This qualitative, descriptive study was based on focus group interviews using qualitative content analysis to derive how diabetes specialty nurses describe conditions for “good care” in type 2 diabetes. The focus group interviews took place between January and May 2009.

A convenient sample of experienced diabetes specialty nurses from 17 health care centers in mid-sized cities in northern Sweden was invited to participate in the study. The nurses were contacted either by their executive managers or through a coordinating diabetes specialty nurse. The nurses were informed about the study by telephone or in person before the focus group interviews, and all of those requested accepted participation. Nineteen women and two men were included. All were registered nurses, specialty nurses in primary health care, and had specialized education in diabetes care. The participants had been nurses from 15 to 41 years and had been working in diabetes care between 2 and 19 years.

Participants were interviewed in three focus groups of six to eight people since this group size was estimated to be small enough to maximize discussion yet still maintain order.²² The interviews were introduced with an open question about the participants’ perceptions of conditions for good care in type 2 diabetes from the diabetes specialty nurses’ perspectives. The participants were also asked to give examples of occasions when they felt that they succeeded, as well as when they felt they failed in offering quality care and reasons for that.

The role of the interviewer was to moderate the interviewees to maintain focus, to inspire broader or deeper answers by probing, and to support all interviewees in co-operating and reflecting upon the questions. When divergent opinions were obvious, the participants were asked to clarify their thoughts for further discussion and reflection. An observer participated and kept memorandum notes of the content of the interview, which was reviewed within the group before finishing the interview.²³ Interviews were performed either at a health care centre or at another public area connected with the nurses’ work and lasted between 50 to 90 minutes. All interviews were recorded and transcribed verbatim.

The study was approved by the Regional Ethical Review Board. Participants were informed about the study and about the fact that participation was voluntary; they could choose to leave the interview at any point without giving any reason. Participants were guaranteed confidentiality. All participants were de-identified during the analysis and in the presentation of quotations. Findings are presented at group level only, and some quotations have been modified to decrease the participants’ risks of identification.²⁴

Data were analyzed using qualitative content analysis according to Graneheim and Lundman.²⁵ Content analysis systematically analyzes written or verbal communication,²⁶ focusing on differences and similarities in the text. The interpretation process results in themes. A theme is a thread of meaning running through categories on an interpretative level.²⁵

The analysis was performed in several steps. First, the text was transcribed and thoroughly read times by all authors in order to gain a basic understanding of the content. An initial understanding was discussed in the research group. Then, the text was read again by the first author and meaning units corresponding to the aim were identified and condensed. The condensed meaning units were labeled with codes and sorted into subcategories and tentative categories based upon similarities and dissimilarities. Finally, to arrive at an agreeable interpretation, each category was critically read and analyzed by all authors, and themes were formulated. Throughout the analysis process codes, categories and themes were discussed and reflected upon in the research team, resulting in consolidation of the findings.

The findings demonstrate a contradiction between ideal versus real conditions for “good” type 2 diabetes care. Four themes illustrate the findings: 1) Diabetes counseling built on empowerment versus governance, 2) Diabetes management built on comprehensive versus biomedical views, 3) Diabetes organization built on nurse-led versus physician-led care, and 4) Diabetes policies built on quality versus equality. The themes are illuminated by quotations from the original text. Table 1 demonstrates the findings about ideal versus real conditions of diabetes care as described by diabetes specialty nurses.

Figure 1

Table 1. Ideal versus Real Conditions for Type 2 Diabetes Care

Participants described that ideal diabetes care requires effective counseling to get empowered patients. Empowered patients were described as those who are active in self-management, adherent and aware of their responsibility for taking action. They were also described as willing to confide their problems in order to gain the nurses’ support in solving those problems. Meeting such patients who take initiatives and are actively involved in their own self-management, maintaining contact with the diabetes specialty nurses and asking for help when needed were described as consistent with ideal diabetes care. The nurse participants also expressed that active patients demonstrate their efforts to manage the disease, which they viewed as a confirmation that the diabetes care was working.

Participants stated that in ideal care it was important that diabetes specialty nurses made clear to patients what they expected from them and what the patients are responsible for. The nurses also said that their responsibility was to inform and support patients in improving their lifestyle and to help them manage self-tests and medication. The patients’ responsibility was to follow the advice given.

However, in contrast to these ideal conditions, the nurses talked about patients who did not take enough responsibility. These patients were perceived as hard to manage and needed governing to handle self-care, which represented the real condition. The nurses viewed tangible proposals for self-care actions as important for patients and as necessary for the self-care to be effective. Participants stated that some patients in particular need governance since they reject self-care and do not understand that good self-care is in their own best interests.

