Patient satisfaction with diabetes care

Prioritizing Patient Experiences in the Management of Diabetes and Its Complications: An Endocrine Society Position Statement

Diabetes can be an arduous journey both for people with diabetes (PWD) and their caregivers. While the journey of every person with diabetes is unique, common themes emerge in managing this disease. To date, the experiences of PWD have not been fully considered to successfully implement the recommended standards of diabetes care in practice. It is critical for health-care providers (HCPs) to recognize perspectives of PWD to achieve optimal health outcomes. Further, existing tools are available to facilitate patient-centered care but are often underused. This statement summarizes findings from multistakeholder expert roundtable discussions hosted by the Endocrine Society that aimed to identify existing gaps in the management of diabetes and its complications and to identify tools needed to empower HCPs and PWD to address their many challenges. The roundtables included delegates from professional societies, governmental organizations, patient advocacy organizations, and social enterprises committed to making life better for PWD. Each section begins with a clinical scenario that serves as a framework to achieve desired health outcomes and includes a discussion of resources for HCPs to deliver patient-centered care in clinical practice. As diabetes management evolves, achieving this goal will also require the development of new tools to help guide HCPs in supporting PWD, as well as concrete strategies for the efficient uptake of these tools in clinical practice to minimize provider burden. Importantly, coordination among various stakeholders including PWD, HCPs, caregivers, policymakers, and payers is critical at all stages of the patient journey.

Person-reported outcomes in diabetes care: What are they and why are they so important?

In this review, we aim to show how person-reported outcomes (PROs) and person-reported experiences (PREs) can significantly contribute to the way diabetes care is delivered, the involvement of people with diabetes in diabetes care, and the collaboration between health care professionals and people with diabetes. This review focuses on the definition and measurement of PROs and PREs, the importance of PROs and PREs for person-centred diabetes care, and integrating the perspectives of people with diabetes in the evaluation of medical, psychological and technological interventions. PROs have been increasingly accepted by Health Technology Assessment bodies and are therefore valued in the context of reimbursement decisions and consequently by regulators and other health care stakeholders for the allocation of health care resources. Furthermore, the review identified current challenges to the assessment and use of PROs and PREs in clinical care and research. These challenges relate to the combination of questionnaires and ecological momentary assessment for measuring PROs and PREs, lack of consensus on a core outcome set, limited sensitivity to change within many measures and insufficient standardization of what can be considered a minimal clinically important difference. Another issue that has not been sufficiently addressed is the involvement of people with diabetes in the design and development of measures to assess PROs and PREs.

Patient's experiences of diabetes care at a tertiary health facility in Lilongwe, Malawi

BACKGROUND

Little is known about experiences of rural people with diabetes care at a tertiary health facility in low-income settings. Understanding their experiences is essential for developing effective diabetes care interventions.

METHODS

The study employed a qualitative narrative inquiry. Participants were identified at a diabetes clinic at a tertiary-level healthcare facility. Ten participants from the rural areas attending the diabetes clinic were purposively selected. Data were collected through in-depth interviews in the privacy of the homes of the study participants and analysis was done using the Riessman approach to thematic narrative analysis.

RESULTS

In this study, the following four themes emerged: (1) the long pathway to a diagnosis of diabetes; (2) Poverty-related hardships and diabetic clinic attendance; (3) The impact of health worker attitudes and behavior on diabetes care; and (4) Low resources and their impact on self-management.

CONCLUSIONS

Rural-based patients living with diabetes encounter enormous challenges as they access diabetes care. One of the challenges is delayed diagnosis of diabetes. There is a need to introduce point-of-care (POC) testing to improve diabetes diagnosis. In addition, there is a need to strengthen awareness campaigns among the population so that people are well informed about the signs and symptoms of diabetes to promote early diagnosis. Diabetes care must be decentralized from tertiary hospitals to primary health centers. This will improve access to diabetes care and reduce the burden associated with traveling a long distance to access diabetes care in Malawi.

Patient Experience with Their Health Care Provider Among Non-Pregnant Women of Childbearing Age with Diabetes Mellitus by Race and Ethnicity in the United States

Objectives

The study objective was to investigate differences in patient experiences with health care providers among non-pregnant women of childbearing age with diabetes mellitus (DM) by race/ethnicity.

Design

This study used cross-sectional data from the 2012-2018 Medical Expenditure Panel Survey. The sample was limited to women of childbearing age (18-45 years) who have ever been told they had diabetes (n = 763; weighted n = 903,670). The key independent variable was race/ethnicity. The variables of interest included patient experiences with health care in the past 12 months: patient-provider communication (PPC); patient-provider racial/ethnic concordance; patient-provider gender concordance; and satisfaction.

Results

After adjusting for age, marital status, education, poverty level, health insurance, and perceived health status, non-Hispanic (NH) Black women had lower odds (adjusted odds ratio [aOR] = 0.04; 95% confidence interval [CI] = 0.01-0.11) of receiving care from a health care provider of the same race compared with NH white women. Similar results were found among Hispanic and NH women of other or multiple races. Hispanic women had lower odds (aOR = 0.18; 95% CI = 0.06-0.50) of seeing a health care provider of the same race/ethnicity compared with NH white women in adjusted models. There were no statistically significant differences in PPC, patient-provider gender concordance, and satisfaction with their health care provider among Hispanic, NH Black, or NH women of other or multiple races in comparison to NH White women.

