Table Of ContentScandinavian Journal of Primary Health Care, 2013; 31: 241–247
ORIGINAL ARTICLE
Challenges in managing elderly people with diabetes
in primary care settings in Norway
MARIT GRAUE1 , TRISHA DUNNING2 , MARIE FJELDE HAUSKEN 3 & BERIT ROKNE4
1 Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway 2 Centre for Nursing and Allied Health Research,
Deakin University and Barwon Health, Geelong, Australia, 3 Department of Medicine, Section of Endocrinology, Stavanger
University Hospital Stavanger, Norway, and 4 Department of Global Health and Primary Health Care, University of Bergen,
Bergen, Norway
Abstract
Objective . To explore the experiences and clinical challenges that nurses and nursing assistants face when providing high-
quality diabetes-specifi c management and care for elderly people with diabetes in primary care settings. D esign . Focus-group
interviews. Subjects and setting . Sixteen health care professionals: 12 registered nurses and four nursing assistants from
nursing homes (10), district nursing service (5), and a service unit (1) were recruited by municipal managers who
had local knowledge and knew the workforce. All the participants were women aged 32– 59 years with clinical experience
ranging from 1.5 to 38 years. R esults . Content analysis revealed a discrepancy between the level of expertise which the
participants described as important to delivering high-quality care and their capacity to deliver such care. The discrepancy
was due to lack of availability and access to current information, limited ongoing support, lack of cohesion among health
care professionals, and limited confi dence and autonomy. Challenges to delivering high-quality care included complex,
diffi cult patient situations and lack of confi dence to make decisions founded on evidence-based guidelines. C onclusion .
Participants lacked confi dence and autonomy to manage elderly people with diabetes in municipal care settings. Lack of
information, support, and professional cohesion made the role challenging.
Key Words: C hronic illness , diabetes , elderly people , focus groups , general practice , home-based services , Norway , nursing homes ,
qualitative research
Introduction with diabetes in extended-care facilities does not
meet American Diabetes Association (ADA) guide-
The dramatic increase in the prevalence of diabetes
lines [7,8]. In addition, care of elderly people is
worldwide threatens the health and quality of life of
inadequate in the Nordic countries [9,10]. For
millions of people and represents a major challenge
example, less than 20% of the people with type 2
to already burdened health care services in provid-
diabetes in Norway achieve the recommended treat-
ing high-quality diabetes management [1,2]. Many
ment goals in primary care [9], and diabetes care in
elderly people have several comorbidities and
Sweden ’ s home nursing services is inadequately
complex care needs, take multiple medicines, are
documented [10].
vulnerable to isolation and depression, and are at
In the future, more care for elderly people will be
risk of adverse events such as falls and medicine transferred from specialist to primary care in the
mismanagement [3,4]. Norwegian health care services [11]. Patients who
Nursing home residents in the United Kingdom live at home receive follow-up care from the district
have an average of four comorbid conditions in addi- nursing service. Several studies show that nurses’
tion to diabetes and have signifi cant care needs and knowledge concerning diabetes and its care is
defi ciencies [5,6]. Elderly people living at home or inadequate [3,12]. Further, evidence indicates that
in nursing homes in the United States receive inad- diabetes training for community-based health care
equate medical care, and the care of elderly people professionals signifi cantly improves the metabolic
Correspondence: Marit Graue, Centre for Evidence-Based Practice, Bergen University College, Postbox 7030, N-5020 Bergen, Norway. Tel: (cid:2) 47 55 58 55 30
or (cid:2) 47 55 58 75 00. Fax: (cid:2) 47 55 29 83 64. E-mail: marit.graue@hib.no
(Received 11 October 2012 ; accepted 7 October 2013 )
ISSN 0281-3432 print/ISSN 1502-7724 online © 2013 Informa Healthcare
DOI: 10.3109/02813432.2013.854445
242 M. Graue et al.
interested in diabetes care. All 12 registered nurses
This study enhances understanding concerning
had bachelor’ s degrees in nursing, and one had
the clinical challenges nurses and nursing assis-
specialist training in geriatrics and psychiatry. The
tants face when providing high-quality diabetes
four nursing assistants had undertaken the formal
care for elderly people.
