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Swedish health care professionals’ diverse understandings of diabetes care
Patient Education and Counseling 51 (2003) 53–58
Swedish health care professionals’ diverse understandings of diabetes care Inger Holmstro¨ma,*, Christina Halforda, Urban Rosenqvista,b a
b
Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Uppsala, Sweden The Research and Development Unit for the Elderly (ANV), Northwest Stockholm County Council, Stockholm, Sweden Received 25 January 2002; received in revised form 15 June 2002; accepted 8 July 2002
Abstract Knowledge of health care professionals’ different understandings of diabetes care is important when preparing such professionals in patient education. For patients to manage illness effectively, the actions of health care professionals are crucial. Patients’ understanding of their condition should be taken as the point of departure when creating a learning situation. The professionals’ understandings of diabetes care were mapped using a survey including 169 primary care doctors, nurses, assistant nurses and chiropodists in Stockholm, Sweden. The responses were analysed using a phenomenographic approach. Five understandings were identified: the professionals treat the patients, the professionals give information, the professionals focus relation and organisation, the professionals seek the patient’s agreement, and the professionals focus the patient’s understanding of the situation. Only 20 (12%) of the 169 professional caregivers focused the patient’s understanding. Professionals need to develop their understandings of health care and the professional–patient interaction in order to support the patients’ learning. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Sweden; Diabetes; Patients’ learning; Patient encounter; Phenomenography
1. Introduction A sizeable number of studies exist today suggesting that patients who have knowledge about and comprehend the nature of their illness and its treatment are more likely to succeed in managing their illness [1,2]. Care of diabetes is an excellent example of the intimate relation between understanding one’s illness and illness management. A patient with diabetes who understands the illness and how it can be treated successfully has a documented higher likelihood of attaining near normal blood-glucose levels than a patient who does not have such knowledge [3–5]. However, keeping the blood-glucose levels as low as possible to reduce complications is a fine balancing act for the patient [6–8]. Sufficient time in the professional–patient encounter, easy access to care, good communication and mutual trust and respect are important factors in achieving this goal [3,9,10]. Effective patient education and intervention are obviously needed but evidence suggests that they have been difficult to achieve [11,12]. To be efficacious the professional–patient encounter in diabetes care needs to focus on the individual’s * Corresponding author. Tel.: þ46-18-611-3569; fax: þ46-18-50-6404. E-mail address: [email protected] (I. Holmstro¨m).
experiences and adapt the learning pace to the patient [5,13,14]. However, diabetes care has often been ‘‘checklist driven’’ via clinical guidelines and has focused on technical advice [3]. Furthermore, patients have raised complaints against such standardised textbook approaches [3,10]. Traditional patient education has had little or no effect on patients’ understanding of their condition and thus in the treatment of diabetes [3,5,15,16]. Few studies have demonstrated a clear link between continuous professional development (CPD) courses for health care professionals and clinical outcomes for patients [12,17]. Consequently, a need exists for a new and qualitatively different competence development for professionals working in diabetes care. Contemporary theories of competence and its development have shown that competence is the result of how people understand their work [18]. A beginning step in the process of competence development within this field would be to show and establish the understandings, or conceptions, that health care professionals bring with them in diabetes care and patient education. The purpose of this study then was to identify, in one catchment area in Stockholm, Sweden, the various understandings health care professionals have of the core aspects of diabetes care and how such understandings are disbursed. The baseline results are part of a larger study
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designed to develop communication skills of health care professionals working in the general practices of the catchment area in question. The pedagogic framework for this development is based on phenomenographic theories of learning [19,20].