Conclusion

There is a need to improve PPC quality and satisfaction in this patient population. Patient-provider racial/ethnic discordance among women of color with DM is concerning given the existing diabetes-related disparities. More research on women with DM is needed to inform and improve patient experience and health outcomes.

Evaluation of Patient Reported Satisfaction and Clinical Efficacy of Insulin Glargine 300 U/mL Versus 100 U/mL in Patients With Type 1 Diabetes Using Flash Glucose Monitoring System

Background and Aims:

To analyze patient-reported satisfaction and clinical effectiveness of concentrated insulin glargine 300 U/mL (Gla-300) among patients with type 1 diabetes (T1D) using a flash glucose monitoring (FGM) system.

Methods:

This comparative study was conducted among 86 patients with T1D (aged 14-40 years), who were treated with Glargine 100 U/mL (Gla-100) and switched to Gla-300 at day 1 (baseline). The following data were collected from each patient: demographic information, clinical parameters, and glycemic control markers. All patients completed the Diabetes Treatment Satisfaction Questionnaire (Arabic version), first at baseline and then after 12 weeks. A comparison was done for all the data recorded at baseline (on Gla-100) and after 12 weeks (on Gla-300) and subjected to analysis.

Results:

Compared to patients treated with Gla-100, significant improvements were observed in the Gla-300 group, in terms of the ambulatory glucose profile (AGP) markers, such as percentage of time spent within the target range of the glucose levels (70-180 mg/dL) (P = .037), percentage which fell below the target (<70 mg/dL) (P = .027), and percentage of time spent (<54 mg/dL) (P = .043). Compared to Gla-100, patients treated with Gla-300 experienced significant improvements in the current treatment satisfactions (P = .047), convenient finding treatment recently (P = .034), and flexible finding treatment recently (P = .041), recommend the current treatment (P = .042) and satisfied to continue the current treatment (P = .035).

Conclusion:

Compared to the patients on Gla-100, patients treated with Gla-300 exhibited significant improvements in the AGP markers and degree of treatment satisfaction.

Structural Factors and Quality of Diabetes Health Services in Hail, Saudi Arabia: A Cross-Sectional Study

The chronic disease burden in Saudi Arabia has created adverse health, social and economic consequences that require urgent attention from health and political authorities. Diabetes has become an epidemic in Saudi Arabia. Data on personal and structural factors associated with diabetes in the Hail region are scarce. Such data are imperative to develop effective strategies to control the epidemic in the region. A cross-sectional study of diabetes patients attending diabetes health care facilities in Hail was conducted using a sample of 392 patients. An interviewer-administered questionnaire was used. A slightly higher proportion of female participants (54.1%) were included in the sample. Most of the participants were from rural areas (73.9%), and 70.9% of the participants were from the middle-age (30–50 years) category. A close proximity to the diabetes clinic (OR = 1.98; 95% CI: 1.08–3.44), good transport facilities (OR = 1.67; 95% CI: 1.11–2.78) and feeling contented with supportive services (OR = 2.03; 95% CI: 1.12–4.04) were associated with patients’ satisfaction with the overall quality of the diabetes clinic services. The presence of good-quality health care professionals working in these treatment centers also seemed to contribute to patients’ satisfaction with the services they received. These structural factors associated with patients’ satisfaction with the services they received from diabetes clinics must be considered in diabetes control programs in the region. The minimization of structural barriers will eventually assist the national strategic plan, Vision 2030, which aims to improve the quality of life of the Saudi people by 2030.

Association Between Dissatisfaction With Care and Diabetes Self-Care Behaviors, Glycemic Management, and Quality of Life of Adults With Type 2 Diabetes Mellitus

PURPOSE

The purpose of the study was to examine the associations between patient dissatisfaction and diabetes outcomes among patients with type 2 diabetes.

METHODS

Primary data from 615 adults with type 2 diabetes from 2 adult primary care clinics completed validated questionnaires. Patient dissatisfaction was measured by asking participants to what degree over the past 12 months were they very dissatisfied with the care they received from their primary care provider. Diabetes outcomes included self-care behaviors, quality of life, and A1C. A1C was abstracted from the medical record. Multiple linear regression models were used to assess associations between patient dissatisfaction, self-care, blood glucose, and quality of life.

RESULTS

After adjusting for covariates, this study demonstrated that higher patient dissatisfaction was significantly associated with poor general diet, worse blood glucose levels, and lower mental component score for quality of life.

CONCLUSIONS

In patients with type 2 diabetes, patient dissatisfaction had a significant association with higher blood glucose levels, poor general diet, and low quality of life. Demographic factors driving patient dissatisfaction included young age, low income, and low health literacy. Future studies should investigate how to address patient satisfaction in an effort to improve health outcomes.

