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Psychological skills training to support diabetes self-management: Qualitative assessment of nurses’ experiences
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Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Psychological skills training to support diabetes self-management: Qualitative assessment of nurses’ experiences Helen Graves a,∗ , Christopher Garrett a , Stephanie A. Amiel a , Khalida Ismail b , Kirsty Winkley b a
Diabetes Research Group, Division of Diabetes & Nutritional Sciences, Faculty of Life Sciences and Medicine, King’s College London, SE5 9RJ, UK b Department of Psychological Medicine and Diabetes Research Group, King’s College London & Institute of Psychiatry, Weston Education Centre, London SE5 9RJ, UK
a r t i c l e
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a b s t r a c t
Article history:
Aim: Evidence for the efficacy of psychological skills training as a method of supporting
Received 26 January 2016
patients’ self-management is growing, but there is a shortage of mental health providers
Received in revised form
with specialist diabetes knowledge to deliver them. Primary care nurses are now increasingly
4 March 2016
expected to learn and use these techniques. This study explores nurse experience of training
Accepted 6 March 2016
in six psychological skills to support patients’ self-management of type 2 diabetes.
Available online xxx
Methods: Semi-structured interviews elicited themes relating to nurses’ experiences of par-
Keywords:
employed in GP surgeries in 5 South London boroughs. Thematic framework analysis was
Diabetes
used to compare and contrast themes across participants. Nine nurses delivering the inter-
Type 2 diabetes
vention (n = 11), and 7 from the control intervention (n = 12, no psychological element) were
Primary care nurses
interviewed.
ticipating in a trial of a psychological intervention, the Diabetes-6 study (D-6). Nurses were
Psychological intervention
Results: Three key themes were identified: (i) positive and negative impact of D6 on nurses’
Motivational interviewing
practice: positives included patient empowerment; negatives included patients’ capacity
Process evaluation
to engage; (ii) professional boundaries including concerns about over-stepping role as a nurse and (iii) concerns about degree of support from physicians at participating practices in integrating psychological and diabetes care. Conclusion: Primary care nurses report that psychological skills training can have a positive impact on patient care. Significant role adjustment is required, which may be aided by additional support from the practice team. Qualitative evaluation of effectiveness of psychological interventions may reveal processes that hinder or contribute to efficacy and translation. Appropriate support is necessary for primary care nurses to deliver psychological therapies with confidence. © 2016 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.
∗
Corresponding author. Tel.: +44 2078485780. E-mail address: [email protected] (H. Graves). http://dx.doi.org/10.1016/j.pcd.2016.03.001 1751-9918/© 2016 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.
Please cite this article in press as: H. Graves, et al., Psychological skills training to support diabetes self-management: Qualitative assessment of nurses’ experiences, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.03.001
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1.
Introduction
In the last decade, the management and organisation of care for people with type2 diabetes (T2D) and other long-term conditions has changed. In the UK, the General Practitioner (GP) contracts of 1990 and 2004 [1] have driven primary care health professionals to take significant responsibility for management of such diseases with support from specialist services when necessary [2]. The use of specific psychological treatments such as motivational interviewing (MI) as tools to support patients’ self-management is becoming more widespread as evidence for their efficacy grows [3–5]. However, there is a shortage of professional staff who are specialists in psychology and behaviour change management to deliver these interventions [6,7], and expert mental health providers are costly, scarce and may not have the necessary specialist diabetes knowledge [8]. There is a skills gap, which if closed would have significant long-term benefits for patients. One solution may be that existing general practice staff are trained to deliver psychological therapies effectively [9,10]. For example, a ‘nurse-coaching intervention’ including behavioural change strategies for women with T2D was effective in improving diet and exercise behaviours and reducing diabetes related distress [11]. In this study, the prior experience of the nurse coaches is not described but there is evidence that diabetes specialist nurses can be trained to deliver motivational interviewing (MI) and cognitive behavioural therapy (CBT) and these are associated with significant improvements in glycaemic control in people with type 1 diabetes [12]. Diabetes nurses can deliver diabetes-specific therapy and maintain psychological treatment fidelity [13]. Meanwhile, primary care nurses have been trained successfully to use motivational techniques to improve oral medication adherence in people with T2D [14]. We conducted a randomised controlled trial (RCT), the Diabetes-6 Study (D6), a cluster randomised trial comparing the effectiveness of usual diabetes care delivered by primary care nurses trained in 6 psychological skills, with an attention control group (same frequency and duration of appointments, no psychological skills training) in improving glycaemic control in patients with T2D and persistent suboptimal glycaemic control. The component skills are drawn from MI and CBT and the nurses in the intervention arm of the study received training and support from a clinical psychologist. The aim of the present study is to explore the primary care nurses’ experiences of psychological skills training as part of the D6 Study.
2.