2. Method 2.1. Mapping health care professionals’ understanding of diabetes care In 1996, all (23) health care centres (HCCs) in one catchment area in Stockholm, Sweden were invited to participate in a programme intended to provide information about diabetes and diabetes care. Of the 23 invited centres, 20 accepted (one centre rejected the invitation and two did not reply) to take part in the study. The participants were general practitioners (GPs), nurses, assistant nurses and chiropodists. We decided to study the group of professionals as a whole, as they were working in teams and all had substantial influence over diabetes care carried out at the various health centres. The health care professionals from the 20 centres were invited to attend specially arranged information meetings about the project. In these meetings the participants were asked to write down their responses to the following questions: What do you think is the central feature(s) of diabetes care? Give a concrete example. What do you find difficult to deal with regarding diabetes care? Give a concrete example. When do you think you have been successful regarding diabetes care? Give a concrete example. The first two questions are derived from Dall’Alba [21] and all three have been used in our previous research [22,23]. Through seeking descriptions of concrete situations, the focus was maintained on the professionals’ work-related experiences and not on how the professionals would like things to be or thought they ought to be [21]. In addition to their responses to these three questions, the participants were asked to provide their name, profession, diabetes-related education and the average number of appointments with patients with diabetes that they encounter each month. Most patients with diabetes treated at the health centres have Type 2 diabetes. 2.2. Phenomenographic analysis Qualitative methods are increasingly used within health care research [20,24] because they allow the investigation of research questions of a qualitative character (e.g. emphasis is given to human thoughts and experiences). Data for qualitative research often consist of interview material, but could also consist of written material, participant observation or video recordings [24,25]. The choice of a particular qualitative method for data collection and analysis largely
depends on the research question posed and the theoretical framework adopted. The theoretical framework for this project was phenomenographic theories of learning and competence development. Hence, a phenomenographic analysis of the participants’ written answers was performed. Phenomenography is a qualitative research approach in which the main goal is to describe the essential variation in the understanding or ways of experiencing a given phenomenon [26]. Ways of understanding or experiencing is also referred to as ‘‘conceptions’’ or ‘‘views.’’ The phenomenographic approach has been developed over the past 20 years and has been used extensively to investigate learning and teaching. More recently, however, the approach has been used in health care research [21,27]. In this study we wish to identify different understandings that health care professionals have of diabetes care and relate these to each other in an outcome space, representing the logical relations between the experiences health care professionals have in encountering patients with diabetes [23]. The various understandings, which are dynamic and context specific, are judged to be fundamental to the way in which we act, understand, form our beliefs and experience our world [20]. The present analysis was performed by one of the authors (CH) with the principal author (IH) as co-reader. When opinions differed between authors with respect to classification of responses into categories and assigning labels to categories, we returned to the text and consulted the third author (UR) until agreement was reached on categorisation. Each category should be labelled as closely to the data as possible [28]. In accordance with Sandberg, the analysis was carried out in five steps [29]. Step 1: To master a general knowledge of the material the texts were read several times. No predetermined categories or theories were used at this stage of the analysis. Step 2: In this step the what aspects (i.e. the content and goal of diabetes care and the perspective of the health care professionals) were examined. The professionals described the different aspects of diabetes care (e.g. patients’ blood-glucose). Step 3: In this third step, the how aspect (i.e. the process of attaining the primary goal of diabetes care) was studied. The respondents’ responses were then sorted into themes; for example, one theme was measures: the professionals’ role in the treatment explained as medical knowledge, to medically treat, control, prevent, etc. Step 4: In this phase, each survey was again studied as a whole unit. The ‘what’ and ‘how’ aspects of the respondents’ responses were examined iteratively. Using this technique, several variations of understanding emerged. Step 5: In the final step the variations of understanding were related to each other by identifying and describing the logical relations between them. 3. Results Twenty of the 23 invited centres participated in the survey. Approximately 50% of the health care professionals
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employed at the health care centres in the catchment area in Stockholm took part in the introductory meetings. Roughly, 90% (or 169) of those persons who participated responded to the written survey items described above. Of the 169 respondents, 65 were doctors, 63 were nurses and 29 were assistant nurses or chiropodists; the occupation(s) of the remaining 12 respondents was unspecified. Gender distribution within the occupational groups closely followed the national pattern in Sweden, with almost 95% of the nurses, all of the assistant nurses and chiropodists and approximately half of the GPs being female. A majority of the health care professionals had previously attended specific diabetes training programmes, which ranged from single-day courses to extensive 10-week course. About 40% of the respondents were encountering between 5 and 10 diabetes patients per month (range 0–110 patient encounters per month). 3.1. Understanding of diabetes care The analysis of the participants’ responses identified five categories that describe the essential features of the variations in understanding in diabetes care. Within these five categories of understanding, the respondents delineated their unique understanding of diabetes care in terms of the purpose of care, as well as the nature of the relationship between the patient and the health care professional and the kind of knowledge upon which treatment was conceived to be based. Each respondent could embrace more than one understanding and interrelations and overlapping between categories do exist. However, in the results reported below we focus on the respondents’ main understanding of diabetes care. The five categories of understanding are described below though details about a particular category are not included. The quotes are given to illustrate each category. 3.1.1. Understanding A: the professionals treat the patient Understanding A reflects the belief that health care professionals envision treatment and its result in terms of primary medical facts. They inform or give advice to the patient. Recommendations, even in individual lifestyle-related questions, are based solely on the professionals’ view of what is ‘right’ or ‘wrong’—the patient’s individual perspective is largely ignored. The professionals are the active agents when it comes to diagnosis and treatment. The difficulties encountered are often described in terms of ‘‘they do not do as I tell them,’’ and to succeed with care in terms of ‘‘I managed to change the patients’ life style.’’ The patient is described in passive terms, expected to accept the prescribed treatment and follow recommendations without questioning the professional’s advice (i.e. patient compliance): ‘‘advice about diet, life style and diabetes itself. Follow-up in these matters and complimentary treatment with tablets and insulin, follow-up and control according to complications and prevent these, as eye- and kidney-failure. . .’’