'I wish my health professionals understood that it's not just all about your HbA1c !'. Qualitative responses from the second Diabetes MILES - Australia (MILES-2) study

AIMS

Optimal diabetes management requires daily selfmanagement. While little time is spent with health professionals, they can have a substantial impact on how a person manages and feels about living with diabetes. The aim of this qualitative study was to explore what people with diabetes wish their health professionals understood about living with diabetes.

METHODS

Thematic analysis was conducted of responses to a single open-ended question, 'What do you wish your health professional understood about living with diabetes?', which was part of the Diabetes MILES-2 survey, assessing the psychological and behavioural aspects of living with type 1 or type 2 diabetes in Australian adults.

RESULTS

In total, 1316 responses (56% response rate) were collected, with 1190 responses included for analysis (54% from respondents with type 1 diabetes, 46% from those with type 2 diabetes). Seven major themes emerged; respondents wished their health professional understood: 1) the potential barriers to diabetes management; 2) that it is 'easier said than done'; 3) the social/emotional impact; 4) that they want, need and deserve more; 5) that judgements, assumptions and negative perspective are not helpful; 6) more about diabetes; and 7) that the respondent is the expert in his/her diabetes. Other comments suggested satisfactory experiences with health professionals, highlighting that some respondents had no wish for their health professional to understand more.

CONCLUSIONS

This study highlights that, although some adults with diabetes are satisfied with their health professionals' understanding of living with diabetes, many report unmet needs and perceive a lack of person-centred care from their health professionals.

The Self-Management Assessment Scale: Development and psychometric testing of a screening instrument for person-centred guidance and self-management support

AIM

To develop and psychometrically test the Self-Management Assessment Scale (SMASc), a screening instrument for person-centred guidance and self-management support of persons with type 2 diabetes (T2D).

BACKGROUND

T2D is a common and globally increasing chronic condition. Improved self-management is a vital and integral component of diabetes care to prevent complications from poorly managed diabetes. For diabetes nurses to better understand persons with diabetes experienced challenges and needs regarding self-management and further for persons with T2D to take an active role in managing their condition, an instrument measuring this is needed.

DESIGN

Instrument development and psychometric testing of the content and construct validity, factor structure and reliability.

METHOD

The SMASc was psychometric tested on a sample of participants (September 2017-November 2017) with a confirmed diagnosis of T2D (N = 104).

RESULTS

Psychometric findings were satisfactory and supported the scale´s reliability. Cronbach's alpha, CVI and goodness-of-fit were acceptable.

CONCLUSION

Self-Management Assessment Scale is a short validated screening instrument, which can indicate possible barriers for self-management that ought to be approached during the conversation between the person with T2D and the primary healthcare nurses. Therefore, it is a promising instrument to be used to facilitate person-centred guidance and to improve self-management of people living with T2D.

Living with type 1 diabetes as experienced by young adults

AIM

Describe young adults` (19-30 years) experiences of living with Type 1 Diabetes (T1D).

BACKGROUND

Young adulthood is characterized by adaption to adult roles, gradual separation from parental support and leaving the parental home. Living with T1D in young adulthood raises challenges and concerns.

DESIGN

This study has a qualitative design.

METHODS

Semistructured interviews with 12 young adults living with T1D for 3-14 years, analysed with qualitative content analysis.

RESULTS

The analysis revealed contradictory ways of handling the illness, as is illuminated in two main categories (a) and five subcategories (b). Handling the situation and dealing with different opinions (a), (b) managing daily life, emotional roller coaster and general attitudes, own views and apprehensions, ignorance and lack of motivation. Most participants were motivated, had knowledge and were in control of their long-term illness. Planning and structure were an essential part of their daily life. The participants were anxious about losing control of their bodies, the situation, die or be a burden to other people.

Patients' Interpersonal Communication Experiences in the Context of Type 2 Diabetes Care

The aim of our study is to determine the relational communication characteristics of professional-patient communication situations that have either facilitated or impeded patients' self-management. Conducted from the perspective of Finnish patients in the context of type 2 diabetes care, we used as our research methods an open e-survey and semistructured interviews. Data were analyzed using inductive qualitative content analysis. The critical incident technique was utilized throughout in all these methods. The results show that both positive and negative experiences described by patients were connected to four multidimensional relational communication characteristics: (a) building trust in the other party in the professional-patient relationship, (b) willingness to communicate, (c) emotional presence, and (d) appropriateness. Although the findings support the recommendations of earlier studies concerning individually tailored patient-centered care, acknowledging the characteristics in question can be used as a communication frame for constructing significant care relationships from the perspective of patients' self-management.

Theory that explains an Aboriginal perspective of learning to understand and manage diabetes

OBJECTIVE

To use grounded theory and participatory research methodology to explain how Aboriginal people learn to understand and manage type 2 diabetes.

METHODS

Aboriginal people with diabetes were invited to participate in one of five focus groups (n=25, male=12, female=13). Focus groups and education sessions were conducted by Aboriginal members of the research team. Focus groups were audio recorded and transcribed, with coding and first level analysis undertaken by all members of the research team.

RESULTS

Participants described colonisation and dislocation from Country and family members' experiences with diabetes as significant historical influences which, in conjunction with the model of care experienced and the type of interaction with health services, shaped how they came to understand and manage their diabetes.

