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Table 2 Quotes relating to identified themes

From: Roles and relationships between health professionals involved in insulin initiation for people with type 2 diabetes in the general practice setting: a qualitative study drawing on relational coordination theory

Theme

Quotes

Ambiguous roles

DNE108: How long before GPs say well okay, we’re using the practice nurses to start glargine, why don’t they do this and why don’t they do that? Is the aim of this to put CDEs out of a job…That’s where I have my real concern is that if GPs start using practice nurses to start glargine that this is the very first step. I understand clinics that can’t get CDEs, that they can’t get these people to put on to insulin and things like that. Look, I understand that there are clinics that have this and that’s – that’s our role in the CDE is to get CDEs into these clinics rather than using practice nurses who have very, very limited education and understanding in that area.

 

PN415: The general gist is what you get for prac nurses is when are you going back to real nursing, is everything that you get. Or you must be really bored, you must not do anything. People’s perception of practice nurses is you sitting on your backside drinking coffee and doing blood pressures unfortunately. Usually - that’s what I said, in practice nursing you can be as proactive or not as proactive as you like. So it really depends on the nurse, the team you’ve got and the things within your facility and your reach that you can reach out to.

 

PHY527: Practice nurses would interrelate with your diabetes nurse eds and all that and would probably reduce their load as well. Because it’s another set of eyes and ears if you educate them appropriately.

Uncertain competency and capacity

DNE148: So with practice - I think some practice nurses do believe they’re - but it’s a personality type - they’re above and beyond and they can manage everything. Why did we (DNEs) go and spend $10,000 to get a qualification that reaps us no rewards at the end of the day? Apart from the fact we don’t need to wear a uniform at some places. But that’s their personality, that they think they can do stuff. Within their nurse role they should be able to titrate insulin. It’s a drug like any other drug. They should know how to do it. But do they have the competence to do it, that’s debatable, and do they understand the mechanisms behind it? Sometimes that will be a challenge but as long as they know they can ask for help then there’s no issue.

 

PHY509: Well, I mean - I think increasingly [practice nurses] are doing sorts of work like - they are preparing the patients in between consultations - I don’t know, maybe weighing them, taking their blood pressure, maybe assisting people with teaching them other various things. I mean, I’m sure that practice nurses do a different series of jobs. But not - see, what’s being said now is that the practice nurse can be doing all sorts of diabetes education activities. I don’t know to what degree they’re doing that - so, yeah - I mean, I don’t know whether there’s a job description that far, that covers all practices, I doubt it.

Varying relationships and communication

PHY503: What I found the most helpful is when we’ve had a couple of really tricky patients, we just do all our consults together, me and the educator, just see them together so you’re all on the same page and it’s more of a team thing and try and have it as a conversation between three people rather than being too didactic… There was quite a few times when I saw people with the educator, that crowd, they’re mainly older decrepit people basically. That was really helpful and I find that you’re doing it together, even the first consult you do that together because you can be asking a question, both of you ask questions and if you forget something, you get the full picture and you both know what’s going on.

 

PHY509: But, I mean, I would hope that we – we don’t - we honestly don’t deliberately try and hold on to people but it’s just in this context of where you never hear anything back and you don’t - and people come back and you’ve suggested various things to get done and that hasn’t been done. You don’t know whether it’s because the patient didn’t do it or because the doctor didn’t do it or because of a whole lot of reasons. So, you tend - in that sort of context, your tendency is to say, okay well - no, we’ll do this - we’ll do this here now and…See you again to see what’s wrong.

 

GP744: The difficult stories are the patients who go to the [public] Hospital or something like that in the public. They’ve got type 2 diabetes; we get the most dreadfully pointless, vanilla reports back. We don’t - there’s this kind of out of touch process.

 

DNE148: So we sort of know people in common. But you have to go to sort of the company dinners to meet the other endocrinologists and the other GPs, just so they know who you are and what you’re doing. Then you’ll get a better response….[Do the endocrinologists interact with you differently compared to the GPs?] Absolutely…I think they - or the ones I’ve dealt with anyway - see us as part of the team. I guess I’m fortunate I work with good people but you’re there, you’re the one that gets the difficult patient. You’re the one that has to speak to them about their diet and exercise every month for the next six months until you get through to them. So they can see that there’s our role and there’s their role and most of them are quite flexible about what’s what and who’s who. So you work together as a team…

Developing trust and respect

DNE148: [Do you think the GPs trust you?] Some do. If I didn’t - if I hadn’t have worked for so long with this one cranky-pants GP, I would think it would personal. But it’s not, it’s their mindset. As much as you know some people can’t drive Fords or Holdens, it’s no, diabetes nurse educators are not worth anything. So it’s not personal and if you can explain it as a professional, sometimes they don’t know - I guess diabetes educators can be nurses, they can be podiatrists, dietitians, they can be dentists. So they don’t know what angle you’re coming from but once you identify you’re a nurse and this is what happens and this is how it goes, then there’s a bit more respect.

 

DNE102: So I suppose I don’t have as much of that battle that a lot of nurses in hospitals have with the doctors. It’s probably because I’m older as well maybe, I don’t know, and also it’s your relationship with them - in terms of how you respond. It’s not like I want you to, it’s would you consider? There are ways of talking and communicating in a way that they feel like they’re making the decision. [So you still feel that you need to do it that way?] Only with some. The others I will just - they’ll just ring or they’ll send them in and say just do whatever [the DNE] asks sort of thing. There’s no point anyway, she’s going to change it they go.

 

GP730: I think - certainly in the way that [DNE] practiced, so she would review patients and have it sort of scheduled in, she was almost acting like an endocrinologist in terms of her suggestions and her knowledge about therapies and what was appropriate. So she - to some extent, her experience vastly outweighed pretty much every GP at the practice and her knowledge base was such that we all felt comfortable with her suggesting treatment options and guidelines which we would then put in place.

 

PN415: Because I understand when you’ve taken the initiative and you’re doing a course and - I’ve looked at the diabetes course and the credentialing and I’ve had friends and I’ve been with them while they’ve gone through it. It is a gruelling process. It is a lot of - a lot to take on in a year and then being credentialed and then how you - what you have to do to stay credentialed. So yes they are specialised in that.