Consultations between nurse prescribers and patients with diabetes in primary care: A qualitative study of patient views
Introduction
The prevalence of diabetes is increasing worldwide (Wild et al., 2004). In response to increasing demand, there is a drive to improve the efficiency and quality of services for people with diabetes (DoH, 2003, Audit Commission, 2000, International Diabetes Federation, 2005). Empowering patients to self-manage their condition is considered central to good quality diabetes care. In order to empower patients, guidance calls for a greater focus on individual support and collaboration with patients, improved provision of information to patients and better service continuity (International Diabetes Federation, 2005, Roberts, 2007). This move towards a more patient-centred focus with increased patient participation in health care has been the goal of many national and international health policies (Thompson, 2007, Bolster and Manias, 2010). This is backed by evidence about what people want from health services and by growing evidence that involving patients in decisions about their healthcare can improve health outcomes (Greenfield et al., 1988, DoH, 2004).
Increasingly, care for the majority of patients with diabetes is managed within primary care where patients are seen primarily by General Practitioners (GPs, i.e. doctors based in community practices) and nurses (Audit Commission, 2000). The core values of both nurses and GPs have been based upon bio-psycho-social or holistic models of care whereby aspects of patients’ lifestyle and thinking are considered alongside biological factors when reaching care decisions (Hardey, 1998, Howie et al., 2004). In addition, both professions value the need to identify and respect patients’ priorities when reaching care decisions. These values are considered conducive to promoting patient-centred principles in practice (Howie et al., 2004), however, the extent these principles are demonstrated by health professionals varies (Stewart, 2001). In relation to diabetes care, there is some evidence that patients consider nurses as more adept at, and more often practicing, patient-centred principles than doctors (Audit Commission, 2000). A qualitative study of service user and carers’ views of NHS diabetes services (Hiscock et al., 2001), found that learning about diabetes was an interactive and ongoing process for patients. The approach of the health professional was crucial to this process, with preference for holistic principles of friendliness, equality, a partnership approach to treatment, a willingness to discuss and answer questions and account for differences in lifestyle. In general, nurses were seen as more accessible and more often practicing these principles than doctors.
It is recognised that nurses contribute to supporting patients in managing their diabetes with nurse's role being patient education and promotion of self-care (Peters et al., 2001, Carey and Courtenay, 2007a). In addition, nurses are increasingly involved in medications management and prescribing for patients with diabetes (James et al., 2009). The numbers of countries in which nurses can prescribe is increasing, although there is great variation in the extent of prescriptive authority within and between countries (Ball, 2009). Long-term conditions, such as diabetes, have been selected as suitable conditions for which nurses can prescribe in a number of countries, including the UK, Ireland, Netherlands and Canada (Ball, 2009). The main aims of introducing nurse prescribing in the UK were to improve patient care and access to medications, increase patient choice, make better use of the skills of healthcare professionals and contribute to more flexible team working (DoH, 2006). Approximately 18,000 nurses in the UK have qualified as Nurse Independent Prescribers (NIP) and, as such, are able to independently assess, diagnose and prescribe products for patients within their area of competence. Surveys indicate that around a third of these nurses prescribe for patients with diabetes (Carey and Courtenay, 2007b, Courtenay and Gordon, 2009).
Fears have been voiced that patient-centred principles may be threatened when nurses adopt prescribing (Tye and Ross, 2000, Bradley et al., 2008). However, a review of substitution of doctors by nurses in primary care found patient outcomes remained similar with higher patient satisfaction for nurse-led care (Laurant et al., 2004). Research on the influence of prescribing on nursing roles indicates that nurses who prescribe for patients with diabetes strive to maintain a patient-centred focus to consultations and claim that prescribing brings additional benefits to patients (Stenner et al., 2010a). In this study, Stenner et al. (2010a) report that stakeholders (doctors, nurses and administrators) thought patients regarded nurses as more approachable and friendly in general than doctors and that nurses tended to give clear and understandable explanations to patients. These nurse prescribers regarded their use of a holistic patient centred approach as promoting greater opportunity for discussion and patient involvement.