Norwegian Nursing Aide training (two-semester
• It is essential that nurses and nursing assis- programme). All participants were women, aged
tants in primary care have access to current 32 – 59 years with clinical experience ranging
information and ongoing support. between 1.5 and 38 years. Ten participants worked
• They need enhanced professional authority in nursing homes, fi ve in the district nursing service,
and confi dence to manage challenging clin- and one in a serviced unit. Fewer frail elderly people
ical situations and make appropriate care live in services units than in nursing homes. Eight
decisions. participants worked full time. Participants’ clinical
• Refl ective practice forums and targeted edu- experience caring for people with diabetes ranged
cation and training programmes are needed from fi ve to more than 20 years.
in primary care settings. The participants were responsible for providing
• Specialist health care services and general care to men and women aged 62– 97 years with type
practitioners with expertise in managing 1 or type 2 diabetes. Some elderly people also had
diabetes have a pivotal role in developing dementia, cardiovascular disease, chronic obstruc-
programmes that enhance the skills and com- tive pulmonary disease, stroke, kidney problems,
petence of nurses and nursing assistants. Parkinson ’ s disease, schizophrenia, depression, or
were overweight.
control and quality of life of people with diabetes
Data collection
[13] and that good diabetes management can pre-
vent or delay the development of diabetes-related We conducted focus-group interviews because they
complications [14]. are interactive and participants can share and com-
Norway ’ s new primary care reforms and policies pare experiences, which enables shared opinions to
represent an opportunity to further explore the emerge and generates deep insights into complex
determinants of high-quality care for elderly people issues that enables patterns and trends to be identi-
with diabetes and the knowledge and competence fi ed within and among groups [16,17]. Four focus
nurses and nursing assistants need to care for elderly groups with respectively four, fi ve, four, and three
people with diabetes. The current study therefore participants were organized. We developed a semi-
aimed to explore the experiences and clinical chal- structured interview guide to guide the discussion
lenges primary care nurses and nursing assistants based on the study aims.
face when providing high-quality diabetes care for The researchers are all female registered nurses:
elderly people. three researchers and one charge nurse. MG, BR,
and TD are experienced researchers and have exten-
sive knowledge of diabetes; MFH has fi rst-hand
knowledge of both primary and specialist diabetes
Material and methods
care. One of the researchers moderated the groups,
Participants and recruitment strategy which were audiotaped. In addition, notes were
taken during the discussion to capture non-verbal
We carried out the study in a municipality in south-
language and clarify indistinct audiotaped informa-
ern Norway with 60 000 inhabitants. Some 17% of
tion. Following each focus group, the discussion
nursing home residents in the region have diagnosed
themes were summarized for the participants to
diabetes [15]. The municipality has fi ve zones: each
clarify and correct any misunderstandings. We tran-
has a base for coordinating home-based services and
scribed the audiotapes verbatim after each focus
nursing home care in the nine municipal nursing
group and checked the transcripts for accuracy. All
homes. We aimed to recruit nurses and nursing
audiotapes were listened to and cross-checked with
assistants from all fi ve municipal zones.
the transcripts and the notes.
The municipality’ s nursing management (nurse
leaders in charge) invited 21 nurses and nursing
assistants to participate in the study, and 16
Data analysis
(12 registered nurses and four nursing assistants)
participated. Some of the participants were novice We used Kvale ’ s [18] approach to qualitative con-
practitioners whereas others had previously been tent analysis to analyse the data and fi nd meaning
Diabetes care among elderly people 243
and categories, condense the categories, and inter- Lack of diabetes-specifi c knowledge on which to
pret the meaning. We read through the transcribed make sound clinical decisions based on clinical
data once to gain a general understanding of the observations and patient assessments was challeng-
text. The transcriptions were then reread and cate- ing for the participants. Lack of confi dence in their
gories were formed on the basis of the interview ability to manage complex patient situations was par-
guide. During this process, the text was searched ticularly demanding because many doctors providing
for units of meaning that corresponded to the cat- home-based diabetes services gave inconsistent
egories. We condensed them and placed them in advice. In addition, participants often felt alone and
appropriate categories. We sorted the categories and unsupported when doctors indicated they were
their units of meaning again because some units uncertain about standards of diabetes care and were
were originally placed in more than one category. reluctant to make medical decisions. The participants
found general practitioners’ uncertainty especially
confusing because they are responsible for prescribing
Results insulin and managing unstable blood glucose levels.
One participant said:
The participants experienced numerous clinical chal-
lenges providing care for elderly people with diabe- You sit there and feel completely alone with an
tes. Three main themes emerged: the availability and insulin problem.
accessibility of information and support, professional
Further, nurses described a range of challenges in
cohesion, and confi dence and autonomy.
observing and detecting changes in the patients’ sit-
uation and/or needs and their ability to interpret
Availability and accessibility of information changes and to manage the change. The participants
and support wanted guidance on exactly what signs and symp-
toms to look for from specialist diabetes clinicians.
The most common theme emerging in all groups
One participant said:
was that having diabetes-related knowledge and
information and imparting it to patients, relatives, What I would like … there is a palliative team
and colleagues are fundamental to high-quality at the [hospital] that is very good to have and
care. Nurses’ knowledge and profi ciency in diabetes that you can call … I would like to have [the
care, and the importance of nurses ’ confi dence in specialists] come [to the users] and see how
their professional ability were exemplifi ed by the their blood glucose is and be guided e xactly in
following quote: relation to each user.
