Telemedicine in diabetes foot care delivery: health care professionals’ experience

Background: Introducing new technology in health care is inevitably a challenge. More knowledge is needed to better plan future telemedicine interventions. Our aim was therefore to explore health care professionals’ experience in the initial phase of introducing telemedicine technology in caring for people with diabetic foot ulcers. Methods: Our methodological strategy was Interpretive Description. Data were collected between 2014 and 2015 using focus groups (n = 10). Participants from home-based care, primary care and outpatient hospital clinics were recruited from the intervention arm of an ongoing cluster randomized controlled trial (RCT) (Clinicaltrials.gov: NCT01710774). Most were nurses (n = 29), but the sample also included one nurse assistant, podiatrists (n = 2) and physicians (n = 2). Results: The participants reported experiencing meaningful changes to their practice arising from telemedicine, especially associated with increased wound assessment knowledge and skills and improved documentation quality. They also experienced more streamlined communication between primary health care and specialist health care. Despite obstacles associated with finding the documentation process time consuming, the participants’ attitudes to telemedicine were overwhelmingly positive and their general enthusiasm for the innovation was high. Conclusions: Our findings indicate that using a telemedicine intervention enabled the participating health care professionals to approach their patients with diabetic foot ulcer with more knowledge, better wound assessment skills and heightened confidence. Furthermore, it streamlined the communication between health care levels and helped seeing the patients in a more holistic way. Keywords: telemedicine, diabetic foot ulcer, focus groups, interpretive description, health care professional

Learning to practise the Guided Self-Determination approach in type 2 diabetes in primary care. A qualitative pilot study

Aim: To describe how diabetes nurses in primary care experience the process of learning to practise the person-centred counselling approach Guided Self-Determination among adults with type 2 diabetes. Design: A descriptive qualitative design. Method: Data were collected in 2014–2015 by means of individual interviews with four diabetes nurses at two points in time. The data were analysed using qualitative content analysis. Results: Three themes that reflect nurses’ processes in learning to use the Guided Self-Determination approach were identified: (1) from an unfamiliar interaction to “cracking the code”; (2) from an unspecific approach to a structured, reflective, but demanding approach; and (3) from a nurse-centred to a patient-centred approach. The overall findings indicate that the process of learning to practise Guided Self-Determination increased the nurses’ counselling competence. Moreover, the nurses perceived the approach to be generally helpful, as it stimulated reflections about diabetes management and about their own counselling practices

Patients’ experiences with participating in a team-based person-centred intervention for patients at risk of or diagnosed with COPD in general practice

Abstract Background Symptoms and complications of chronic obstructive pulmonary disease (COPD) can affect daily activities and quality of life, and patients with COPD require long-term follow-up by their general practitioner. Providing patients with or at risk of COPD practical skills and motivation to improve their self-management is important. On this background, an interdisciplinary follow-up program was designed based on the Guided Self-Determination counselling method to facilitate problem-solving and mutual decision-making between healthcare professionals and patients. The aim of the study was to explore patients and healthcare professionals` experiences with the Guided Self-Determination-program to investigate feasibility issues. Methods A qualitative design was used to get insights in the experiences of receiving the Guided Self-Determination counselling program. In total, 13 patients with COPD (mean age 71.7 ± 7.7 years) 4 were current smokers, and 7 at risk of COPD (mean age 54.1 ± 9.9 years) all current smokers, received the Guided Self-Determination program. The researchers performed individual semi-structured telephone interviews after the 12 months Guided Self-Determination program with two patients at risk of COPD, four patients with COPD, three nurses, and five general practitioners. The intervention consisted of structured consultations with the nurse and patient in collaboration with the general practitioner at baseline and after 3, 6, and 12 months. The Guided Self-Determination method comprised facilitation of a mutual reflection process between the patient and the nurse to enhance self-management skills. Each consultation lasted for 60 min. The interviews were analysed using thematic analyses. Results Two themes were identified: (1) A structured follow-up is challenging but motivating. (2) A counselling method that opens for conversation, but it requires resources. Conclusions The findings indicated that patients with or at risk of COPD experienced enhanced self-management skills after participating in a structured and systematic team-based follow-up in general practice with use of the Guided Self-Determination method. The regularity of the follow-up seemed to be important to succeed to help the patients making lifestyle changes to increase health benefits. However, the Guided Self-Determination method was experienced as time consuming among the general practitioners and nurses, and there are currently no available financial rates for this type of treatment in Norway which may be a barrier to further implementation. Trial registration The trial is registered in ClinicalTrials.gov (ID: NCT04076384)

