Converting to insulin in primary care: an exploration of the needs of practice nurses.

BACKGROUND: In order to optimize glycaemic control, substantial numbers of people with type 2 diabetes may require transfer from oral medication to insulin therapy. Although insulin conversion is traditionally a specialist secondary care function, as nursing roles change and expand there is growing pressure for this to be performed within primary care. However, little is known about the potential barriers to such a change, particularly from the standpoint of the frontline staff involved. AIMS: The study aimed to explore the views of practice nurses in the United Kingdom (UK) about converting diabetic patients from oral hyperglycaemic agents to injected insulin within primary care, and to investigate what structures and resources might be useful in supporting such a change. METHODS: Semi-structured interviews were conducted with 25 practice nurses, and interpreted using content analysis to extract key conceptual themes from the transcribed interview texts. FINDINGS: Most of the nurses felt that converting to insulin in primary care had considerable benefits for patients. However, issues of time, training, confidence about performing the change, and the adequacy of support systems, both for patient and nurse, emerged as the main perceived barriers to performing insulin conversions in primary care. Worries about legal and accountability issues surrounding the nurse prescribing elements were also raised. CONCLUSIONS: Where insulin conversion within primary care is being considered, it is suggested that specific training is provided for practice nurses and general practitioners, protected time is made available, and a team-working approach is fostered to prevent isolation and boost patient support. Formal mentoring or supervision support for practice nurses may also help them to adapt to this new approach. LIMITATIONS: These findings are based on the views of nurses from a single UK locality, and so widespread consultation is recommended before applying them in other settings.

The doctor-patient relationship in US primary care.

Changes in the organization of primary care in the UK are driven by a need to improve access and availability, but doctor-patient relationships may suffer. To investigate the importance of such relationships in a different setting, we analysed focus-group data obtained in a primary care facility in the USA (Rochester, NY). The findings pointed to three key factors in these relationships-namely, an asymmetry of perceptions on the two sides, belying the notion of a meeting of experts; the importance on both sides of 'liking'; and the value set by both parties on development of trust. The last two of these factors are probably related to continuity of care, now under threat.

Professional development for general practitioners through fellowship by assessment.

BACKGROUND AND STUDY AIMS: The Royal College of General Practitioners has designed its Fellowship by Assessment (FBA) programme with the twin goals of promoting higher standards of care and offering GPs a professional challenge. By November 2000, 223 eligible doctors (2%) had opted to take FBA. This number is increasing annually. There is, however, little research to account for why GPs undertake it, or what the barriers might be. The aim of our study was to investigate GPs' experience and thinking on this issue. METHODS: A total of 13 GPs who had attained Fellowship by Assessment in the Tamar and Severn Faculties were invited to participate in a qualitative study. They were identified from the list of RCGP Fellows in the Institute of General Practice, University of Exeter, and purposefully selected to include trainers and non-trainers, men and women, rural and urban practitioners, and single-handed and large practices. Analysis of in-depth interviews was informed by grounded theory. FINDINGS: FBA served to acknowledge high standards of care. There was some variation in views about FBA, however, ranging from a perspective which prized the professional award, to the view that endorsed it as a pragmatic and useful way of structuring and monitoring improvements. Fellowship by Assessment improves the care of patients and empowers the doctors by improving their confidence. It is, however, hugely time-consuming and while our findings suggest it should be encouraged, there is a need for ways to be found whereby doctors may be supported in this form of professional development.