Method
All 23 nurses who participated in the D6 study were invited to interview. Nurses in the intervention arm had received training according to the D6 manual, which had been delivered by a clinical psychologist over 12 weekly sessions, prior to the start of the intervention. During the intervention delivery period, nurses in the intervention arm had monthly group supervision sessions with the psychologist. Nurses in both
arms had attended an introductory session, which reviewed current NICE guidelines and psychological therapies for diabetes. Nurses in both arms aimed to deliver 12× 30 min individualised, audio-taped patient sessions over 12 months. The results of this study will be reported elsewhere. This evaluation is deliberately being conducted before the main quantitative results are known to minimise researcher bias in the interviews and interpretation of the data [13]. MI is a brief (usually 1–4 sessions) counselling method for enhancing motivation to change and problematic health behaviours by exploring and resolving ambivalence about change [14]. CBT is a longer therapy (usually a minimum of 6–12 sessions) that aims to enable the patient to identify, challenge and substitute unhelpful cognitions and behaviours with more constructive ones [15,16]. There is evidence in substance misuse settings, and in patients with type 1 diabetes, that integrating CBT and MI may increase effectiveness of each [17]. Both MI and CBT techniques were used to enable the nurse and patient to work collaboratively to address key self-management such as medication adherence, self-testing, physical activity and dietary changes. Semi-structured interviews were conducted with individual nurses at their place of work, after their participation in the D6 study had ended. The topic guide was developed using observational data collected during monthly supervision sessions with intervention nurses and an interview with a member of the research team who recruited the nurses into the study (KW). Two interview topic guides (one for the intervention arm and one for attention control) were developed in response to this preliminary research, and included (see Appendix A): experiences of D6 training; supervision and support (intervention group only); the D6 intervention (intervention group only); self awareness; interaction with study patients; and views about psychological research. The two topic guides consisted of open questions to elicit free responses, with follow up questions for prompting and probing. The interview was piloted with 2 nurses (1 intervention, 1 control), to assess relevance and comprehension. No changes to the schedules were necessary and the data were included in the main study. Fifteen of the 16 interviews were audio recorded and transcribed verbatim. One interview was not recorded at the request of the nurse. In this instance the researcher took notes throughout the interview, which were checked and approved by the nurse concerned. The data were entered into and managed using the qualitative computer software programme Nvivo 10 [18]. A thematic framework approach was used to analyse the data, allowing the researcher to compare and contrast themes across participants [19]. The stages of thematic analysis were as follows (i) familiarisation with the data and simple counting; (ii) open coding to identify themes leading to the development of an initial thematic working framework; (iii) discussion of framework with the research team (KW, KI and HG) until consensus was reached; (iv) indexing or applying the coding to the dataset; (v) inter-rater reliability coding of a random sample of (n = 3) interviews was conducted by an independent researcher (CG); (vi) charting of the data within a framework matrix and (vii) mapping and interpretation.
Please cite this article in press as: H. Graves, et al., Psychological skills training to support diabetes self-management: Qualitative assessment of nurses’ experiences, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.03.001
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3.1.2.
Table 1 – Sample characteristics (n = 16).
Mean age (years) Ethnicity (%) White Black Asian/other
Intervention
Control
49
53
37 80 80
63 20 20
Previous training in psychological therapies (N) 1 Module as part of degree course 1 MI Training as part of smoking cessation course One day or less of MI training 1 1 MI training as part of Co-creating Health Programme Training as part of nursing 1 qualification Previous training unknown 4
3.
1 1 1 0 0 5
Results
Of the 23 nurses eligible, 7 did not respond to repeated (n = 3) invitations to participate. Sixteen nurses therefore participated (9 had been randomised to the intervention and 7 to the control group). The characteristics of the final sample are presented in Table 1. All nurses were female. Three key themes were identified in relation to the nurses’ experiences of participating in the D6 study: (i) positive and negative impact of D6, (ii) professional boundaries and (iii) support. There were sub-themes within each.
3.1.1.
Transferring responsibility to the patient
Of the 16 nurses interviewed, 6/9 nurses in the intervention group felt that D6 had a positive impact in that the D6 skills helped to transfer some responsibility of diabetes management back to the patient. “. . .with the motivational interviewing. . . it’s going to . . .give them that control, and want to change, and this is what happened.” (PTP14L, intervention group) One nurse felt that this emphasis on patient self-regulation had reduced her own sense of burden. “I was psychologically and physically tired because I was taking on too much, I was carrying the patient’s responsibility and so the positive for me. . .is now my consultations are less stressful. . .” (PTP06L, intervention group) One control group nurse felt that the extra time with patients mandated by the study protocol for both intervention and control arms played a part in encouraging patients to change their behaviour and promoted consistency of care. “If you’re seeing somebody really very regularly. . .the patient will have to keep saying to me ‘oh no, actually I’m still not doing my exercise, I’m still not doing that’, it really puts the onus on them.” (PTP02L, control group)
Transferable skills learnt
Five nurses from the intervention group felt they had gained valuable skills from the D6 training and intervention, which could be used with other patient groups. “. . .what’s so good about the D6. . . it’s so versatile, you can use the same skill in many areas, like sexual health. . .I’m always praising the D6 for what it’s done for me, as a clinician.” (PTP14L, intervention group) “I also had a group of patients that were very poorly controlled and had very complex problems. . .and I was seeing that group alongside my D6 with the same frequency. . . I’ve been able to improve the control from a big percentage of our patients.” (PTP06L, intervention group)
3.1.3.
Time luxury
Three nurses from the intervention group and five nurses in the control group reported feeling that the length of D6 appointments was a luxury. D6 appointments were 30 min long for the intervention and control group. They felt able to address wider, lifestyle-related concerns. “I think the length of the appointments most nurses would say reinforce what we always knew, that we need more than ten minutes.” (PTP06L, intervention group) “It gave you the time to actually sit with a patient. . . address their concerns, and try to relieve their fears and anxiety.” (PTP05S, control group)
3.1.4. Positive and negative impact of D6 on nurses’ 3.1. practice
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Patient barriers to D6 protocol adherence
Of the 16 nurses interviewed, 13 (8 intervention, 5 control) described ‘patient barriers’ as a negative aspect of D6. Ten nurses (6 intervention, 4 control) experienced problems with patient non-attendance and lack of willing to commit to D-6 appointments. “When it actually came to making the commitment they weren’t prepared to do it.” (PTP13L, control group) “I would say the chaotic ones who could have really done with the help tended to either. . .not attend follow-up or. . .just drop off.” (PTP09L, control group) Four of these nurses felt that some patients did not feel that diabetes self-management was a priority for them. “. . .not everybody wants to make changes in life, people are happy just plodding along. . .” (PTP04W, intervention group) “. . .it’s not a priority to them, there’s too many other things going on.” (PTP13L, control group) Three nurses suggested that low IQ may be a barrier for some patients. “If someone has a low IQ it is very hard to get them to participate.” (PTP04W, intervention group)
3.1.5.