Diabetessykepleiers ansvars- og funksjonsområder i helsetjenesten

Det er forventet at antall voksne med diabetes vil øke kraftig i hele verden og da spesielt andelen av personer med diabetes type 2. Dette er en utvikling som bekymrer og byr på utfordringer for både primær- og spesialisthelsetjenesten. Da det ikke finnes en systematisk oversikt over hvor mange av medlemmene i Norsk sykepleierforbunds faggruppe for diabetessykepleiere (NSF/FFD) som arbeider i henholdsvis primærhelsetjenesten og spesialisthelsetjenesten, og hvilke ansvars- og arbeidsoppgaver diabetessykepleiere har, ble Høgskulen på Vestlandet kontaktet for å få hjelp til å gjennomføre en undersøkelse blant medlemmene i faggruppen. Høsten 2017 ble det gjennomført en spørreundersøkelse i både primær- og spesialisthelsetjenesten blant alle medlemmer i NSF faggruppe for diabetessykepleiere (NSF/FFD). Et elektronisk spørreskjema med spørsmål om deres ansvars- og funksjonsområder i helsetjenesten ble sendt via e-post til medlemmene. 170 av totalt 328 medlemmer svarte (svarprosent 53 %). Data fra spørreskjemaundersøkelsen ble analysert med deskriptiv statistikk. Resultatene viste at alle deltakerne hadde lang yrkeserfaring og relativt mange hadde videreutdanning. Diabetessykepleiernes ansvars- og funksjonsområder var i stor grad knyttet til deres kunnskaper om behandlingsrelaterte forhold, og utrednings- og behandlings tiltak gitt i nasjonale retningslinjer. Dette bidrar til å sikre at den enkelte får en mest mulig individuelt tilpasset behandling for å forebygge komplikasjoner og fremme god helse og livskvalitet gjennom god medisinsk behandling og evne til egenmestring. Sykepleiernes veiledningsfunksjon var knyttet til sentrale områder innen diabetesbehandlingen, situasjoner og forhold i et livsløpsperspektiv og ikke minst til veiledning innen helsefremming, forebygging og livsstil. Ansvars- og funksjonsområder hadde ulikt vekt og omfang i tråd med ulikheter i pasientgrunnlaget i spesialist- og variasjon i autonomi og kvalitet. Det synes som at det i deler av helsetjenesten er en god struktur og plan for diabetesbehandling, men diabetessykepleieres ansvar og funksjonsområde bør videreutvikles slik at kompetansen kan brukes mer målrettet

