Swedish health care professionals’ diverse understandings of diabetes care

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Abstract

Knowledge of health care professionals’ different understandings of diabetes care is important when preparing such professionals in patient education. For patients to manage illness effectively, the actions of health care professionals are crucial. Patients’ understanding of their condition should be taken as the point of departure when creating a learning situation. The professionals’ understandings of diabetes care were mapped using a survey including 169 primary care doctors, nurses, assistant nurses and chiropodists in Stockholm, Sweden. The responses were analysed using a phenomenographic approach. Five understandings were identified: the professionals treat the patients, the professionals give information, the professionals focus relation and organisation, the professionals seek the patient’s agreement, and the professionals focus the patient’s understanding of the situation. Only 20 (12%) of the 169 professional caregivers focused the patient’s understanding. Professionals need to develop their understandings of health care and the professional–patient interaction in order to support the patients’ learning.

Introduction

A sizeable number of studies exist today suggesting that patients who have knowledge about and comprehend the nature of their illness and its treatment are more likely to succeed in managing their illness [1], [2]. Care of diabetes is an excellent example of the intimate relation between understanding one’s illness and illness management. A patient with diabetes who understands the illness and how it can be treated successfully has a documented higher likelihood of attaining near normal blood-glucose levels than a patient who does not have such knowledge [3], [4], [5]. However, keeping the blood-glucose levels as low as possible to reduce complications is a fine balancing act for the patient [6], [7], [8]. Sufficient time in the professional–patient encounter, easy access to care, good communication and mutual trust and respect are important factors in achieving this goal [3], [9], [10].

Effective patient education and intervention are obviously needed but evidence suggests that they have been difficult to achieve [11], [12]. To be efficacious the professional–patient encounter in diabetes care needs to focus on the individual’s experiences and adapt the learning pace to the patient [5], [13], [14]. However, diabetes care has often been “checklist driven” via clinical guidelines and has focused on technical advice [3]. Furthermore, patients have raised complaints against such standardised textbook approaches [3], [10]. Traditional patient education has had little or no effect on patients’ understanding of their condition and thus in the treatment of diabetes [3], [5], [15], [16]. Few studies have demonstrated a clear link between continuous professional development (CPD) courses for health care professionals and clinical outcomes for patients [12], [17]. Consequently, a need exists for a new and qualitatively different competence development for professionals working in diabetes care. Contemporary theories of competence and its development have shown that competence is the result of how people understand their work [18]. A beginning step in the process of competence development within this field would be to show and establish the understandings, or conceptions, that health care professionals bring with them in diabetes care and patient education. The purpose of this study then was to identify, in one catchment area in Stockholm, Sweden, the various understandings health care professionals have of the core aspects of diabetes care and how such understandings are disbursed. The baseline results are part of a larger study designed to develop communication skills of health care professionals working in the general practices of the catchment area in question. The pedagogic framework for this development is based on phenomenographic theories of learning [19], [20].

Section snippets

Mapping health care professionals’ understanding of diabetes care

In 1996, all (23) health care centres (HCCs) in one catchment area in Stockholm, Sweden were invited to participate in a programme intended to provide information about diabetes and diabetes care. Of the 23 invited centres, 20 accepted (one centre rejected the invitation and two did not reply) to take part in the study. The participants were general practitioners (GPs), nurses, assistant nurses and chiropodists. We decided to study the group of professionals as a whole, as they were working in

Results

Twenty of the 23 invited centres participated in the survey. Approximately 50% of the health care professionals employed at the health care centres in the catchment area in Stockholm took part in the introductory meetings. Roughly, 90% (or 169) of those persons who participated responded to the written survey items described above. Of the 169 respondents, 65 were doctors, 63 were nurses and 29 were assistant nurses or chiropodists; the occupation(s) of the remaining 12 respondents was

Discussion and conclusions

This study shows that there are five qualitatively different understandings of diabetes care among Swedish health care professionals. The study also demonstrated how health care professionals describe their ways of relating to patients with diabetes. Understandings A and B, which focus on the professionals, were the most common understandings reported in our study. Understandings D and E, with focus on agreement with the patient and the patients’ understanding, have the patient, not the

Acknowledgements

The authors are indebted to the health care professionals who participated in the study and to RNT Lisbet Segerros for data collection. Grants were received from The Swedish Council for Social Research No. 97-0077, the Vardal Foundation No. V2001-205, the Research and Development Unit for the Elderly (ANV), Northwest Stockholm County Council, Sweden and Uppsala University.

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