Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review

Background: Despite the availability of evidence-based guidance many patients with type 2 diabetes mellitus do not achieve treatment goals. Aim: To guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians’ and nurses’ perceived influences on care. Design and Setting: Systematic review of qualitative studies with findings organised using the Theoretical Domains Framework. Methods: Sources were Medline, Embase, CINAHL, PsycInfo and ASSIA from 1980 until March 2014. We selected English language qualitative studies in primary care of physician or nurse perceived influences on treatment goals for type 2 diabetes. Results: We included 32 studies; 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient adherence and anxieties about treatment intensification. Conclusions: Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than ‘one-size-fits-all’ approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinician skills and emotions around treatment intensification and facilitation of patient behaviour change

The nature of uncertainty

As far as we are aware, this book is unique in bringing together such a number of diverse perspectives on uncertainty. The collection of essays broadens our understanding of where uncertainty comes from, how we perceive it and how we deal with it. In the next three chapters we weave those insights together, supplementing them with learning from the discussion at the symposium. We use the framework Smithson laid out in Chapter 2 to structure our synthesis, focusing particularly on enriching that framework with new examples and insights

Coping and managing under uncertainty

Uncertainty is an inescapable ingredient of life. Even in familiar situations – such as crossing a street – some level of uncertainty inevitably exists. Past experience is relevant for all decisions involving the future, but contexts change and new elements affecting risk may unexpectedly appear. Usually, this residual uncertainty remains within reasonable bounds and human beings make their way in an uncertain and changing world where existing knowledge and experience suffice as guides to future expectations (Pollack, 2003). But where highly complex systems with extensive connectivity and interaction exist, or where novel problems or technology limit experience as a resource, decisions often must be made under conditions of high uncertainty. It is not surprising, as the various chapters in the volume make clear, that in a world of complex systems involving rapid technological change, highly coupled human and natural systems, and a kaleidoscope of social, economic and political institutions, high levels of uncertainty challenge existing assessment methods and established decision and management procedures

Uncertainty metaphors, motives and morals

If we are to understand how and why people construct and respond to uncertainty as they do, then we need accounts of underpinning motivations and moral orientations. As presented in Chapter 2, metaphors provide insights into these, so we begin by briefly revisiting metaphors about uncertainty, examining those used in the chapters in this volume. We then explore motivational aspects, before moving on to the relatively uncharted territory of morals. While it may seem odd initially to consider the notion of ‘good’ and ‘bad’ uncertainty, it turns out that many disciplines and, especially professions, harbour views of exactly this kind.As Smithson highlighted in Chapter 2, most of the metaphors that are used to describe uncertainty are negative. While a number of these metaphors appear in the chapters of this book, it is interesting that there also appear a number of new and mainly positive ones