CONCLUSIONS

Patient experience of a model of care alone is not what influences understanding and management of diabetes in Aboriginal people. Implications for Public Health: Health service improvements should focus on understanding past experiences of Aboriginal patients, improving interactions with health services and supporting holistic family centred models of care. Focusing on just the model of care in absence of other improvements is unlikely to deliver health benefits to Aboriginal people.

What Is Known About the Benefits of Patient-Centered Care in Patients with Heart Failure

Treatment for chronic heart failure (CHF) has improved, and symptom burden has been identified as an important treatment goal. Because patient-centered care may ease the burden, we need to know its benefits for patients with CHF, hence this systematic literature review. We found that one benefit of person-centered care is an increase in quality of life in patients with CHF. Improvements were found in self-care, physical and mental status, health care costs, general uncertainty regarding illness and recovery, patient dignity, treatment, and systems of care. Improvements also were observed in symptom burden, self-efficacy, and quality of life. These findings indicate that person-centered care is a powerful approach to current and future health care. However, because an appropriate tool to measure person-centered care does not yet exist, it will be a challenge to determine whether the goal has been reached from a long-term and patient perspective.

Patients have unwritten duties: experiences of patients with type 1 diabetes in health care

AIM

To describe the perceptions and experiences of patients with type 1 diabetes, examine their duties and responsibilities for their own care and increase our understanding of the value-based role of patients in the changing healthcare environment.

BACKGROUND

Current type 1 diabetes care highlights the importance of self-care and of patient involvement, which implies the need to evaluate the patients' role. Little is known about patients' views about their own role, and related responsibilities and duties for their own care. This is essential if we are to promote efficient patient involvement.

DESIGN

This study had a qualitative descriptive design.

METHODS

We conducted one-to-one themed interviews with 20 patients with type 1 diabetes during summer 2013 at a diabetes polyclinic in Finland. Data were analysed using inductive content analysis.

FINDINGS

Patients with type 1 diabetes believed that their well-being and self-care required them to consider their own responsibilities and their duties towards themselves, family members, society and healthcare professionals. These duties were seen to have implications for care outcomes, quality of life, and effectiveness and economy in health care. However, patients' background, motivation, relationships with healthcare staff and patient counselling influenced whether they fulfilled those duties, which are all crucial elements in type 1 diabetes care.

CONCLUSION

Patient duties are significant for the well-being of patients with type 1 diabetes, but also for their successful involvement in their care. This study can be used to inform the development of individual care planning and support of patient involvement.

Safe and Effective Use of the Once Weekly Dulaglutide Single-Dose Pen in Injection-Naïve Patients With Type 2 Diabetes

BACKGROUND

This 4-week, phase 3b, multicenter, open-label, single-arm, outpatient study demonstrated the safe and effective use of the dulaglutide single-dose pen containing 0.5 mL of placebo for subcutaneous injection in injection-naïve adult patients with type 2 diabetes (T2D), with A1C ≤ 8.5% (69 mmol/mol), BMI ≥ 23 kg/m2 and ≤ 45 kg/m(2).

METHOD

Patients completed a modified self-injecting subscale of the Diabetes Fear of Injecting and Self-Testing Questionnaire (mD-FISQ) and were trained to self-inject with the single-dose pen. Patients completed the initial self-injection at the site, injected at home for 2 subsequent weeks, and returned to the site for the final injection. The initial and final self-injections were evaluated for success; the final (initial) self-injection success rate was the primary (secondary) outcome measure, and the primary (secondary) objective was to demonstrate this success rate as being significantly greater than 80%. Patients recorded their level of pain after each injection. After the final injection, patients completed the mD-FISQ and the Medication Delivery Device Assessment Battery (MDDAB) to assess their perceptions of the single-dose pen, including ease of use and experience with the device.

RESULTS

Among 211 patients (mean age: 61 years), the primary objective was met, with a final injection success rate of 99.1% (95% CI: 96.6% to 99.7%). Among 214 patients, the initial injection success rate was 97.2% (95% CI: 94.0% to 98.7%), meeting the key secondary objective. Overall, most patients (>96%) found the device easy to use, were satisfied with the device, and would be willing to continue to use the single-dose pen after the study. There was a significant reduction (P < .001) from baseline to study end in patients' fear of self-injecting, as measured by the mD-FISQ.

CONCLUSIONS

The dulaglutide single-dose pen was found to be a safe and effective device for use by patients with T2D who were injection-naïve. A positive injection experience is an important factor for patients and providers when initiating injectable therapy.

Patient-reported outcome measures and risk factors in a quality registry: a basis for more patient-centered diabetes care in Sweden

Diabetes is one of the chronic diseases that constitute the greatest disease burden in the world. The Swedish National Diabetes Register is an essential part of the diabetes care system. Currently it mainly records clinical outcomes, but here we describe how it has started to collect patient-reported outcome measures, complementing the standard registry data on clinical outcomes as a basis for evaluating diabetes care. Our aims were to develop a questionnaire to measure patient abilities and judgments of their experience of diabetes care, to describe a Swedish diabetes patient sample in terms of their abilities, judgments, and risk factors, and to characterize groups of patients with a need for improvement. Patient abilities and judgments were estimated using item response theory. Analyzing them together with standard risk factors for diabetes comorbidities showed that the different types of data describe different aspects of a patient's situation. These aspects occasionally overlap, but not in any particularly useful way. They both provide important information to decision makers, and neither is necessarily more relevant than the other. Both should therefore be considered, to achieve a more complete evaluation of diabetes care and to promote person-centered care.

