthy people. We walk in the forest in well-fitting shoes … carrying a back-pack and eating healthy food.’

However, these high standardswere difficult to maintain. OneDSN said that the picture of thehealthy DSN was somewhat true,but mainly wishful thinking. ‘We arehealthy as a group … but not all of usas individuals … at least not at myhealth care centre.’

Being available. The DSNs expressedthat being available for both patientsand colleagues was important toinspiring feelings of safety. ‘I think itis most important that the patient cancontact us, that we are here for them whenthey have questions, that they can call usany time.’

However, the DSNs also describedhow several time-consuming taskshindered their availability to patientswith diabetes, and they expressedfeelings of self-reproach for notalways being reachable. ‘We are supposed to be everywhere and quite oftenit is not possible to reach us until the following day.’

Being engaged. The DSNs describedtheir desire for close, regular andequal contact with their patients.Being engaged meant being person-ally committed to individual patientsin their particular life situations.‘Yes, I was determined that we had tohelp this man, otherwise he would die ofsome sort of circulation disease … I couldcry for this person.’ However, the DSNs



were troubled by their inability toget on well with all of their patients.They expressed self-doubt whenthey scrutinised their feelingstowards having failed to motivatepatients. ‘It is a personal failure if itdoes not go well.’

DiscussionWe found the profession of DSNdescribed as a multifaceted, poten-tially powerful position, incorporat-ing the roles of expert, fosterer,executive, leader and role model;however, challenges interpreted asrole ambiguities revealed the DSNin a less powerful professional posi-tion. In studies from the UK, DSNsare described as educators, inter-preters, monitors, modulators andreferrers.6,24 This set of role descrip-tions, somewhat different from ourfindings, may be due in part to theUK studies’ inclusion of specialistnurses working in the managementof various chronic diseases otherthan diabetes. The UK studies alsoincluded audit and service evalua-tions which may mirror a particularperspective. Our study investigatedonly how Swedish DSNs perceivedand described their professionalroles working in diabetes care in primary care settings.

The role of expertThe role of expert included beingboth a teacher and a specialist. TheSwedish Council of TechnologyAssessments in Health Care3 hasstated that increased pedagogicalskills are necessary for professionalsin diabetes care who conduct grouppatient education. However, theDSNs in this study saw their contin-uing education as a low manage-ment priority. Expert nurses face anew paradigm in which patientsneed to be supported in their ownproblem-solving skills, and patientsthemselves are considered expertsin their own lives, if not in the disease.25 Graue et al.26 have argued

that, to improve patient outcomes,DSNs need better skills in findingand interpreting research to ensure their practice is evidencebased. Patient-centredness andempowerment are recommendedin diabetes care,3,27 but complianceapproaches are still commonlyused.28–30 DSNs find it problematicto fulfil high medical standards and simultaneously emphasisepatient-centred care.9 Implement -ing patient-centred care andempowerment approaches havebeen shown to be difficult whenprofessionals experience role ambi-guity.31,32 Lack of control over theprofessional role may influenceDSNs negatively and hinder theirability to work in partnership withpatients.31 Therefore, knowledgeabout DSNs’ perceptions of theirprofessional roles will be valuablein enhanced patient-centred careand patient education.32,33

The role of fostererThe role of fosterer involved beinga counsellor, monitor, and supervi-sor. Our results showed that DSNs expressed role ambiguity intheir fostering role, i.e. being suspi-cious and losing hope in patientswho were unwilling to amendharmful health-related behaviours.According to Whitehead,34 suchresignation might lead to patients’resentment and rejection of DSNs,reinforcing the professionals’ suspi-cion of patients’ poor self-manage-ment in an unhealthy cycle. TheDSN is central to improved care forchronic diseases and patients’adoption of healthy behaviours.35,36

However, feeling resigned and notin control of their professionalroles may cause DSNs discomfortand result in their excessive worryover patients,31 which they maythen express in their work by alternating between frighteningpatients and comforting andencouraging them. The conflicting

needs to both frighten and comfortthe patient have been found amongGPs in their preventive work withdiabetes patients.37

The role of leaderThe role of leader included beingthe authority and coordinator indiabetes care. DSNs saw collabora-tion with other professionals as vital.According to Hansson et al.,38

district nurses in primary care aremore willing to collaborate than arephysicians. Nurses’ collaborationwith physicians may be a way tolighten the burden on DSNs, butsuch collaboration with other pro-fessions may also be seen as a threatby DSNs because it may lead to thereplacement of specialist nurses byother less educated health assis-tants.39 Patient outcomes have beenshown to improve when DSNsorganise diabetes care, and DSNsseem to have stronger organisa-tional ability when they have controland management of functional diabetes teams.40 Some authorsargue that it could be clinicallyeffective,41 as well as cost effective,to designate the DSN as the leaderin diabetes care.19