Time management barriers to D6 protocol adherence
Time management issues were raised as a barrier for 8 of the nurses interviewed (4 intervention and 4 control group). Three nurses talked about the extra work created by D-6, and how
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they found it difficult to manage the study in addition to their already heavy workloads. “. . .my workload is so heavy and fast moving I seldomly have the luxury of reflection time. . .when you are studying a new skill and working it’s fine when you’re in the classroom, but. . .if we weren’t getting those frequent [supervision] meetings it would not have been that easy.” (PTP06L, intervention group) “I knew it wouldn’t work if I just tried to do it in the normal sessions. . .with the pressure on appointments.” (PTP13L, control group)
3.1.6.
Change of pace of consultations
The D6 appointments lasted for half an hour, and four of the nurses (2 intervention, 2 control) felt the impact of a change of pace. “Because you’re seeing them so regularly it can get a little bit. . .awkward. . . when you’re thinking “oh I’ve got to see you again in two weeks and I’ve got to think of a plan of what we can discuss.” (PTP08L, control group) “Our consultations are ten minutes so if you haven’t got what [you need] then you have to make another appointment. . .the patients. . .weren’t used to that at all and it was a bit uncomfortable. . .” (PTP01L, intervention group) One nurse felt guilty about conducting D6 appointments in regular surgery hours and expressed concerns that colleagues may have felt she was doing less work than others. “I did feel that actually it looked like I could have been doing other things. . . especially when you’ve got a really busy practice.” (PTP02L, control group)
3.2.
Professional boundaries
3.2.1.
Over-stepping role as a nurse
One control and 3 intervention group nurses expressed concerns about over-stepping their role when delivering the D6 intervention. “They didn’t use it for diabetes, they used it to. . .unload their problems on me and I didn’t know how to deal with these problems because I am not a psychologist, I’m only a nurse.” (PTP04W, intervention group) “I would keep reflecting back to them and doing reflective listening but because I’m not trained in psychological therapies I was actually quite concerned at some points. . .that I might be over stepping my role in terms of my competence.” (PTP12S, control group)
3.2.2.
Harassing the patient
Having experienced problems with patient attendance throughout the study, one control group and three intervention group nurses felt that they were harassing patients to come to appointments.
3.2.3.
Nurse role adjustment
Four nurses in the intervention group and 2 in the control talked about the professional role adjustment that was required by them to participate in the D6 Study. They felt they had to change the style of their consultations. “. . .I didn’t feel confident and was thinking, what should I say next, what should I do next.” (PTP04W, intervention group) “. . .thinking about what the patient’s saying and thinking ‘oh my God, I’ve got to use this. . .skill to get this information out of them.” (PTP03L, intervention group)
3.3.
Support
3.3.1.
Support for nurse from participating surgery
The need for support from the practice physician was raised as an issue by seven of the nurses (4 intervention, 3 control). “I had to fight, I said “okay I’m going to leave the D6. . . you’re the ones who get the money for D6. I’m not getting anything. . .I would like to help my patients but if you have got any problems with me doing the D6 then I will leave . . .and help with open surgery’ . . .they were not that supportive really.” (PTP07S, intervention group) “It’s just another affront of how doctors think. . . they could take the services and the expertise of nurses and use it to their advantage with no recognition. . .” (PTP06L, intervention group) The need for extra support from other teams such as administration and IT was raised by four of the nurses. “I think if I was to do this again I think we would need the whole practice team [to help] and [receive] input from different departments.” (PTP05S, control group) “The good thing is we had an admin person who was specifically there for diabetes, so she was. . .willing to help and support. . .” (PTP09L, control group)
3.3.2.
Supervision of nurses by research team
Four of the intervention group nurses highlighted the importance of supervision from the psychologist at King’s. “it give you that opportunity to offload and you get input from everybody. . .and it also reinforces, okay right, so I was on the right track. . .I’m really going to miss that.” (PTP06L, intervention group) “. . .we discuss our difficult patients. . .and we get some suggestions of how to deal with those that are not getting on well. So I think. . . it’s helping a lot going to those sessions.” (PTP07S, intervention group) Two of the nurses felt however that more supervision would have been helpful. “. . .perhaps because I didn’t have any psychology background a bit more input would have helped really.” (PTP04W, intervention group)
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4.