Patient Satisfaction and it's Relation to Diabetic Control in a Primary Care Setting

Context:

Patient satisfaction is of increasing importance and recognized as an important indicator for quality of care. It is influenced by the patients, physicians and practice's characteristics. The literature on diabetes has increasingly focused on the quality of care and its measurement. The relationship between the quality of diabetes care and patient satisfaction is poorly understood and it requires further elaboration.

Aims:

The aim of this study is to Identify the underlying factors influencing patient's satisfaction with the diabetes care, to assess whether comprehensive diabetes management that provided in diabetic clinic improves satisfaction and glycemic control.

Settings and Design:

Cross-sectional study Family Medicine and Diabetic Clinics at King Abdul-Aziz Medical City.

Materials and Methods:

A total of 230 type two diabetic patients attending their follow-up were requested to fill the questionnaire. The questionnaire identified patients, doctors and practice related factors.

Statistical Analysis Used:

SPSS 16 with appropriate statistical test.

Results:

The response rate was 85%. Mean hemoglobin A1c (HbA1c) level was 0.087 ± 0.020. Around half of the patients were having high satisfaction rate of (>60%). Doctor's communication ranked the highest satisfaction level among other factors. However, no association between satisfaction with other patient's characteristics and HbA1c.

Conclusions:

Physicians play a major role in promoting higher level of satisfaction by good communication with their patients. More efforts are needed to improve certain aspects of diabetic care such as: Patient's education and periodic physical examination. Although the present study did not show any association between satisfaction and important outcome like HbA1c, more studies are needed to explore such complex relationship. To obtain more significant results a bigger sample size might be needed.

Interaction between diabetes specialist nurses and patients during group sessions about self-management in type 2 diabetes

OBJECTIVE

The aim of this study was to explore the interaction between diabetes specialist nurses (DSNs) and patients with type 2 diabetes (T2D) during group sessions about self-management.

METHODS

Ten DSNs and 44 patients were observed during group sessions about self-management, and thereafter the observations were analyzed using qualitative content analysis.

RESULTS

The interaction was characterized by three themes: becoming empowered, approaching each other from different perspectives, and struggling for authority. The interaction was not a linear process, but rather a dynamic process with distinct episodes that characterized the content of the sessions.

CONCLUSION

It is important to achieve an interaction that is patient-centered, where the DSN is aware of each patient's individual needs and avoids responding to patients in a normative way. A satisfying interaction may strengthen patients' self-management, and also may strengthen the DSNs in their professional performance.

PRACTICE IMPLICATIONS

Authority struggles between patients and DSNs could be a prerequisite for patients to become autonomous and decisive in self-management. DSNs might benefit from an increased awareness about this issue, because they can better support patients if they do not perceive authority struggles as threats to their professional role.

Feeling safe during an inpatient hospitalization: a concept analysis

AIM

This paper aims to explore the critical attributes of the concept feeling safe.

BACKGROUND

The safe delivery of care is a high priority; however; it is not really known what it means to the patient to 'feel safe' during an inpatient hospitalization. This analysis explores the topic of safety from the patient's perspective.

DESIGN

Concept analysis.

DATA SOURCES

The data bases of CINAHL, Medline, PsychInfo and Google Scholar for the years 1995-2012 were searched using the terms safe and feeling safe.

METHODS

The eight-step concept analysis method of Walker and Avant was used to analyse the concept of feeling safe. Uses and defining attributes, as well as identified antecedents, consequences and empirical referents, are presented. Case examples are provided to assist in the understanding of defining attributes.

RESULTS

Feeling safe is defined as an emotional state where perceptions of care contribute to a sense of security and freedom from harm. Four attributes were identified: trust, cared for, presence and knowledge. Relationship, environment and suffering are the antecedents of feeling safe, while control, hope and relaxed or calm are the consequences. Empirical referents and early development of a theory of feeling safe are explored.

CONCLUSION

This analysis begins the work of synthesizing qualitative research already completed around the concept of feeling safe by defining the key attributes of the concept. Support for the importance of developing patient-centred models of care and creating positive environments where patients receive high-quality care and feel safe is provided.

Lack of individualized perspective: a qualitative study of diabetes care for immigrants in Sweden

This study describes the care provided by a diabetes nurse specialist, and the care needs expressed by people with type 2 diabetes mellitus and an immigrant background. Clinical encounters between a diabetes nurse specialist and 10 people diagnosed with type 2 diabetes mellitus were observed and analyzed by means of qualitative content analysis. One theme, "the diabetes nurse specialist as the conductor of the visit", and four categories emerged from the findings, illustrating the power imbalance between the patients and the diabetes nurse specialist, as well as the lack of an individual perspective. Shifting from a medical perspective to one of openness towards the people's experiences provides a possibility for caregivers to empower patients suffering from type 2 diabetes mellitus. The medical perspective seemed to steer the visit towards curative activities. Thus, technique-centered care should be developed by including individualized care.