Experiences of an interprofessional follow-up program in primary care practice

Abstract Background An integrative cooperation of different healthcare professional is a key component for high quality health services. With an aging population and many with long-term conditions, more health tasks and follow-up care are being transferred to primary care and locally where people live. Interprofessional collaboration among providers of different professional designations will be of increasing importance to optimizing primary care capacity in years to come. There is a call for further exploration of models of interprofessional collaboration that might be applicable in Norwegian primary care. The aim of this study was to explore experiences of interprofessional collaboration between primary care physicians and nurses working in primary care by applying an intervention for people with type 2 diabetes. Specifically, this study was designed to strengthen and gain deeper insight into interprofessional collaboration between primary care physicians and nurses in primary care settings. Methods We applied Interpretive Description as a research strategy. The participants within this study were primary care physicians and nurses from four different primary care practices in the western and eastern parts of Norway. We used semi-structured telephone interviews for collecting the data between January and September 2021. Results The analysis revealed two key features of the primary care physicians and the nurses experience with interprofessional collaboration in primary care practices. The first involved managing the influence of discrepancies in their expectations of IPC and the second involved becoming aware of the competence they developed that allowed for better complementarity consultation. Conclusions This study indicates that interprofessional collaboration in primary care practice requires that primary care physicians and nurses clarify their expectations and, in turn, determine how flexible they can become in changing their usual primary care practices. Moreover, findings reveal that nurses and primary care physicians had discrepancies in expectations of how interprofessional collaboration should be carried out in primary care practice. However, both the nurses and primary care physicians appreciated the blending of complementary competencies and skills that facilitated a more collaborative care practice. They experienced that this interprofessional collaboration represented an essential quality improvement in the primary care services. Trial registration The trial is registered 03/09/2019 in ClinicalTrials.gov (ID: NCT04076384)

Using HbA1c measurements and the Finnish Diabetes Risk Score to identify undiagnosed individuals and those at risk of diabetes in primary care

BACKGROUND: Prevalence of prediabetes and type 2 diabetes mellitus (T2DM) is increasing worldwide. The objective of this study was to determine the proportion of people in Northern Iceland with prediabetes, at risk of developing T2DM or with manifest undiagnosed T2DM, as this information is lacking in Iceland. METHODS: A cross-sectional study. Clients of the three largest primary health care centres in the Health Care Institution of North Iceland (HSN) were invited to participate if fulfilling the following inclusion criteria: a) aged between 18 and 75 years, b) not diagnosed with diabetes, c) speaking and understanding Icelandic or English fluently and d) living in the included service area. Data collection took place via face-to-face interviews between 1 March 2020 and 15 May 2021. Participation included answering the Finnish Diabetes Risk Score (FINDRISC), measuring the HbA1c levels and background information. RESULTS: Of the 220 participants, 65.9% were women. The mean age was 52.1 years (SD ± 14.1) and FINDRISC scores were as follows: 47.3% scored ≤8 points, 37.2% scored between 9 and 14 points, and 15.5% scored between 15 and 26 points. The mean HbA1c levels in mmol/mol, were 35.5 (SD ± 3.9) for men and 34.4 (SD ± 3.4) for women, ranging from 24 to 47. Body mass index ≥30 kg/m(2) was found in 32% of men and 35.9% of women. Prevalence of prediabetes in this cohort was 13.2%. None of the participants had undiagnosed T2DM. Best sensitivity and specificity for finding prediabetes was by using cut-off points of ≥11 on FINDRISC, which gave a ROC curve of 0.814. CONCLUSIONS: The FINDRISC is a non-invasive and easily applied screening instrument for prediabetes. Used in advance of other more expensive and invasive testing, it can enable earlier intervention by assisting decision making, health promotion actions and prevention of the disease burden within primary health care. TRIAL REGISTRATION: This study is a pre-phase of the registered study “Effectiveness of Nurse-coordinated Follow up Program in Primary Care for People at risk of T2DM” at www.ClinicalTrials.gov (NCT01688359). Registered 30 December 2020

Reconfiguring clinical communication in the electronic counselling context: The nuances of disruption

Aim This study expands on an earlier study about diabetes nurses’ experiences of the Guided Self‐Determination intervention in face‐to‐face consultations among people with type 2 diabetes. This current study investigates Guided Self‐Determination in an electronic format with the aim to explore what can be learned about the written form for health communication from the perspectives of diabetes nurses in primary care. Design The study has an explorative, qualitative design. Method Four diabetes nurses were individually interviewed after completing the electronic intervention. The analysis was guided by Interpretive Description. Results Small sample size apart, the rich empirical data and quality of dialogue point to the interviewees’ earlier contact, comfort and trust with the researcher. The written electronic communication could disrupt nurses’ possibilities for using basic and advanced communication skills. Findings also indicate that written electronic communication can foster thoughtful responses to patients and increase possibilities for a transparent counselling delivery process.publishedVersio