You must at least have a lot of knowledge and
Professional cohesion
information yourself … the more you know
yourself the more you can observe, maybe … the Participants felt professional cohesion was often
more you know how to supervise [staff, people lacking although many nurses and nursing assis-
with diabetes and relatives], maybe. tants worked the same shifts in district nursing
services and in nursing homes. Participants reported
Nurses and nurse assistants in primary care settings inadequate teamwork and inconsistency delivering
depended on various types of support from diabetes care because the aims and standards of
colleagues with specifi c clinical knowledge of diabetes care were not consistent. For example, there are:
to interpret and act on their clinical observations. In
particular, participants highlighted the importance of … so many groups and so many shifts, and every-
good communication with general practitioners to one has different opinions about something.
determine their confi dence and autonomy to make
clinical decisions. This, in turn depended on their Improved team communication would encourage
diabetes-related knowledge and competence: collaboration and facilitate consensus about how to
implement evidence-based guidelines. While refl ect-
We have to fi nd out what to discuss with the ing on how a team approach improved the
doctor and what we can do ourselves … and leg ulcers of one elderly woman with diabetes, one
whether it is good enough for … what is best for participant said:
the patient. And for that you have to have know-
ledge … and if we don’ t know what to evaluate, it … we have worked well together in relation to
most likely won’ t be discussed with the doctor, and [preventing and treating foot ulcers] and … the
the patient will miss out [on better treatment]. whole personnel group has had a common
244 M. Graue et al.
understanding about it and what we should look in relation to going to the units and distributing
for in relation to minor signs of developing ulcers tablets and doing considerable work that I feel
… we have become good at preventing ulcers. a long way down in my gut.
Further, participants indicated that communication
was inadequate within and among the professional Discussion
disciplines and there were defi ciencies in working
Principal fi ndings
together. One participant said:
The fi ndings suggest there is a discrepancy between
[what we do] is somewhat in bits and pieces …
the knowledge and expertise participants described
we don’ t always follow the interventions that we
as being important for delivering high-quality care
set … it is so important that everyone work in
for elderly people with diabetes. Their actual capac-
the same way, that we be a team: otherwise the
ity to deliver quality of care was compromised by
intervention is worth nothing.
many challenges of daily clinical practice, including
lack of access to current information, limited pro-
Lack of professional confi dence and autonomy fessional support, and inadequate professional
cohesion. In addition, participants lacked confi -
The participants stated that they require adequate
dence and autonomy. Poor communication among
training and support and enhanced professional
care providers and within disciplines, the discrep-
competence and confi dence to have autonomy to
ancy between the level of professional expertise par-
make care decisions. They indicated that competence
ticipants described as being important to the
in specialties such as diabetes has become increas-
delivery of diabetes management, and the actual
ingly critical to enable primary care nurses and nurs-
care they were competent to deliver was compro-
ing assistants to observe, evaluate, and act on the
mised by several challenges. These included staffi ng
complex needs of the growing ageing population.
and roster issues that need to be addressed at ser-
However, as one participant reported:
vice and clinical levels.
… courses are often sporadic … “ you and you Participants described challenges in relation to
can take a course ” , there is no teaching plan at the working environment and the organization of
the nursing home… . health care. Consequently, participants often felt
alone and unsupported by experienced clinicians in
Moreover, prioritizing and balancing care delivery diabetes care, which they construe as a lack of a
with the documentation required to comply with cohesive professional approach. In the future, efforts
regulations and standards of care are challenging. should focus on establishing systems such that spe-
In addition, work routines were lacking or were not cialist health care contributes to developing expertise
followed or evaluated: in a reinforced municipal health service in primary
care settings in Norway.