Parental expectations in the care of their children and adolescents with diabetes

There is little research about what parents of children with diabetes want and need from their health-care providers as they negotiate life with diabetes. Sixty-three parents of children with type 1 diabetes were interviewed. Interviews were tape-recorded and transcribed verbatim, and a content analysis of text data was conducted. Three themes emerged describing what they wanted in their relationships with diabetes providers: laying the foundation, providing clinical care, and engaging families as partners. Collectively, these data provide vivid insights into the parent's perspective regarding their needs from diabetes providers as well as their perceptions of interactions that were unhelpful or worse, hurtful or undermining.

Digging deeper: the role of qualitative research in behavioral diabetes

Qualitative research methodology is more recognized and valued in diabetes behavioral research in recent years. Qualitative methods help clinicians answer questions that quantitative research may not be able to answer, such as exploring patients' motivations, perceptions, and expectations. This paper reviews recent (2005-present) rigorous qualitative studies of children, adolescents, and adult patients with type 1 and type 2 diabetes with the aim of answering the following research question: How has qualitative research contributed to our understanding of behavioral diabetes care? We focus on studies exploring patients', health care providers', and families' interpersonal experiences of diabetes as well as patients' psychosocial experiences of diagnosis and treatment, self-care, complications, and cultural factors. After reviewing the research in each area, we conclude by discussing how qualitative research contributes to our increased understanding of behavioral diabetes.

To handle the unexpected - the meaning of caring in pre-hospital emergency care

The patient's voice has not been present to the same degree as the professional perspective in caring research in a pre-hospital context. In order to further develop and improve pre-hospital care, it is therefore important to explore patients' situations not only in life threatening but also in non-traumatic situations. This is especially important as these patients might be defined as inappropriate attendees of ambulance services. The aim of this study was to interpret and explain experiences of caring in pre-hospital care situations that are not defined as traumatic or life threatening. Twenty informants aged between 34 and 82 years were interviewed. The design of the study was exploratory, and it used an interpretative approach in order to understand the meaning of pre-hospital caring. The findings show that pre-hospital caring can be understood and explained as a matter of interplay between carer(s) and patient with potentials for positive as well as negative outcomes. Our conclusion is that the initial meeting is of vital importance in how patients experience pre-hospital care. It is suggested that general public information on the development of Swedish pre-hospital care received in turn may facilitate the first encounter between patient and carer(s).

Staff's awareness of abuse in health care varies according to context and possibilities to act

OBJECTIVES

The aim of this study was to explore awareness of abuse in health care (AHC) from a staff perspective. Patient evaluation studies often focus on patient satisfaction, and serious negative experiences might therefore be obscured. In our research, we have found that abuse in health care (AHC) is commonly reported by male and female patients, when asked for in a strait way, but so far no intervention studies against AHC have been published. Investigating staff's awareness of AHC is our first step toward developing interventions against AHC.

STUDY DESIGN

Data were collected at a Swedish clinic of obstetrics and gynecology. Qualitative interviews with 21 informants were analysed with constant comparative analyses.

RESULTS

The core category - 'Staff's awareness of AHC varies according to context and possibilities to act' - was derived from the interaction between five categories; Moral imagination, Relativism, Explanations, Dissociation from AHC and Acting against AHC. Awareness of AHC was not a permanent state that did/did not exist as all participants displayed both high and low awareness; depending on the context.

CONCLUSION

Staff's awareness depends on more than personal characteristics; therefore, AHC interventions have to target individual behavior as well as cultures and structures in health care.

Experiences of the encounter with the diabetes team-a comparison between obese and normal-weight type 2 diabetic patients

OBJECTIVE

the aim of this study was to highlight and compare obese and normal-weight type 2 diabetic patients' perceptions and reported behaviors in terms of their care encounter with the diabetes team.

METHODS

interviews were conducted with 28 diabetic patients. Qualitative content analysis was used as analysis method.

RESULTS

the experiences revealed that when the care encounters took place from a health care perspective, there were no opportunities for individual support. For the obese diabetic patients, especially women, this gave rise to feelings of being stuck, defiance and shame, for those of normal weight, it created a sense of being left, despair and confusion. When encounters took place from the perspective of the individual, the diabetic patients need for support was fulfilled. For the obese diabetic patients this meant that the health care professionals recognised their needs and for those of normal weight, a feeling of security was created.

CONCLUSIONS

the results demonstrate differences in the experiences of obese and normal-weight diabetic patients' men and women in terms of their encounters with the diabetes team.

PRACTICE IMPLICATION

diabetic patients, especially the obese diabetic women, require tailor-made support provided by the health professionals in the diabetes team.

The meaning of a consultation with the diabetes nurse specialist

OBJECTIVE

The aim of this study was to elucidate the essential meaning of a consultation between diabetes nurse specialists and patients to gain a deeper understanding of the patients' experiences.