Discussion
The aim of this study was to explore primary care nurses’ experience of psychological skills training and implementation as part of the D6 Study. The most important findings identified from emergent themes included the identification of patient barriers, which prevented nurses from implementing D6 according to protocol. These included lack of attendance at appointments, lack of willingness to commit to scheduled appointments and patients not prioritising diabetes self-management, and they may be explained by the fact that the D6 sample was drawn from a population with poor glycaemic control who are likely to have lower levels of commitment to self-management and poorer records of attendance. Nurses in both control and intervention groups also raised concerns about professional boundaries and nurses in the intervention group were concerned that they were overstepping their professional role when using MI skills or dealing with emotive consultations, as they were not qualified as psychologists. This could be considered an inevitable ‘sideeffect’ of this type of training and it may need to be addressed in the design of further research. Indeed, nurses in both groups felt they needed to adjust their role in order to facilitate the use of D6 skills (intervention group), or to fill longer appointment times (control group). Despite these concerns, nurses trained in psychological skills perceived that those skills were valuable and transferable in a primary care setting. If a similar service were implemented in practice, it may have the potential to benefit patients with other long-term conditions. Nurses in both groups felt that they had been undersupported by their practice during their participation in D6, and the need for input from other practice departments was highlighted. It is also worth noting that nurses required significant support from the D6 research team. Again, this may have implications for future research. The strength of this study is that it was developed a priori as part of the process evaluation of the D6 Study and that, as the results of the RCT were not known at the time of data collection or analysis, there is less bias in nurse or researcher reporting. Trials of psychological therapies are, by nature, complex and there are multiple contextual variables and processes, which may vary between and within study participants, interventionists and sites to mediate outcome. These can be assessed qualitatively, and used to assist in the interpretation of quantitative findings and translating the research into practice [17,18]. This study has identified, for example, barriers to the implementation of the D6 study according to protocol, which may help explain any future negative findings. The data also indicate that use of D6 skills produced effects consistent with MI such as patient empowerment, which may enhance explanatory power when interpreting any effects observed when the main trial outcome data is analysed. Within the existing evaluation literature, our study is consistent with findings that qualitative interview techniques can reveal mechanisms and processes that hinder or contribute to the efficacy of an intervention and translation of skills into practice [17].
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A limitation of the study may be that nurses felt potentially uncomfortable raising certain issues, for example about the supervision and support they received from the research team during their participation. They may also have been reluctant to admit any mistakes in adherence to protocol. As expectations rise for more management of long-term conditions in primary care, its staff will need more skills in behaviour change. Our findings indicate that nurses working in primary care require significant support from other practice team members and a qualified psychologist in order to adjust their consultation style and schedule within a busy general practice. When this support is received however, they can feel capable and competent to deliver a psychological therapy. Qualitative evaluation of psychological interventions may help to reveal mechanisms which hinder or promote implementation of the intervention according to protocol. Future research may involve incorporating qualitative studies into the analysis plan of RCTs of similar interventions in different settings and with different populations to see if similar findings are identified.
Funding The D-6 study was part of independent research funded by the NIHR under its Programme Grants for Applied Research scheme (RP-PG-0606-1142).
Ethical approval This study was approved by the King’s College Hospital Ethics Committee. Ref: 09/H0808/97.
Conflicts of interest The authors have no conflicts of interest to declare.
Acknowledgements The authors would like to thank all the nurses who participated in this interview study. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
Appendix A. Interview topic guides for intervention and control groups D6 Nurse interview schedule (intervention) Training You were allocated to the intervention arm of the trial, which meant that you attended King’s for training in the D6 skills. • What were your views about being randomised to the intervention arm of the study?
Please cite this article in press as: H. Graves, et al., Psychological skills training to support diabetes self-management: Qualitative assessment of nurses’ experiences, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.03.001
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• What did you think about the timing of the training sessions? ◦ Frequency ◦ Length • Can you tell me about any problems you experienced with the training? ◦ What would have made it easier for you? • Can you tell me any ways in which you think the training could have been improved? • Have you had any previous training in psychological therapies?
Supervision • What are your views about the supervision you received throughout the study? • What are your views about the support you received from the research team in general? • How did other members of staff at your practice feel about you taking part in the study? ◦ Were they supportive/not supportive? How so? ◦ What would have made it easier for you to participate?
D6 nurse interview schedule (control) Training You were allocated to the control arm of the trial, which meant that you did not attend King’s for training in the D6 skills. • What were your views about being randomised to the control arm of the trial? • Have you had any previous training in psychological therapies?
Supervision • What are your views about the supervision you received throughout the study? • What are your views about the support you received from the research team in general? • How did other members of staff at your practice feel about you taking part in the study? ◦ Were they supportive/not supportive? How so? ◦ What would have made it easier for you to participate?
D6 intervention
D6 intervention
• How did you find the actual sessions with patients? ◦ How did you find the length of the sessions? • What are your views about the admin time involved in the study? • What are your views about D6 as a potential training for other practice nurses?
• How did you find the actual sessions with patients? ◦ How did you find the length of the sessions? • What are your views about the admin time involved in the study? • What are your views about D6 as a potential training for other practice nurses?
Self awareness
Self awareness
• How confident did you feel about delivering the intervention? • How confident did you feel about managing the caseload?
• How confident did you feel about delivering the intervention? • How confident did you feel about managing the caseload?
Patients
Patients
• Can you tell me about any difficulties you experienced in getting patients to attend the sessions? ◦ Did you book the patients in yourself or did a researcher or receptionist do this for you? • Thinking about the patients that did attend, how do you think they feel about seeing you less often again now that the extra sessions have come to an end? • What were the challenges that you faced in using D6 skills with these patients?
• Can you tell me about any difficulties you experienced in getting patients to attend the sessions? ◦ Did you book the patients in yourself or did a researcher or receptionist do this for you? • Thinking about the patients that did attend, how do you think they feel about seeing you less often again now that the extra sessions have come to an end? • What were the challenges that you faced in seeing these patients?
Values about psychological research
Values about psychological research
• What are your views about the value of psychological interventions to improve outcomes in diabetes? • How has participating in D6 affected your views about taking part in other research studies in the future?
• What are your views about the value of psychological interventions to improve outcomes in diabetes? • How has participating in D6 affected your views about taking part in other research studies in the future?
Final comments
Final comments
Is there anything else at all you would like to say that we have not already covered?