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3.1.2. Understanding B: the professionals give information In contrast to understanding A, understanding B emphasises the importance of patients having an awareness and understanding of treatment principles. Patient participation is sometimes described in general terms, as patients being able to ‘‘manage their treatment.’’ Participation is described as an understanding of treatment principles, acknowledging the fact that patients make day-to-day decisions about medical treatment, allowing improvising on lifestyle-related issues. In most cases, however, there is no mention as to how patients develop knowledge of this kind. Some respondents talk of ‘‘making patients understand’’ treatment. The health care staff describe themselves as consultants or advisors to patients, with a responsibility for helping patients develop knowledge that allows them to take responsibility for treatment decisions: ‘‘to reach the patient with ‘the message’ and make the patient change his/her behaviour.’’ However, the health care professionals present only that information and knowledge that they find relevant to the patient: ‘‘to give the patient knowledge about the disease so that he or she might have control over treatment and understand the three-way connection insulin-diet exercise.’’ 3.1.3. Understanding C: the professionals’ focus on relation and organisation Understanding C, unlike A and B, focuses the organisational aspects of the consultation and/or the establishment of a good emotional contact between professional and patient during the consultation. Organisational aspects refer to allocating sufficient time to discuss treatment plans with patients or ensuring that patients are offered continuity of care: ‘‘arrange sufficient time for the patient. Continuity regular visits—check-ups. . .’’ Establishing a good relation between professional and patient is an important goal for some professionals. The quality of communication or the emotional content of the consultation should be ‘good’ or one in which there is a mutual sense of trust: ‘‘good contact with the patient and mutual confidence.’’ The outcomes of the encounter are also described in emotional terms: ‘‘the patient feels well both physically and psychologically.’’ However, nor the meaning of good contact neither feels well is described more in-depth. 3.1.4. Understanding D: the professionals seek the patient’s agreement Unlike A–C, the emphasis in understanding D is on collaboration between health care professionals and patients, i.e. professional–patient concordance in problem identification, diagnosis, and treatment. Collaboration is used in general terms in some cases, but in most cases it denotes co-operation in establishing goals for treatment. The meaning of working jointly is not always clear, however: ‘‘to sit down together with the patient and get a description of life conditions . . . with departure from the description and lab results form the individual diabetes treatment.’’ This view might imply that professionals, with help of
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information from the patient, view their task as a process of determining goals for treatment. In this case, patients take on a passive role, as in understandings A and B. Yet, it could also be interpreted to mean that the central aspect of this understanding is that the patient is active in formulating the goal for treatment: ‘‘dialogue between staff and the patient in which they together decide optimal treatment regimens and goals and quality of life together. . .’’ thus, as in C, the dialogue implies a focus on the relational aspects of the encounter. 3.1.5. Understanding E: the professionals’ focus on the patients’ understanding of the situation The focus in understanding E is on the importance of patients’ understanding of their current situation, the illness, and its treatment. Most respondents described responsibility in rather general terms as patients ‘‘taking responsibility for their own health.’’ Examples of self-care include selfimprovement care as changing eating habits, learning to take insulin injections, and self-control of blood-glucose levels, i.e. what patients do or how they act. The profession-patient role is more or less explicit, and should be in order to ‘‘support the patient or be a support for help to self-help.’’ This means that, unlike A–D, the professionals’ role is described as supporting the patient in seeking knowledge relevant for the unique patient in his or her own context. Accordingly, doing a good job with a successful outcome implies that ‘‘the patient has taken responsibility of the illness and its treatment and thereby accepted the illness with self-controls and feels comfortable in doing it.’’ 3.2. The distribution of participant responses A little more than half (87 of 169) of the participants described the core aspect of diabetes care in terms of medically treating the patient (Table 1). Twenty of the respondents described the patients’ understanding, and thus learning, as the central aspect of the encounter. None of the 20 health care centres included all five understandings of the core aspects of diabetes care among their staff though as many as four variations of understanding were noted in seven of the Table 1 Variations in the understandings (A–E) of diabetes care among 169 Swedish health care professionals Understandings A–E A The professionals treat the patient B The professionals give information C The professionals’ focus on relation and organisation D The professionals seek the patient’s agreement E The professionals’ focus on the patients’ understanding of the situation Incomplete answers Total
Number of Answers answers (%) 87 34 9
51.5 20.1 5.3
10 20
5.9 11.8
9
5.3
169
100
centres. The staff of one centre had only two variations of understanding (A and B), variations that focused on only the professionals’ role in health care.
