Diabetes management by primary health care nurses in Auckland: A cross-sectional study

Abstract

Aim: The main aim of this thesis is to investigate the role of primary health care (PHC) nurses and their impact in the clinical management of diabetes patients in the largest city in New Zealand. Specific aims include, identifying and describing PHC nurses demographic and workplace details, education and training needs, their diabetes knowledge and factors associated with best practice. Methods: A total of 287 PHC nurses, 26% of the total number working in Auckland, the largest urban area in New Zealand, were randomly sampled in a cross-sectional survey. The nurses completed a self-administered questionnaire and telephone interview – (86% response rate). All three groups of PHC nurses (practice, district and specialist diabetes) involved in the management of diabetes patients in a community setting were included in the survey. In addition, details were collected for 265 diabetes patients, who had been consulted by 41% of the nurse participants on a randomly selected day. Results: Almost half of the practice nurses (PNs) and specialist nurses (SNs) were aged over 50 years and tended to be older than district nurse (DNs), of whom 46% were 41 to 50 years old. A greater proportion of SNs had post-graduate qualifications and specific diabetes education and experience compared with PNs and DNs, while more DNs (35%) and PNs (32%) had worked in their current workplace for >10 years compared with SNs (14%, p=0.004). DNs had the least administrative facilities available, particularly regarding access to computers and patient information, and also felt the least valued in the management of diabetes. Most nurses (96%) were able to identify excess body weight as a major risk factor for type 2 diabetes and elevated blood glucose levels or glycosylated haemoglobin (86%) for diabetes-related complications. In contrast, cardiovascular risk factors were less well identified, particularly smoking, although more by SNs (43%) than PNs (14%) and DNs (12%, p=0.0005). Cardiovascular complications, especially stroke, were less well known than microvascular complications, and by significantly fewer PNs (13%) and DNs (8%) than SNs (36%, p=0.002). In general, stronger associations were found between nurse’s knowledge of elevated glycosylated haemoglobin as a risk factor for diabetes-related complications and management activities related to blood glucose levels and medication, compared with knowledge of cardiovascular risk factors, which was not associated with assessment of blood pressure or knowledge of patient’s total cholesterol or smoking status. PNs consulted almost 60% of the patients sampled, while patients consulted by DNs tended to be older and were more likely to be European New Zealanders, tobacco users, have diabetes-related complications and co-morbidities; while SNs consulted more Māori and Pacific patients and those with co-morbidities. The proportion of patients smoking (16%) was over double that of diabetes patients reported in international studies, and patients who were consulted by DNs were more likely to smoke, OR=3.53 (1.49, 8.37, p=0.005), compared with those who consulted PNs, and those consulted by SNs OR=1.69 (0.75, 3.78); while older patients (>67 years) were less likely to smoke compared with those aged < 50 years, OR=0.23 (0.08, 0.62, p=0.004). Most patients had a systolic blood pressure (62%) and total cholesterol (71%) above recommended levels. Māori and Pacific ethnicity were positively associated with glycosylated haemoglobin, while being aged over 66 years was negatively associated. Male gender and Asian ethnicity were positively associated with total cholesterol which was negatively associated with systolic blood pressure. Conclusion Although the majority of nurses targeted elevated blood glucose levels or glycosylated haemoglobin, more effective management is required to reduce cardiovascular risk factors, particularly smoking. Education, training and support is vital for PNs because they consult the majority of diabetes patients, and for DNs (who consult patients with their families or Whānau) to adopt cardioprotective lifestyles, including easy access to nicotine replacement therapy, so that both groups of nurses have a greater impact in the primary prevention of diabetes. The PNs consulted almost 60% of the patients sampled, while patients consulted by DNs tended to be older and were more likely to be European New Zealanders, tobacco users, have diabetes-related complications and co-morbidities; while SNs consulted more Māori and Pacific patients and those with co-morbidities. The proportion of patients smoking (16%) was over double that of diabetes patients reported in international studies, and patients who were consulted by DNs were more likely to smoke, OR=3.53 (1.49, 8.37, p=0.005), compared with those who consulted PNs, and those consulted by SNs OR=1.69 (0.75, 3.78); while older patients (>67 years) were less likely to smoke compared with those aged < 50 years, OR=0.23 (0.08, 0.62, p=0.004). Most patients had a systolic blood pressure (62%) and total cholesterol (71%) above recommended levels. Māori and Pacific ethnicity were positively associated with glycosylated haemoglobin, while being aged over 66 years was negatively associated. Male gender and Asian ethnicity were positively associated with total cholesterol which was negatively associated with systolic blood pressure. Conclusion Although the majority of nurses targeted elevated blood glucose levels or glycosylated haemoglobin, more effective management is required to reduce cardiovascular risk factors, particularly smoking. Education, training and support is vital for PNs because they consult the majority of diabetes patients, and for DNs (who consult patients with their families or Whānau) to adopt cardioprotective lifestyles, including easy access to nicotine replacement therapy, so that both groups of nurses have a greater impact in the primary prevention of diabetes.