Is there anything else at all you would like to say that we have not already covered?
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Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Psychological skills training to support diabetes self-management: Qualitative assessment of nurses’ experiences Helen Graves a,∗ , Christopher Garrett a , Stephanie A. Amiel a , Khalida Ismail b , Kirsty Winkley b a
Diabetes Research Group, Division of Diabetes & Nutritional Sciences, Faculty of Life Sciences and Medicine, King’s College London, SE5 9RJ, UK b Department of Psychological Medicine and Diabetes Research Group, King’s College London & Institute of Psychiatry, Weston Education Centre, London SE5 9RJ, UK
a r t i c l e
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Article history:
Aim: Evidence for the efficacy of psychological skills training as a method of supporting
Received 26 January 2016
patients’ self-management is growing, but there is a shortage of mental health providers
Received in revised form
with specialist diabetes knowledge to deliver them. Primary care nurses are now increasingly
4 March 2016
expected to learn and use these techniques. This study explores nurse experience of training
Accepted 6 March 2016
in six psychological skills to support patients’ self-management of type 2 diabetes.
Available online xxx
Methods: Semi-structured interviews elicited themes relating to nurses’ experiences of par-
Keywords:
employed in GP surgeries in 5 South London boroughs. Thematic framework analysis was
Diabetes
used to compare and contrast themes across participants. Nine nurses delivering the inter-
Type 2 diabetes
vention (n = 11), and 7 from the control intervention (n = 12, no psychological element) were
Primary care nurses
interviewed.
ticipating in a trial of a psychological intervention, the Diabetes-6 study (D-6). Nurses were
Psychological intervention
Results: Three key themes were identified: (i) positive and negative impact of D6 on nurses’
Motivational interviewing
practice: positives included patient empowerment; negatives included patients’ capacity
Process evaluation
to engage; (ii) professional boundaries including concerns about over-stepping role as a nurse and (iii) concerns about degree of support from physicians at participating practices in integrating psychological and diabetes care. Conclusion: Primary care nurses report that psychological skills training can have a positive impact on patient care. Significant role adjustment is required, which may be aided by additional support from the practice team. Qualitative evaluation of effectiveness of psychological interventions may reveal processes that hinder or contribute to efficacy and translation. Appropriate support is necessary for primary care nurses to deliver psychological therapies with confidence. © 2016 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.
∗
Corresponding author. Tel.: +44 2078485780. E-mail address: [email protected] (H. Graves). http://dx.doi.org/10.1016/j.pcd.2016.03.001 1751-9918/© 2016 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.
Please cite this article in press as: H. Graves, et al., Psychological skills training to support diabetes self-management: Qualitative assessment of nurses’ experiences, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.03.001
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1.
Introduction
In the last decade, the management and organisation of care for people with type2 diabetes (T2D) and other long-term conditions has changed. In the UK, the General Practitioner (GP) contracts of 1990 and 2004 [1] have driven primary care health professionals to take significant responsibility for management of such diseases with support from specialist services when necessary [2]. The use of specific psychological treatments such as motivational interviewing (MI) as tools to support patients’ self-management is becoming more widespread as evidence for their efficacy grows [3–5]. However, there is a shortage of professional staff who are specialists in psychology and behaviour change management to deliver these interventions [6,7], and expert mental health providers are costly, scarce and may not have the necessary specialist diabetes knowledge [8]. There is a skills gap, which if closed would have significant long-term benefits for patients. One solution may be that existing general practice staff are trained to deliver psychological therapies effectively [9,10]. For example, a ‘nurse-coaching intervention’ including behavioural change strategies for women with T2D was effective in improving diet and exercise behaviours and reducing diabetes related distress [11]. In this study, the prior experience of the nurse coaches is not described but there is evidence that diabetes specialist nurses can be trained to deliver motivational interviewing (MI) and cognitive behavioural therapy (CBT) and these are associated with significant improvements in glycaemic control in people with type 1 diabetes [12]. Diabetes nurses can deliver diabetes-specific therapy and maintain psychological treatment fidelity [13]. Meanwhile, primary care nurses have been trained successfully to use motivational techniques to improve oral medication adherence in people with T2D [14]. We conducted a randomised controlled trial (RCT), the Diabetes-6 Study (D6), a cluster randomised trial comparing the effectiveness of usual diabetes care delivered by primary care nurses trained in 6 psychological skills, with an attention control group (same frequency and duration of appointments, no psychological skills training) in improving glycaemic control in patients with T2D and persistent suboptimal glycaemic control. The component skills are drawn from MI and CBT and the nurses in the intervention arm of the study received training and support from a clinical psychologist. The aim of the present study is to explore the primary care nurses’ experiences of psychological skills training as part of the D6 Study.
2.