Prevalence of increased risk of type 2 diabetes in general practice: a cross-sectional study in Norway

Abstract Background Type 2 diabetes (T2D) is a global public health problem, but the onset can be delayed or prevented with adequate intervention in individuals with increased risk. Therefore, a major challenge in general practice is to identify individuals at risk of diabetes. However, limited knowledge is available about the prevalence of high diabetes risk individuals in a primary care population. In a cohort of consecutive patients in general practice we examined the prevalence of known diabetes and estimated risk of diabetes using The Finnish Diabetes Risk Score (FINDRISC) calculator, by sociodemographic and clinical characteristics. Methods This study was a cross-sectional study conducted in four general practices in Western and Eastern Norway. A total of 1682 individuals, 20–80 years of age, were assessed for eligibility from May to December 2019. We excluded patients who actively declined participation (n = 112), were lost because of various organization challenges (n = 103) and patients who did not fulfil the inclusions criteria (n = 63). Diabetes prevalence and prevalence of individuals at risk of T2D with 95% confidence intervals (CI) were estimated for the total sample, by age group and for men and women separately. We tested for differences between groups using t-test for continuous variables and chi-square test (Pearson Chi-Square) for categorical variables. Results Of 1404 individuals, 132 reported known diabetes, yielding a prevalence of 9.9% (95% CI 8.4–11.6). Among participants without a known diagnosis of diabetes, the following estimates of elevated risk assessment scores were found: FINDRISC score ≥ 11 32.8% (95% CI 30.3–35.4) and FINDRISC ≥ 15 10.0% (95% CI 8.6–11.9). Comparable results were found between the sexes. Conclusions Detection of unknown diabetes and individuals with increased risk, is of high public health relevance for early implementation of preventive measures aimed to reduce the risk of diabetes and its complications through lifestyle modification. A simple, non-expensive questionnaire, such as FINDRISC, may be valuable as an initial screening method in general practice to identify those in need for preventive measures

Interprofessional follow-up for people at risk of type 2 diabetes in primary healthcare – a randomized controlled trial with embedded qualitative interviews

To examine the effects of an empowerment-based interprofessional lifestyle intervention program among people at risk of type 2 diabetes on knowledge, skills, and confidence in self-management, health, psychological well-being, and lifestyle characteristics, and to explore the participants’ perceptions of participating in the intervention. In line with the Medical Research Council complex interventions research methods framework, we conducted a randomized controlled trial with embedded qualitative interviews in primary healthcare clinics in Norway between 2019–2021. Of the patients at risk (The Finnish Diabetes Risk Score Calculator (FINDRISC) ≥15 or Body Mass Index (BMI) ≥30) 142 accepted the invitation, and 14 participants from the intervention group participated in individual interviews after the 12-month follow-up. Our primary outcome was the Patient Activation Measure (PAM-13). Secondary outcomes were EQ-5D-5L, EQ-VAS, WHO-Overall health, WHO-Overall QOL, weight, height, waist circumference, and regularity of physical activity. We used thematic analysis to analyse the qualitative data. There was no clinically relevant differences of neither the primary nor the secondary endpoints between intervention and control group. As to the qualitative data, we identified two distinct features: ‘Meaningful perspectives on lifestyle changes’ and ‘Lifestyle change is not a linear process due to challenges faced along the way’ putting ownership of their choices in life into picture. The negative results of the RCT stand in contrast to the findings given by the participants voices, perceiving the intervention as a key eye opener placing their health challenges in perspective. How to interpret these seemingly conflicting findings of participants being seen, heard, and understood, helping them to take more conscious ownership of their choices in life, and at the same time demonstrating no improvements in symptoms or measures, is a dilemma that needs further exploration. We should be careful to implement interventions that do not demonstrate any effects on the quantitative outcomes.</p