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.

70 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(1), 6875


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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

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Diabetes_care_practice_nurse_roles_attitudes_and_concerns.pdf