Perceptions of insulin use in type 2 diabetes in primary care: a thematic synthesis.

BACKGROUND: Increasing numbers of patients with type 2 diabetes mellitus are progressing to insulin therapy, and despite its potency many such individuals still have suboptimal glycaemic control. Insulin initiation and intensification is now often conducted by Practice Nurses and General Practitioners in many parts of the UK. Therefore, gaining insight into perspectives of patients and primary care clinicians is important in determining self-management and engagement with insulin. A thematic synthesis of studies was conducted exploring the views and experiences of people with type 2 diabetes and of healthcare professionals on insulin use and management in the context of primary care. METHODS: Protocol based systematic searches of electronic databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and Web of Science) were performed on 1 October 2014 and updated on 31 March 2015, to identify studies that identified the views and experiences of adults with type 2 diabetes or primary care clinicians on the use of insulin in the management of type 2 diabetes. Studies meeting the review inclusion criteria were critically appraised using the CASP qualitative research checklist or Barley's checklist for survey designs. A thematic synthesis was then conducted of the collected studies. RESULTS: Thirty-four studies were selected. Of these, 12 used qualitative interviews (nine with patients and three with healthcare professionals) and 22 were survey based (14 with patients, three with healthcare professionals, and five with both). Twelve key themes were identified and formed three domains, patient perceptions, healthcare professional perceptions, and health professional-patient relationships. The patient-centred themes were: insulin-related beliefs, social influences, psychological factors, hypoglycaemia, and therapy barriers. The clinician-related themes were: insulin skills of general practitioners, healthcare integration, healthcare professional-perceived barriers, hypoglycaemia, and explanations for adherence. Healthcare professional-patient relationship themes were drawn from the perspectives of patients and from clinicians. CONCLUSIONS: This review reveals multiple barriers to optimal insulin use in primary care at both the patient and healthcare professional levels. These barriers indicate the need for multimodal interventions to: improve the knowledge and competencies of primary care professionals in insulin use; provide more effective patient education and self-management support; and introduce integrated insulin support systems.

National standards for asthma self-management education.

BACKGROUND: Asthma education reimbursement continues to be an issue in the United States. Among the greatest barriers is the lack of a standardized curriculum for asthma self-management education recognized by a physician society, non-physician health care professional society or association, or other appropriate source. The applicable Current Procedural Terminology codes for self-management education and training are 98960 through 98962, stating that "if a practitioner has created a training curriculum for educating patients on management of their medical condition, he or she may employ a non-physician health care professional to provide education using a standardized curriculum for patients with that disease." Without a standardized curriculum, reimbursement from payers is beyond reach. OBJECTIVE: Representatives from the Joint Council of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; American Academy of Allergy, Asthma, and Immunology; American Lung Association; American Thoracic Society; National Asthma Educator Certification Board; American College of Chest Physicians; and Association of Asthma Educators gathered to write a standardized curriculum as a guideline for payer reimbursement. METHODS: The Task Force began with a review of the American Lung Association and American Thoracic Society's Operational Standards for Asthma Education. Board members of the National Asthma Educator Certification Board incorporated comments, rationale, and references into the document. RESULTS: This document is the result of final reviews of the standards completed by the Task Force and national health care professional organizations in September 2014. CONCLUSION: This document meets the requirements of Current Procedural Terminology codes 98960 through 98962 and establishes the minimum standard for asthma self-management education when teaching patients or caregivers how to effectively manage asthma in conjunction with the professional health care team.

Conflict on interprofessional primary health care teams--can it be resolved?

Increasingly, primary health care teams (PHCTs) depend on the contributions of multiple professionals. However, conflict is inevitable on teams. This article examines PHCTs members' experiences with conflict and responses to conflict. This phenomenological study was conducted using in-depth interviews with 121 participants from 16 PHCTs (10 urban and 6 rural) including a wide range of health care professionals. An iterative analysis process was used to examine the verbatim transcripts. The analysis revealed three main themes: sources of team conflict; barriers to conflict resolution; and strategies for conflict resolution. Sources of team conflict included: role boundary issues; scope of practice; and accountability. Barriers to conflict resolution were: lack of time and workload; people in less powerful positions; lack of recognition or motivation to address conflict; and avoiding confrontation for fear of causing emotional discomfort. Team strategies for conflict resolution included interventions by team leaders and the development of conflict management protocols. Individual strategies included: open and direct communication; a willingness to find solutions; showing respect; and humility. Conflict is inherent in teamwork. However, understanding the potential barriers to conflict resolution can assist PHCTs in developing strategies to resolve conflict in a timely fashion.

Mechanisms for communicating within primary health care teams.

OBJECTIVE: To explore the types of communication used within primary health care teams (PHCTs), with a particular focus on the mechanisms teams use to promote optimal clinical and administrative information sharing. DESIGN: A descriptive qualitative study. SETTING: Primary health care teams in Ontario between August 2004 and October 2005. PARTICIPANTS: Purposive sampling was used to recruit 121 members from 16 PHCTs reflecting a range of health care professionals, including family physicians, nurse practitioners, nurses, pharmacists, dietitians, social workers, office managers, health promoters, and receptionists. METHODS: Individual in-depth interviews were conducted. An iterative analysis process was used to examine the verbatim transcripts created from the interviews. Techniques of immersion and crystallization were used in the analysis. MAIN FINDINGS: Analysis of the data revealed that communication occurs through formal and informal means. Formal communication included regular team meetings with agendas and meeting minutes, memorandums, computer-assisted communication, and communication logs. Informal communication methods were open and opportunistic, reflecting the traditional hallway consultation. For patient care issues, face-to-face communication was preferred. Team member attributes facilitating communication included approachability, availability, and proximity. Finally, funding issues could be an impediment to optimal communication. CONCLUSION: Primary health care is experiencing demands for enhanced and efficient communication that optimizes team functioning and patient care. This study describes formal and informal mechanisms of communication currently used by PHCTs. Attributes that facilitate team communication, such as approachability, availability, and proximity of team members, were highlighted. New funding arrangements might alleviate concerns about remuneration for attendance at meetings.

Who should provide continuous renal replacement therapies? Nephrology nurses are better prepared to provide CRRT.

Although critical care nurses are fully capable of learning CRRT, there are substantial, irrefutable challenges to achieving and sustaining proficiency. There is also diminished opportunity and motivation for critical care nurses to advance CRRT practice through quality initiatives, education, or research when it is a small piece of their practice. Consequently, I believe that it is incumbent upon acute care nephrology nurses to clarify the magnitude and value of what we do and to support our critical care colleagues in doing what they do best. The debate as to who should perform CRRT began in an effort to explore the better opportunity for cost-saving; but, in the end, it really boils down to the better opportunity for life-saving. I suspect improving outcomes for patients requiring CRRT will ultimately save hospitals more money than the short-sighted gains from critical care nurses performing tasks outside of universally-applied critical care RN processes.

Beyond knowledge transfer: a model of knowledge integration in a clinical setting.

Current conceptualizations of knowledge transfer reinforce the notion of a linear process between researchers and clinicians, who are seen as operating separately with different agenda. This paper uses a case study to illustrate a dynamic model of knowledge integration involving integrated and interdependent relationships among researchers, clinicians, and decision-makers. We believe the principles of this model are more likely to lead to effective use of research evidence in clinical practice.