METHODS

Twenty patients with type 2 diabetes were interviewed about their experience of a consultation at an annual check-up with the diabetes nurse specialist. A phenomenological hermeneutic method was used in the analysis and interpretation of the text.

RESULTS

The patient's experience of a consultation was interpreted as manifestation of hold on the disease control. This means a safeguard to continue daily life shown in the four themes being controlled, feeling exposed, feeling comfortable, and feeling prepared.

CONCLUSION

The patients' experiences of a consultation with the diabetes nurse specialist became the basis for a health maintenance process in dealing with critical health-disease aspects. IMPLICATIONS TO PRACTICE: In a consultation, professionals have to take into account the potential emotional turbulence that disease progression can mean to a patient. Diabetes care implies patient dependence on support to avoid a potential self-management insufficiency and call attention to professionals' time for listening to patients' perceptions.

Patient-provider interaction from the perspectives of type 2 diabetes patients in Muscat, Oman: a qualitative study

BACKGROUND

Patients' expectations and perceptions of the medical encounter and interactions are important tools in diabetes management. Some problems regarding the interaction during encounters may be related to a lack of communication skills on the part of either the physician or the patient. This study aimed at exploring the perceptions of type 2 diabetes patients regarding the medical encounters and quality of interactions with their primary health-care providers.

METHODS

Four focus group discussions (two women and two men groups) were conducted among 27 purposively selected patients (13 men and 14 women) from six primary health-care centres in Muscat, Oman. Qualitative content analysis was applied.

RESULTS

The patients identified some weaknesses regarding the patient-provider communication like: unfriendly welcoming; interrupted consultation privacy; poor attention and eye contact; lack of encouraging the patients to ask questions on the providers' side; and inability to participate in medical dialogue or express concerns on the patients' side. Other barriers and difficulties related to issues of patient-centeredness, organization of diabetes clinics, health education and professional competency regarding diabetes care were also identified.

CONCLUSION

The diabetes patients' experiences with the primary health-care providers showed dissatisfaction with the services. We suggest appropriate training for health-care providers with regard to diabetes care and developing of communication skills with emphasis on a patient-centred approach. An efficient use of available resources in diabetes clinics and distributing responsibilities between team members in close collaboration with patients and their families seems necessary. Further exploration of the providers' work situation and barriers to good interaction is needed. Our findings can help the policy makers in Oman, and countries with similar health systems, to improve the quality and organizational efficiency of diabetes care services.

Type 2 diabetic patients' experiences of two different educational approaches--a qualitative study

OBJECTIVE

The aim of the current study was to explore patients' experiences of participating in an empowerment group education programme or receiving individual counselling.

METHOD

In total, 28 patients from seven primary care centres were interviewed. Of these, 14 had received individual counselling and the remaining 14 had also participated in 4-5 empowerment group sessions. The semi-structured interviews were tape-recorded, transcribed verbatim and analysed using qualitative content analysis.

FINDINGS

Three main categories crystallized from the interviews: (I) relationships, (II) learning and (III) controlling the disease. The relationships in the individual counselling seemed vertical, characterized by one-way communication with care providers acting as superiors and patients as subordinates. The relationships in the empowerment group appeared to be horizontal, characterized by trust and mutual communication. Those who had received individual counselling talked about learning by compliance--care providers acted as superiors, giving advice they expected the patients to follow. In the empowerment groups the patients talked more about participatory learning, whereby the facilitators and patients shared their knowledge and experiences. Controlling the disease could be labelled external in individual counselling, which made it difficult for patients to take responsibility for and control of their diabetes self-care. On the contrary, the patients in the empowerment group achieved the insight that diabetes is a serious disease but can be influenced, which contributed to their experience of self-control.

CONCLUSIONS

The current study indicates that vertical relationships, learning by compliance and external control seem to limit patients' ability to take responsibility for their disease, while horizontal relationships, participatory learning and self-control may contribute to strengthening patients' ability to influence and be actively involved in their own care.

Impact of pharmacy care services on patients' perceptions of health care quality for diabetes

OBJECTIVES

To (1) construct and evaluate a measure of patients' perceptions of the quality of diabetes care and (2) determine the impact of pharmacy care services (PCSs) on patients' perceptions of the quality of their diabetes care while controlling for patient-related factors.

DESIGN

Two-phased study using a single-group, pretest-posttest design.

SETTING

Community pharmacies that provided PCSs to diabetic patients as part of the Patient Self-Management Program for Diabetes in North Carolina, Georgia, Ohio, and Wisconsin.

PARTICIPANTS

218 patients with diabetes covered by self-insured employers' health plans.

INTERVENTIONS

Pharmacist-provided care services using scheduled consultations, clinical goal setting, monitoring, and collaborative drug therapy management with physicians and referrals to diabetes educators.

MAIN OUTCOMES MEASURES

Changes in patients' perceptions of quality measured by a self-administered questionnaire that included a six-item scale of information quality, a five-item scale of provider quality, and a one-item overall rating of care.