The role of executive The role of executive concernedbeing both a bureaucrat and anadministrator. The NDR guide -lines42 greatly influenced the DSNs’work and were often a tool to helpthe bureaucrat structure the clinicalencounter. However, it could be achallenge for the executives to lookbeyond clinical measures and focuson supporting self-managementinstead.40 The DSNs in our studydescribed an ambiguity betweentheir specialised mission and theincluded role of administrator.Occupying specialist nurses withhands-on work and lower skill workmay be a deliberate short-term decision taken to prevent the nursesfrom becoming too powerful while



saving labour costs in a decreasinghealth care budget.39

The role of role model The role of role model entailedbeing healthy, available, andengaged. Role models in healthcare may inspire patients by beinggood examples, but the DSNs’expectations of being good exam-ples were sometimes difficult to fulfil. Being role models mightaffirm their professional credibility,and nurses who have integratedhealthy behaviours into their ownlives might feel higher professionaladequacy,43 but patient-centredencounters are more dependent onequality and partnership than onrole modelling.44 Being a rolemodel, e.g. being slim and healthy,may actually increase the distancebetween the professional and thepatient not fulfilling such goals.There is a need for nurses in thecare of chronic illness to reflectupon their own role with thepatient and to become more awareof their own attitudes.45,46 In inter-actions with patients with diabetesthere may be a need of support forpsychosocial issues47 and the aspectof role modelling versus equalitybecomes of particular interest.

Overview of roles and expectationsThe DSN’s profession is multifaceted,encompassing several roles and expec-tations. Multiple roles could lead torole ambiguities through the impreci-sion generated by overlapping expec-tations.48 It is argued that nursingroles in general are in transition from the ideal of a selfless, tender,domestic approach to a more techni-cal, autonomous and collaborativeapproach.49 Patients’ expectationsand views on nurses’ attitudes are alsoessential to highlight in order todecrease role problems. Traditionalaspects of diabetes nursing, such as aone-sided disease perspective, profes-sionals’ high adherence expectations,

and paternalistic attitudes, have beendescribed as problematic issues inefforts towards patient-centred care.50

Strengths and limitations of the studyA strength of this study was the focus group interview design, which is effective for clarifying experiences and problems related to specific topics and considers all participants as active members ofthe group. The small size of somefocus groups might be a limitation,but smaller focus groups can alsohave benefits due to the more inti-mate climate.21 This study is limitedto the context of DSNs working inSweden, but we believe that the find-ings may be transferable to othercontexts and other countries, sincethe work tasks and responsibilities inSweden are similar to those in theUK, for example, and follow inter-national guidelines.4 Unlike DSNsin the UK, however, Swedish DSNsin primary health care most oftendo not work full-time in diabetescare, which may relate to the toosparsely populated geographiccatchment areas to support full-time DSN positions, especially innorthern Sweden. The increasingdemands and challenges that comewith increasing numbers of patients,more complex work tasks and morenurse-led clinics, will influence thefuture role of DSNs, not only inSweden, but internationally.20

The trustworthiness of theseresults was established through several discussions among theresearch team during the analysis.In addition, we presented the find-ings to one-third of the participantsin a later session in which the participants expressed their recog-nition of the interpreted roles.

Conclusion and relevance toclinical practiceThe results demonstrate that theDSN has a multifaceted professionwith various roles that can be quite

complicated to combine. The DSNsdescribed themselves as experts, fosterers, leaders, executives androle models, and they emphasisedtheir strength and capability.

However, role ambiguities indi-cated their position was less power-ful than they wished or believed andhad a smaller positive impact inclinical encounters with patients.Patient-centred care and empower-ment, recommended as successfulapproaches in diabetes care, can bedifficult to accomplish when DSNsexperience role ambiguity.

The main indication for clini-cal practice is the DSNs’ need tostrengthen their professional roleto emphasise patient-centred careand empowerment; hence, aware-ness about their roles and atti-tudes in encounters with patientsand other professionals need further study.

Observation of the clinicalencounter and the interactionbetween DSNs and patients may bea topic for further research.

AcknowledgementsWe acknowledge with thanks fund-ing provided by the SwedishDiabetes Association, StrategicResearch Programme in CareSciences, and the Department ofNursing and Faculty of Medicine,Umeå University.

The authors would especiallylike to thank the responding dia-betes specialist nurses for their par-ticipation in the study.

Special thanks go to LenaJutterström for her help with thedata collection.

Declaration of interestsThere are no conflicts of interestdeclared.

ReferencesReferences are available viaEuropean Diabetes Nursing online atwww.onlinelibrary.wiley.com.


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Documents

Diabetes specialist nurses' perceptions of their multifaceted role