The majority of the nurses said that they lacked tools and knowledge to effectively counsel non-compliant patients, and therefore the diabetes care lacked quality. The nurses perceived that they continued to perform annual diabetes check-ups in these patients, but often considered such a waste of time since the information they gave at the check-up often did not have the desired effect. These patients “did not know what’s good for them”.

The nurses described that ideal diabetes care requires effective management of the disease. A comprehensive view on patients was desirable, and they described that diabetes specialty nurses were able to provide comprehensive care. The nurses expressed themselves as engaged with their patients and kept on developing their skills. They described diabetes specialty nurses in general as having an unflagging interest in their work with patients, which they said was invaluable. This engagement, they stated, ‘rubbed off’ on their patients, who then prioritized and took more responsibility for their diabetes self-care.

The nurses described patient centeredness as being an ideal comprehensive approach, acknowledging the patient’s experience of living with diabetes, which required that the diabetes specialty nurse was sensitive and asked questions about the patient’s preferences, and tried to understand how the patient experienced and understood the illness. With an emphasis on relational aspects, the nurses related how they focused on building trust and on viewing the patient as a whole. Participants felt that this approach increased their patients’ confidence in them, allowing the patients to open up to the nurses and be honest, daring to ask questions, and admitting their problems. This trustful relationship was perceived by the nurses as supporting the patients’ capacity for self-care.

Participants described the real condition of mainly focusing on biomedical measurements, metabolic balance, and targets for metabolic measurements and that these measures were seen as most essential in diabetes care. The diabetes specialty nurses considered themselves as highly competent in diabetes care and expressed themselves willing to develop in that role through attending meetings with experts, and participating in conferences and educational sessions on new diabetes treatments. They stated that this development distinguished them from many General Practitioners (GPs) who – they experienced – were not up-to-date with the latest developments in diabetes treatment and generally seemed less engaged while the diabetes nurse specialists performed follow-ups with patients according to recommendations in guidelines and had more stringent limits regarding blood glucose than do the GPs.

The nurse participants described situations where GPs did not have enough time to motivate the patients to intensify their self-care and just left this care aspect to the nurses or prescribed medication instead. The principal task for GPs in diabetes care was, by the nurses, described as prescribing medication.

The nurses described that ideal diabetes care requires an effective organization to reach the goals for diabetes care. Nurse-led care was by these participants seen as ideal, since this care could improve continuity and evaluations of treatment recommendations. Continuity and regularity among personnel, and particularly continuity in diabetes specialty nurse contacts, was desirable. The nurses stated that as the patients got to know their nurse, they felt safe and secure. This fact, the nurses perceived, became even more important when a shortage of physicians existed, which, according to them, was common. They also expressed that they were the ones who represented continuity in diabetes care. Meeting the patient more often, so they expressed, gave the nurse a unique position based on personal awareness of the patient as a whole, something described as being of particular interest in nursing. Regularity in appointments and follow-ups to the diabetes specialty nurse were described as important for providing quality care. The responsibility for registry in the National Diabetes Register (NDR) was also described as very important and related to regularity in appointments, and increasing their chances to remind patients of the importance of self-management to reach treatment goals.

The nurses stated that ideally prescriptions by the GPs should take into account recommendations made by the nurses, who – as they told – managed everything else in diabetes care. Furthermore, the nurses said that GPs’ support of the nurses’ suggestions for intensified or changed treatment would be one way of showing respect for the diabetes nurses’ specialized up-to-date knowledge, skills, and patient-centered attitude. The nurses expressed that commonly GPs had “old-fashioned” ideas about the severity of type 2 diabetes, as well as about targets for HbA1c, blood pressure, and serum lipids.

Participants described the real conditions as diabetes care that is physician-led since the GPs were the ones who finally decided about the treatment. The nurses said they would like improved collaboration with the GPs, including respect for the nurses’ unique competence and their updated standpoints regarding treatment goals and treatment options. They expressed that GPs needed to update their own diabetes knowledge in order to support the nurses. The nurses described GPs as ‘lone wolves’ who usually did not collaborate on or discuss treatment options and prescriptions with the nurses. They stated that many GPs used outdated targets and therefore their recommendations were not in sync with the nurses, who often requested intensified treatment (e.g., insulin therapy, while the GPs were more willing to wait before prescribing). The nurses expressed a problem with this attitude since they perceived that it made them lose their authority among patients.