… when they [nurses] are at work, they have so
much to do that keeping nursing plans and
interventions updated falls away… . L imitations and strengths
There appears to be a need to provide nurses in pri- One limitation was participant recruitment. We
mary care settings with enhanced professional asked municipal managers to help with recruitment
authority and confi dence to enable them to take the because they knew the workforce and had estab-
lead in delivering high-quality diabetes care. Heavy lished networks. The participants responded to the
workloads and limited time to complete tasks because request from their leaders to participate in the study
of understaffi ng hamper nurses’ confi dence and concerning the challenges in providing high-quality
autonomy to deliver diabetes care. care. Thus, they may have been more receptive to
Dilemmas related to lack of capacity to provide sharing their understanding of the inadequacies
high-quality care also correspond to organizational than nurses and nurse assistants who did not par-
challenges faced by health care services. Many ser- ticipate. Also, power differences within focus groups
vices do not have enough nurses employed which can affect group processes. Some participants knew
means many nursing assistants work outside their each other quite well because they worked together
scope of practice and competence, which puts in the same zone, whereas others met for the fi rst
patients at risk: time. Some participants may not disclose important
information or participate less fully or openly
… [assistants] are given a responsibility that I because of experiencing less power, and participants
wouldn ’ t have believed it was legal to give them from the same population might provide different
Diabetes care among elderly people 245
information. Each focus group comprised only 3– 4 Participants in the present study described a work
participants. Interaction among participants can be environment that appears to be fragmented. The
both the key to success and the root of failure in work environment was characterized by many work
focus groups. Small groups may generate excessive shifts consisting of many staff members, lack of con-
pressure to speak; large groups might inhibit inter- sensus on treatment, and lack of cohesion about how
action. Krueger & Casey [16] suggested focus to implement diabetes care. Inadequate teamwork
groups ideally consist of 6 – 10 participants. Our and poor management can affect the physical and
choice to conduct smaller groups points to some of psychological well-being of elderly people with
the factors related to teamwork such as understand- diabetes. The ADA Standards of Medical Care in
ing roles and responsibilities, which might not have Diabetes [23] indicate that a fragmented, inade-
emerged in larger groups. Likewise, more examples quately designed delivery system contributes to sub-
of doctor – nurse collaboration and team communi- optimal chronic disease care. Personnel must have
cation that worked may have been identifi ed if we access to current information and resources and
had included members of other professions, who ongoing support to increase their confi dence and
might have different opinions from those of the autonomy to make appropriate care decisions
study participants. In addition, all care personnel in founded on evidence-based guidelines. People with
the municipality were women, and thus only women chronic illness, especially elderly people with diabetes
participated. living at home or in nursing homes, do not receive
One strength was including participants provid- optimal care [7,8,24,25].
ing community care from all fi ve municipal zones There is sound evidence that a “ team ” approach
and those working in nursing homes and home- to chronic illness care, where the team has expertise
based services. Strategies to strengthen reliability in managing chronic illnesses using evidence-based
include using a semi-structured interview guide guidelines, improves patient satisfaction, health care
carefully designed by both experienced diabetes professionals’ adherence to guidelines, clinical out-
nurse researchers and a clinical charge nurse. The comes, and health status, and reduces the utilization
guide elicited the required information to meet the of health services [26,27]. More specifi cally, well-
study aim. coordinated primary care teams that have clearly
defi ned and explicitly delegated roles, as well as the
necessary competence, and who meet regularly can
Discussion of key fi ndings
deliver high-quality care to people with chronic
Participants stated that many patients had comorbid illness [26]. Furthermore, health professionals’
health conditions, which is usual among elderly peo- mutual relationship with the person is essential to
ple with diabetes [19]. Multi-morbidity increases their understanding of “ personhood” generally and
markedly with age [20], increases the complexity of individual people in particular [28].
care required, and signifi cantly increases the risk of The fi ndings of the current study show that
polypharmacy and adverse events such as falls and primary care workers face many organizational
pain. Further, participants’ comments and the way challenges such as understaffi ng and lack of qualifi ed
they expressed themselves showed they often felt nurses, which led to heavy workloads and insuffi cient
uncertain about what to do, especially when the pri- time to optimally care for elderly people with diabe-
mary care doctor appeared to have little diabetes tes, and that important documentation and nursing
knowledge. The study suggests that primary care care plans and patient profi les were not updated.
nurses and nursing assistants lack professional sup- Further, clinical care and service delivery were not
port, particularly from general practitioners. Our routinely evaluated, and staff members had little time
fi ndings are similar to those of Cytryn et al., who to update diabetes knowledge. These fi ndings are
reported that primary care practitioners had knowl- similar to those of Morgan et al. [29] and suggest
edge defi cits and lacked confi dence, particularly in that workload issues such as inadequate staffi ng
prescribing insulin, managing the complexities of levels affect the ability to provide high-quality care
diabetes, and competence in using diagnostic and in hospitals and nursing homes.
treatment guidelines to plan and monitor care [21]. Another consequence of understaffi ng and the
Improved collaboration depends on developing pro- lack of qualifi ed nurses is that unqualifi ed personnel
fessional relationships among general practitioners, are given responsibilities they are not trained to
practice staff, and allied health professionals [22]. provide, which can have adverse outcomes for
Factors such as lack of face-to-face interaction and community-based elderly people, including unneces-
poor understanding of the roles of other professions’ sary hospital admissions. Previous studies identifi ed
competences might limit teamwork and professional the devalued image of nurses who work with elderly
relationships. people. A systematic review of the experiences of
246 M. Graue et al.
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