Method
All 23 nurses who participated in the D6 study were invited to interview. Nurses in the intervention arm had received training according to the D6 manual, which had been delivered by a clinical psychologist over 12 weekly sessions, prior to the start of the intervention. During the intervention delivery period, nurses in the intervention arm had monthly group supervision sessions with the psychologist. Nurses in both
arms had attended an introductory session, which reviewed current NICE guidelines and psychological therapies for diabetes. Nurses in both arms aimed to deliver 12× 30 min individualised, audio-taped patient sessions over 12 months. The results of this study will be reported elsewhere. This evaluation is deliberately being conducted before the main quantitative results are known to minimise researcher bias in the interviews and interpretation of the data [13]. MI is a brief (usually 1–4 sessions) counselling method for enhancing motivation to change and problematic health behaviours by exploring and resolving ambivalence about change [14]. CBT is a longer therapy (usually a minimum of 6–12 sessions) that aims to enable the patient to identify, challenge and substitute unhelpful cognitions and behaviours with more constructive ones [15,16]. There is evidence in substance misuse settings, and in patients with type 1 diabetes, that integrating CBT and MI may increase effectiveness of each [17]. Both MI and CBT techniques were used to enable the nurse and patient to work collaboratively to address key self-management such as medication adherence, self-testing, physical activity and dietary changes. Semi-structured interviews were conducted with individual nurses at their place of work, after their participation in the D6 study had ended. The topic guide was developed using observational data collected during monthly supervision sessions with intervention nurses and an interview with a member of the research team who recruited the nurses into the study (KW). Two interview topic guides (one for the intervention arm and one for attention control) were developed in response to this preliminary research, and included (see Appendix A): experiences of D6 training; supervision and support (intervention group only); the D6 intervention (intervention group only); self awareness; interaction with study patients; and views about psychological research. The two topic guides consisted of open questions to elicit free responses, with follow up questions for prompting and probing. The interview was piloted with 2 nurses (1 intervention, 1 control), to assess relevance and comprehension. No changes to the schedules were necessary and the data were included in the main study. Fifteen of the 16 interviews were audio recorded and transcribed verbatim. One interview was not recorded at the request of the nurse. In this instance the researcher took notes throughout the interview, which were checked and approved by the nurse concerned. The data were entered into and managed using the qualitative computer software programme Nvivo 10 [18]. A thematic framework approach was used to analyse the data, allowing the researcher to compare and contrast themes across participants [19]. The stages of thematic analysis were as follows (i) familiarisation with the data and simple counting; (ii) open coding to identify themes leading to the development of an initial thematic working framework; (iii) discussion of framework with the research team (KW, KI and HG) until consensus was reached; (iv) indexing or applying the coding to the dataset; (v) inter-rater reliability coding of a random sample of (n = 3) interviews was conducted by an independent researcher (CG); (vi) charting of the data within a framework matrix and (vii) mapping and interpretation.
Please cite this article in press as: H. Graves, et al., Psychological skills training to support diabetes self-management: Qualitative assessment of nurses’ experiences, Prim. Care Diab. (2016), http://dx.doi.org/10.1016/j.pcd.2016.03.001
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3.1.2.
Table 1 – Sample characteristics (n = 16).
Mean age (years) Ethnicity (%) White Black Asian/other
Intervention
Control
49
53
37 80 80
63 20 20
Previous training in psychological therapies (N) 1 Module as part of degree course 1 MI Training as part of smoking cessation course One day or less of MI training 1 1 MI training as part of Co-creating Health Programme Training as part of nursing 1 qualification Previous training unknown 4
3.
1 1 1 0 0 5
Results
Of the 23 nurses eligible, 7 did not respond to repeated (n = 3) invitations to participate. Sixteen nurses therefore participated (9 had been randomised to the intervention and 7 to the control group). The characteristics of the final sample are presented in Table 1. All nurses were female. Three key themes were identified in relation to the nurses’ experiences of participating in the D6 study: (i) positive and negative impact of D6, (ii) professional boundaries and (iii) support. There were sub-themes within each.
3.1.1.
Transferring responsibility to the patient
Of the 16 nurses interviewed, 6/9 nurses in the intervention group felt that D6 had a positive impact in that the D6 skills helped to transfer some responsibility of diabetes management back to the patient. “. . .with the motivational interviewing. . . it’s going to . . .give them that control, and want to change, and this is what happened.” (PTP14L, intervention group) One nurse felt that this emphasis on patient self-regulation had reduced her own sense of burden. “I was psychologically and physically tired because I was taking on too much, I was carrying the patient’s responsibility and so the positive for me. . .is now my consultations are less stressful. . .” (PTP06L, intervention group) One control group nurse felt that the extra time with patients mandated by the study protocol for both intervention and control arms played a part in encouraging patients to change their behaviour and promoted consistency of care. “If you’re seeing somebody really very regularly. . .the patient will have to keep saying to me ‘oh no, actually I’m still not doing my exercise, I’m still not doing that’, it really puts the onus on them.” (PTP02L, control group)
Transferable skills learnt
Five nurses from the intervention group felt they had gained valuable skills from the D6 training and intervention, which could be used with other patient groups. “. . .what’s so good about the D6. . . it’s so versatile, you can use the same skill in many areas, like sexual health. . .I’m always praising the D6 for what it’s done for me, as a clinician.” (PTP14L, intervention group) “I also had a group of patients that were very poorly controlled and had very complex problems. . .and I was seeing that group alongside my D6 with the same frequency. . . I’ve been able to improve the control from a big percentage of our patients.” (PTP06L, intervention group)
3.1.3.
Time luxury
Three nurses from the intervention group and five nurses in the control group reported feeling that the length of D6 appointments was a luxury. D6 appointments were 30 min long for the intervention and control group. They felt able to address wider, lifestyle-related concerns. “I think the length of the appointments most nurses would say reinforce what we always knew, that we need more than ten minutes.” (PTP06L, intervention group) “It gave you the time to actually sit with a patient. . . address their concerns, and try to relieve their fears and anxiety.” (PTP05S, control group)
3.1.4. Positive and negative impact of D6 on nurses’ 3.1. practice
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Patient barriers to D6 protocol adherence
Of the 16 nurses interviewed, 13 (8 intervention, 5 control) described ‘patient barriers’ as a negative aspect of D6. Ten nurses (6 intervention, 4 control) experienced problems with patient non-attendance and lack of willing to commit to D-6 appointments. “When it actually came to making the commitment they weren’t prepared to do it.” (PTP13L, control group) “I would say the chaotic ones who could have really done with the help tended to either. . .not attend follow-up or. . .just drop off.” (PTP09L, control group) Four of these nurses felt that some patients did not feel that diabetes self-management was a priority for them. “. . .not everybody wants to make changes in life, people are happy just plodding along. . .” (PTP04W, intervention group) “. . .it’s not a priority to them, there’s too many other things going on.” (PTP13L, control group) Three nurses suggested that low IQ may be a barrier for some patients. “If someone has a low IQ it is very hard to get them to participate.” (PTP04W, intervention group)
3.1.5.
