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Experiences of community-based Clinical Nurse Specialists in supporting the delivery of integrated diabetes care: A qualitative study

Authors: Fiona Riordan, University College Cork, IE, Niamh McGrath, University College Cork, IE, Sheena M. McHugh, University College Cork, IE, Patricia M. Kearney, University College Cork, IE

Introduction: In Ireland, more Diabetes Nurse Specialists DNS have been introduced into the community as part of a national programme to standardise and improve diabetes care.  DNS support the delivery of a new model of care whereby uncomplicated type 2 diabetes T2DM is managed in primary care, and complicated T2DM is managed between primary and secondary care. Historically diabetes care in Ireland has often been delivered in an unstructured way, with a lack of integration between primary and secondary care. Given this context we wanted to understand the experiences of community-based DNS in supporting the delivery of integrated care.
Methods: We purposively sampled DNS from community-based respondents to a national survey n=25, according to four administrative regions of the National Health Service.  We conducted focus groups and interviews using a semi-structured topic guide. Interviews were digitally recorded and transcribed into NVivo V.11 for coding and analysis.  Coding was data-driven, with a focus on DNS actions or behaviours, the causes and conditions, and any consequences of those actions. 
Results: Nineteen DNS participated in two focus groups n=8, and 11 individual interviews. Lacking guidance on their role, DNS felt setting up their service was a case of ‘sink or swim’; they used initiative to establish the service. DNS adapted to working with a ‘whole different MDT’ in the community. They lacked the ‘safety net’ of the hospital team to check things with and ‘bounce ideas off’. As a result they worked more autonomously and perceived themselves to be ‘practicing at a higher level’, which some felt was ‘daunting’. For some, this highlighted the importance of maintaining their expertise and specialist skills. DNS needed to ‘blend in’ with how things were done in GP practices; being flexible and responsive to the practice’s experience in diabetes. The lack of a shared record between settings meant patient information from hospital appointments was not readily accessible by DNS at practices and vice versa, making patient follow-up and case discussion difficult. DNS often acted as an information link, sometimes ‘the only link, [or] bit of integration between the hospital and GP’.  DNS felt managers and consultants did not understand their role, creating difficulty when negotiating certain aspects, including flexible working hours. One community DNS found integrating care difficult when not seen as part of the team. DNS needed to explain their role which required ‘quite good interpersonal skills’ and initiative on their part.
Discussions: Community-based DNS used initiative to respond to challenges presented by the healthcare context.
Conclusions: Challenges included how the role was introduced, understanding by management and colleagues, and characteristics of the health system e.g. ICT infrastructure.Lessons learned: DNS may need to be better supported to deliver their role to ensure effective delivery of  integrated diabetes care.
Limitations: This study is limited to DNS in Ireland; the findings may not reflect experiences of DNS in other countries working in a health service with different characteristics.Suggestions for future research: Future work should evaluate ongoing changes to DNS support.

Keywords: integrated care, nurse specialists, diabetes

How to Cite: Zonneveld N, Miller R, Minkman M. Values and principles of person-centered integrated care: a systematic literature review (SIG meeting). International Journal of Integrated Care. 2017;17(5):A251

Published on 23 Oct 2018