Participants also described that the policies for diabetes care ideally should be build on quality and equality. However, current diabetes care was described being organized more towards equality. Offering annual and semi-annual appointments irrespective of the actual needs by the patients were one example of striving for equality. Ideally, the nurses perceived that offered diabetes care should be based on quality evaluations, and accessibility should be adapted after patients needs. They also expressed that enough resources must be available and health care managers must support quality diabetes care.

The nurses described strong support from managers higher up in the health care organization as ideal. The managing executives’ support of diabetes care was seen as particularly important with regard to being given enough time and other resources for diabetes care.

The diabetes nurses expressed that, in reality, diabetes care was both unequal and lacking quality. People living far from a health care centre were described as disadvantaged, with less access to optimal care. Long distances were obstacles that nurses suggested could be solved by the health care organization (e.g., by relocating diabetes nurses to sparsely populated areas). The nurses described inequality in health care availability as depending on the number of nurses and GPs in the catchment area. The nurses said that – ideally – all patients should have the opportunity to get their questions answered the same day as they contacted the nurses. However, in reality, the nurses could not live up to this ideal, but patients mostly found it acceptable to wait for a physician considerably longer.

The nurses described diabetes care quality as insufficient, with much potential for development. They also considered the use of models for quality registration and evaluation as an important step towards improved quality of care. In particular, the nurses expected the NDR to influence care quality by allowing comparison between various units and various treatment options. However, except for the NDR, the nurses described the tools for quality evaluation as insufficient, and a lack of resources and knowledge about using such tools. Evaluations of patient satisfaction with care were described as lacking in general.

The nurses described ideal care as relying upon enough resources to deliver such care. The nurses mainly defined resources as time devoted to the delivery of diabetes care. Increased resources meant increased opportunities for preventive actions and consequently fewer people falling ill, earlier detection, and reduced complications among those diagnosed. With lacking resources, they preferred to focus on newly diagnosed patients and those with insulin treatment while the needs of other patient groups were minimized. The nurses described retrenchment programs as a threat that had led to a lower priority for patients with diabetes.

The majority of the participants were female which may have influenced the findings. However, most diabetes specialty nurses are female and therefore, these investigators consider the findings transferable to other, similar contexts. Furthermore, this study describes perceptions of Swedish diabetes nurses. However, these investigators consider the findings as transferable to similar context since nurses in primary health working with patients with diabetes work in a similar way, with national and international policy documents as guidelines.

Focus group interviews are suitable for calling attention to various aspects of an area of research since many participants’ experiences and reflections are raised in the discussions. The disadvantage is that “group thinking” can occur and may be exacerbated if participants who are not in agreement do not have an opportunity to state their views. When specialists who usually work in relative isolation come together, they possibly strive to make a good impression on others and may present themselves and their views in a somewhat idealized light.

According to Krippendorff,²⁶ a text never implies one meaning only; the interpretation merely implies the most probable meaning from a particular perspective. Thus, the interpretation of study findings should be seen as one possible understanding of diabetes nurses’ perception of ideal versus real conditions for type 2 diabetes care. The trustworthiness of this interpretation is based on the fact that throughout the analysis, process codes and categories as well as themes were discussed both among the research group and in seminars with other researchers in order to validate the findings.

Routines for person centred care must be established to initiate, integrate, and safe guard partnership between professionals and patients in daily clinical practice. The study findings indicate that person centredness is not a real condition in diabetes care. Diabetes specialty nurses commonly describe their work as patient centred, but it seems difficult for them to provide patient centred care in practice. Therefore, diabetes specialty nurses and also physicians need training in providing patient-centred care and opportunities for reflection about their work demands in order to better support patients’ self-management in type 2 diabetes. The roles of nurses and physicians must be clearer, and respect must be built between them based on an understanding of their unique competences. A desired outcome is enhanced collaboration between nurses and physicians to reach a common understanding about their different work tasks in diabetes care. Both nurses' and physician's competences are needed. Joint education, patient centred training and discussions about the performance of high quality diabetes care, including relational aspects, are therefore important. A crucial element is that patients are present at meetings with the diabetes team to ensure that the patient perspective of care is represented. Ongoing “medicalization” of illness, health care and nursing, with quality registration that focuses primarily on biomedical measurement, may lead to a compromised comprehensive care model. A large problem is that nurses describe lack of time to care for people who really need time-consuming support. Furthermore, nurses may lack the tools to manage “difficult” patients. A vision for the future is that patient centred care is implemented more structured and that diabetes specialty nurses view non-adherent patients as a challenge and furthermore, that they reflect upon their own role and attitudes when communication with patients is insufficient.^{34, 36, 46} Suggested future research is for evaluations of patient-centred nursing interventions in diabetes care, where team-work in diabetes care is focused and where patient centredness and biomedical issues are integrated.