Time management barriers to D6 protocol adherence
Time management issues were raised as a barrier for 8 of the nurses interviewed (4 intervention and 4 control group). Three nurses talked about the extra work created by D-6, and how
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they found it difficult to manage the study in addition to their already heavy workloads. “. . .my workload is so heavy and fast moving I seldomly have the luxury of reflection time. . .when you are studying a new skill and working it’s fine when you’re in the classroom, but. . .if we weren’t getting those frequent [supervision] meetings it would not have been that easy.” (PTP06L, intervention group) “I knew it wouldn’t work if I just tried to do it in the normal sessions. . .with the pressure on appointments.” (PTP13L, control group)
3.1.6.
Change of pace of consultations
The D6 appointments lasted for half an hour, and four of the nurses (2 intervention, 2 control) felt the impact of a change of pace. “Because you’re seeing them so regularly it can get a little bit. . .awkward. . . when you’re thinking “oh I’ve got to see you again in two weeks and I’ve got to think of a plan of what we can discuss.” (PTP08L, control group) “Our consultations are ten minutes so if you haven’t got what [you need] then you have to make another appointment. . .the patients. . .weren’t used to that at all and it was a bit uncomfortable. . .” (PTP01L, intervention group) One nurse felt guilty about conducting D6 appointments in regular surgery hours and expressed concerns that colleagues may have felt she was doing less work than others. “I did feel that actually it looked like I could have been doing other things. . . especially when you’ve got a really busy practice.” (PTP02L, control group)
3.2.
Professional boundaries
3.2.1.
Over-stepping role as a nurse
One control and 3 intervention group nurses expressed concerns about over-stepping their role when delivering the D6 intervention. “They didn’t use it for diabetes, they used it to. . .unload their problems on me and I didn’t know how to deal with these problems because I am not a psychologist, I’m only a nurse.” (PTP04W, intervention group) “I would keep reflecting back to them and doing reflective listening but because I’m not trained in psychological therapies I was actually quite concerned at some points. . .that I might be over stepping my role in terms of my competence.” (PTP12S, control group)
3.2.2.
Harassing the patient
Having experienced problems with patient attendance throughout the study, one control group and three intervention group nurses felt that they were harassing patients to come to appointments.
3.2.3.
Nurse role adjustment
Four nurses in the intervention group and 2 in the control talked about the professional role adjustment that was required by them to participate in the D6 Study. They felt they had to change the style of their consultations. “. . .I didn’t feel confident and was thinking, what should I say next, what should I do next.” (PTP04W, intervention group) “. . .thinking about what the patient’s saying and thinking ‘oh my God, I’ve got to use this. . .skill to get this information out of them.” (PTP03L, intervention group)
3.3.
Support
3.3.1.
Support for nurse from participating surgery
The need for support from the practice physician was raised as an issue by seven of the nurses (4 intervention, 3 control). “I had to fight, I said “okay I’m going to leave the D6. . . you’re the ones who get the money for D6. I’m not getting anything. . .I would like to help my patients but if you have got any problems with me doing the D6 then I will leave . . .and help with open surgery’ . . .they were not that supportive really.” (PTP07S, intervention group) “It’s just another affront of how doctors think. . . they could take the services and the expertise of nurses and use it to their advantage with no recognition. . .” (PTP06L, intervention group) The need for extra support from other teams such as administration and IT was raised by four of the nurses. “I think if I was to do this again I think we would need the whole practice team [to help] and [receive] input from different departments.” (PTP05S, control group) “The good thing is we had an admin person who was specifically there for diabetes, so she was. . .willing to help and support. . .” (PTP09L, control group)
3.3.2.
Supervision of nurses by research team
Four of the intervention group nurses highlighted the importance of supervision from the psychologist at King’s. “it give you that opportunity to offload and you get input from everybody. . .and it also reinforces, okay right, so I was on the right track. . .I’m really going to miss that.” (PTP06L, intervention group) “. . .we discuss our difficult patients. . .and we get some suggestions of how to deal with those that are not getting on well. So I think. . . it’s helping a lot going to those sessions.” (PTP07S, intervention group) Two of the nurses felt however that more supervision would have been helpful. “. . .perhaps because I didn’t have any psychology background a bit more input would have helped really.” (PTP04W, intervention group)
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4.