Despite claims that nurses follow patient-centred principles, the extent to which nurses involve patients in decisions about their treatment has been questioned (Bolster and Manias, 2010, Stevenson et al., 2004). Two mixed method case studies of nurse prescribing (Courtenay et al., 2009a, Latter et al., 2007) report inconsistencies during observations of nurse–patient consultations in the extent to which nurses provided information about side-effects and the risks and benefits of treatment options. The authors argue that these are necessary prerequisites for informed choice. A similar multi-method study was conducted on nurse prescribing for patients with diabetes (Courtenay et al., 2009b). Findings that the majority of patients highly rated all aspects of nurse communication, such as: listening, showing concern, explaining conditions or treatment, giving information about medications and answering queries, were congruent with previous work (Courtenay et al., 2009a, Latter et al., 2007). In observations of videotaped consultations, nurses consistently demonstrated use of listening skills, were sensitive to patient concerns, planned for future needs and provided instructions to patients about their medication. Nurses were observed to encourage informed choice in around 70% of consultations, but there were discrepancies in the extent that nurses were observed to provide information on risks, benefits and side-effects. The study did not, however, seek to explore the views of patients.
Where patients’ views and opinions of nurse prescribing have been elicited, the majority of patients have been accepting of and confident to take medications prescribed by a nurse (Page et al., 2008, Wix, 2007, Jones et al., 2007, Brooks et al., 2001). A number of studies point to nurses’ interpersonal skills as being pivotal to positive evaluations of nurse prescribing by patients. Of particular importance are nurses’ approachability, empathy, understanding, tendency to treat patients as individuals, and ability to provide clear information (Luker et al., 1997, Page et al., 2008, Brooks et al., 2001).
We are not aware of any studies that have sought the views of patients with diabetes about nurse prescribing. Given the importance placed on the patient-centred approach and on matching services to patient requirements, exploring patients’ views on nurse prescribing and any impact on care is essential if we are to better understand how to improve care.
The aim of the study was to explore nurse prescribing from the point of view of patients with diabetes. The main objective being to explore patients’ views about their consultations with a nurse prescriber and any impact of this on medications management. Findings relating to patients’ opinions about nurse prescribing in relation to diabetes are reported elsewhere (Courtenay et al.,2010).
Section snippets
Design and setting
This was a qualitative study using semi-structured interviews to explore the views of patients with diabetes under the care of a diabetes nurse prescriber. Patients were recruited from the case-load of 7 nurse prescribers. In the UK, the majority of patients with diabetes are seen in primary care and likewise the majority of diabetes nurse prescribers are based in primary care settings (Carey and Courtenay, 2007b). The chosen sites reflected the key settings in which nurses typically prescribe
Findings
Participants had a mean age of 67 years, ranging from 37 to 87 years, 63.4% (n = 26) were male, 36.6% (n = 15) female, 83% (n = 34) were white British and 17% (n = 7) of ethnic minority background. Average time since diagnosis was 9 years 8 months, ranging from 9 months to 39 years. Most (n = 39, 95%) had type 2 diabetes, 2 (4.8%) had type 1 diabetes. The length of time with the current diabetes nurse varied from being the first visit (n = 2, 4.9%), 2–4 visits within a year (n = 14, 34%), multiple visits
Discussion
This is an important first study to explore the views of patients with diabetes about their relationships with a nurse prescriber. The way patients described these consultations demonstrates that nurse prescribers can and do adopt principles of patient-centred care and this was beneficial to patients. The benefits imply greater concordance over treatment decisions, which theoretically should improve treatment adherence and ultimately health outcomes in line with guidance on services for
Conclusions
This study confirms that nurse prescribers can contribute significantly to providing recommended service improvements. This is important given the high proportion of nurses who prescribe for patients with diabetes. The study provides new knowledge about the benefits of consultations with a nurse prescriber from the perspective of patients with diabetes. In addition to those benefits associated with person-centred nursing, the study highlighted benefits of improved understanding of treatment and
Acknowledgements
We would like to thank the individual patients and nurse prescribers who generously gave up their time to participate in this study. We also thank Jill Hill (Diabetes Nurse Consultant) for her advice on the study conception and Tanya Hector for her contribution to data collection.
Contributions: MC and KS were involved in study design, KS and TH in data collection, KS and NC in analysis, KS, MC and NC in manuscript preparation.Conflict of interest
None declared.
Funding
The study was funded by an
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