RESULTS

The assessment of the baseline data (Phase I) demonstrated that the measures of perceived quality possessed acceptable psychometric properties. After PCSs were implemented (Phase II), the scores for the information scale improved significantly (paired t = 7.64, P < 0.01), as did the scores for the provider scale (paired t = 6.30, P < 0.01) and the overall rating (paired t = 5.54, P < 0.01). In multivariate analyses, the improvement in perceived quality was not explained by the change in glycosylated hemoglobin when controlling for age, gender, race/ethnicity, and baseline quality perceptions.

CONCLUSION

PCSs enhanced patients' perceived quality of their diabetes care. The improvement in perceived quality was not explained by the change in glycemic control, which suggests that nonclinical factors in care are important to patients' evaluations of quality.

The meaning of living with a long-term disease. To revalue and be revalued

AIM

The aim of this study was to describe the meaning of living with a long-term disease. Design. The study had an interpretive, descriptive design.

METHOD

Eight persons aged between 55-79 years with different diagnoses were interviewed. The interviews were analysed using a phenomenological-hermeneutic method.

FINDINGS

The findings are presented in five themes and eleven subthemes. The theme 'Loss and uncertainty threaten everyday order' deals with the difficulties to sustain the goals and the ingrained order of daily living. The theme 'Learning one's capacity and living accordingly' concerns perceptions of the values of the outside world related to what is seen as normal, worthy or right. The theme 'Maintaining fellowship and belonging' sheds light on specific values in human interaction. The theme 'Having a source of strength' describes the need for confirmation and support when being put aside and suffering as a consequence. The theme 'Building anew' means that people with long-term diseases have the ability to live life in accordance with their own wishes, goals and values.

CONCLUSIONS

The interpretation of the text as a whole was that in the participants, long-term disease brought about a revaluation of the self and of prevailing values, and a sense of being revalued by the world.

RELEVANCE TO CLINICAL PRACTICE

This study may help to gain a deeper insight into the complexity of living life with a long-term disease, and to the process of integrate the demands of the disease into daily life.

Measuring individualized nursing care: assessment of reliability and validity of three scales

AIM

This paper is a report of a study to assess the reliability and convergent validity of three measures of nursing care individualization.

BACKGROUND

Individualized care is a key element of nursing care quality, yet little is known about the extent to which it is implemented, its effects, and the factors that help or hinder nurses in giving individualized care. Therefore reliable and valid instruments are needed to measure individualized nursing care.

METHOD

A cross-sectional correlational survey design was used. The purposive sample consisted of 861 patients from six hospitals in Finland (response rate 82%). Data were collected in 2004. The Individualized Care Scale was administered simultaneously with translated versions of the Schmidt's Perceptions of Nursing Care Survey and the Oncology Patients' Perceptions of the Quality of Nursing Care Scale. Internal consistency reliability and convergent validity were assessed for each scale.

FINDINGS

Evidence for convergent validity was identified between the Individualized Care Scale (part A/B), the Individualization subscale (r = 0.64 with Part A, r = 0.66 with part B) and the Seeing the Individual Patient subscale (r = 0.68 with part A, r = 0.71 with part B). Cronbach alpha coefficient was 0.97 for the Individualized Care Scale, 0.82 for Seeing the Individual Patient and 0.87 for the Individualization subscale.

CONCLUSION

Data provided preliminary evidence for the convergent validity of the individualized care scales, as well as acceptable internal consistency reliability for each scale. These scales represent useful measures for assessing patients' perceptions of the individualization of nursing care received.

Quality of interaction between primary health-care providers and patients with type 2 diabetes in Muscat, Oman: an observational study

Background

A good patient-physician interaction is particularly important in chronic diseases like diabetes. There are so far no published data regarding the interaction between the primary health-care providers and patients with type 2 diabetes in Oman, where diabetes is a major and growing health problem. This study aimed at exploring how health-care providers interact with patients with type 2 diabetes at primary health-care level in Muscat, Oman, focusing on the consultation environment, and some aspects of care and information.

Methods

Direct observations of 90 consultations between 23 doctors and 13 diabetes nurses concerned with diabetes management during their consultations with type 2 diabetes patients in six primary health-care centres in the Muscat region, using checklists developed from the National Diabetes Guidelines. Consultations were assessed as optimal if more than 75% of observed aspects were fulfilled and sub-optimal if less than 50% were fulfilled.

Results

Overall 52% of the doctors' consultations were not optimal. Some important aspects for a positive consultation environment were fulfilled in only about half of the doctors' consultations: ensuring privacy of consultation (49%), eye contact (49%), good attention (52%), encouraging asking questions (47%), and emphasizing on the patients' understanding of the provided information (52%). The doctors enquired about adverse effects of anti-diabetes drugs in less than 10% of consultations. The quality of the nurses' consultations was sub-optimal in about 75% of 85 consultations regarding aspects of consultation environment, care and information.

Conclusion

The performance of the primary health-care doctors and diabetes nurses needs to be improved. The role of the diabetes nurses and the teamwork should be enhanced. We suggest a multidisciplinary team approach, training and education to the providers to upgrade their skills regarding communication and care. Barriers to compliance with the guidelines need to be further explored. Improving the work situation mainly for the diabetes nurses and further improvement in the organizational efficiency of diabetes services such as lowering the number of patients in diabetes clinic, are suggested.