Discussion
The aim of this study was to explore primary care nurses’ experience of psychological skills training and implementation as part of the D6 Study. The most important findings identified from emergent themes included the identification of patient barriers, which prevented nurses from implementing D6 according to protocol. These included lack of attendance at appointments, lack of willingness to commit to scheduled appointments and patients not prioritising diabetes self-management, and they may be explained by the fact that the D6 sample was drawn from a population with poor glycaemic control who are likely to have lower levels of commitment to self-management and poorer records of attendance. Nurses in both control and intervention groups also raised concerns about professional boundaries and nurses in the intervention group were concerned that they were overstepping their professional role when using MI skills or dealing with emotive consultations, as they were not qualified as psychologists. This could be considered an inevitable ‘sideeffect’ of this type of training and it may need to be addressed in the design of further research. Indeed, nurses in both groups felt they needed to adjust their role in order to facilitate the use of D6 skills (intervention group), or to fill longer appointment times (control group). Despite these concerns, nurses trained in psychological skills perceived that those skills were valuable and transferable in a primary care setting. If a similar service were implemented in practice, it may have the potential to benefit patients with other long-term conditions. Nurses in both groups felt that they had been undersupported by their practice during their participation in D6, and the need for input from other practice departments was highlighted. It is also worth noting that nurses required significant support from the D6 research team. Again, this may have implications for future research. The strength of this study is that it was developed a priori as part of the process evaluation of the D6 Study and that, as the results of the RCT were not known at the time of data collection or analysis, there is less bias in nurse or researcher reporting. Trials of psychological therapies are, by nature, complex and there are multiple contextual variables and processes, which may vary between and within study participants, interventionists and sites to mediate outcome. These can be assessed qualitatively, and used to assist in the interpretation of quantitative findings and translating the research into practice [17,18]. This study has identified, for example, barriers to the implementation of the D6 study according to protocol, which may help explain any future negative findings. The data also indicate that use of D6 skills produced effects consistent with MI such as patient empowerment, which may enhance explanatory power when interpreting any effects observed when the main trial outcome data is analysed. Within the existing evaluation literature, our study is consistent with findings that qualitative interview techniques can reveal mechanisms and processes that hinder or contribute to the efficacy of an intervention and translation of skills into practice [17].
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A limitation of the study may be that nurses felt potentially uncomfortable raising certain issues, for example about the supervision and support they received from the research team during their participation. They may also have been reluctant to admit any mistakes in adherence to protocol. As expectations rise for more management of long-term conditions in primary care, its staff will need more skills in behaviour change. Our findings indicate that nurses working in primary care require significant support from other practice team members and a qualified psychologist in order to adjust their consultation style and schedule within a busy general practice. When this support is received however, they can feel capable and competent to deliver a psychological therapy. Qualitative evaluation of psychological interventions may help to reveal mechanisms which hinder or promote implementation of the intervention according to protocol. Future research may involve incorporating qualitative studies into the analysis plan of RCTs of similar interventions in different settings and with different populations to see if similar findings are identified.
Funding The D-6 study was part of independent research funded by the NIHR under its Programme Grants for Applied Research scheme (RP-PG-0606-1142).
Ethical approval This study was approved by the King’s College Hospital Ethics Committee. Ref: 09/H0808/97.
Conflicts of interest The authors have no conflicts of interest to declare.
Acknowledgements The authors would like to thank all the nurses who participated in this interview study. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
Appendix A. Interview topic guides for intervention and control groups D6 Nurse interview schedule (intervention) Training You were allocated to the intervention arm of the trial, which meant that you attended King’s for training in the D6 skills. • What were your views about being randomised to the intervention arm of the study?
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• What did you think about the timing of the training sessions? ◦ Frequency ◦ Length • Can you tell me about any problems you experienced with the training? ◦ What would have made it easier for you? • Can you tell me any ways in which you think the training could have been improved? • Have you had any previous training in psychological therapies?
Supervision • What are your views about the supervision you received throughout the study? • What are your views about the support you received from the research team in general? • How did other members of staff at your practice feel about you taking part in the study? ◦ Were they supportive/not supportive? How so? ◦ What would have made it easier for you to participate?
D6 nurse interview schedule (control) Training You were allocated to the control arm of the trial, which meant that you did not attend King’s for training in the D6 skills. • What were your views about being randomised to the control arm of the trial? • Have you had any previous training in psychological therapies?
Supervision • What are your views about the supervision you received throughout the study? • What are your views about the support you received from the research team in general? • How did other members of staff at your practice feel about you taking part in the study? ◦ Were they supportive/not supportive? How so? ◦ What would have made it easier for you to participate?
D6 intervention
D6 intervention
• How did you find the actual sessions with patients? ◦ How did you find the length of the sessions? • What are your views about the admin time involved in the study? • What are your views about D6 as a potential training for other practice nurses?
• How did you find the actual sessions with patients? ◦ How did you find the length of the sessions? • What are your views about the admin time involved in the study? • What are your views about D6 as a potential training for other practice nurses?
Self awareness
Self awareness
• How confident did you feel about delivering the intervention? • How confident did you feel about managing the caseload?
• How confident did you feel about delivering the intervention? • How confident did you feel about managing the caseload?
Patients
Patients
• Can you tell me about any difficulties you experienced in getting patients to attend the sessions? ◦ Did you book the patients in yourself or did a researcher or receptionist do this for you? • Thinking about the patients that did attend, how do you think they feel about seeing you less often again now that the extra sessions have come to an end? • What were the challenges that you faced in using D6 skills with these patients?
• Can you tell me about any difficulties you experienced in getting patients to attend the sessions? ◦ Did you book the patients in yourself or did a researcher or receptionist do this for you? • Thinking about the patients that did attend, how do you think they feel about seeing you less often again now that the extra sessions have come to an end? • What were the challenges that you faced in seeing these patients?
Values about psychological research
Values about psychological research
• What are your views about the value of psychological interventions to improve outcomes in diabetes? • How has participating in D6 affected your views about taking part in other research studies in the future?
• What are your views about the value of psychological interventions to improve outcomes in diabetes? • How has participating in D6 affected your views about taking part in other research studies in the future?
Final comments
Final comments
Is there anything else at all you would like to say that we have not already covered?
Is there anything else at all you would like to say that we have not already covered?
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