4. Discussion and conclusions This study shows that there are five qualitatively different understandings of diabetes care among Swedish health care professionals. The study also demonstrated how health care professionals describe their ways of relating to patients with diabetes. Understandings A and B, which focus on the professionals, were the most common understandings reported in our study. Understandings D and E, with focus on agreement with the patient and the patients’ understanding, have the patient, not the professional, in focus, whereas understanding C is something in between A and B, and D and E. Only 30 (17.8%) of 169 professionals tended to focus their understandings on the patient and the patient’s understanding of illness and treatment. This is noteworthy as there is a well know association between the patients’ understanding of their illness and the likelihood of attaining good control of blood glucose [4,30]. The results are consistent with a phenomenographic asthma management study in which only a few of the participants (all GPs) focused on the patient’s entire life situation [27]. Focus on staff and procedures are, according to Benner, the very first step of professional development from novice to expert [31]. The concept of patient-centeredness [32] that has been discussed in recent years [33] is not explicitly reflected in the way most participants in this study expressed their understanding of diabetes care. To treat (understanding A) and inform (understanding B) the patient are important aspects of diabetes care. However, the professional practice will be carried out in different ways depending on whether the professionals see this as their only professional task, or as a part of the larger project of supporting the patients’ learning and reflection. The professionals who were willing to attend the introductory meetings and complete the survey are likely to be individuals who have a greater interest in diabetes care than those who did not attend these meetings. The distribution of the health care professionals’ different understandings of the phenomenon of diabetes care is especially noteworthy because of this possibility. The result raises the issue of how well health care educational programmes prepare students and professionals for dealing with the chronically ill and in supporting the patient’s learning process. Nursing and medical education still largely rely on a prescriptive model based on medical facts [3,34]. Such an approach, we believe, might be counter-productive to students’ learning process and in their application of this approach when encountering patients. Teachers and persons in supervisory positions in health care education have to consider which views of the health care practice they communicate to their students, especially when such beliefs are known to influence the opinions and professional role of those being educated [35].
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According to Dall’Alba, it is essential that the medical education system functions to enrich the students’ understanding of medical practice in a variety of ways [21]. The importance of such influences from teachers and supervisors are equally important in other health care educations. If health care professionals are not encouraged to reflect on their actions as ‘‘teachers,’’ it is likely that they will uncritically use the same methods for teaching as they themselves were taught [27]. Because health care professionals’ understanding of care and of the clinical encounter is crucial to the patients’ learning process, the awareness of the essential variation in the understanding of a particular phenomenon needs to be taken into account when developing and implementing educational programmes for health care professionals [27]. Saleh-Stattin showed that effective educational interventions for patients with diabetes were attained when health care professionals used a reflective model based on patients’ lived experiences of diabetes [5]. The need to explore patients’ understanding of their particular illness and take it as the starting point for a learning process should thus be emphasised [36]. We have in two small-scaled studies performed educational interventions where we took the participating health care professionals’ understanding of diabetes care as the starting point for their learning [22,23]. The processes of observing and reflecting seemed to serve as a means for developing a new understanding of the clinical encounter. Participation in those interventions resulted in discoveries that induced the professionals to question their earlier way of working and to focus attention on the patient’s learning process [22,23]. van den Arend et al. noted that patients of doctors with a special interest in diabetes care were able to achieve better glycaemic control in Type 2 diabetes [2]. In the present study we were not able to analyse patient outcomes, which meant that we could not relate these outcomes to the professionals’ diverse understandings of diabetes care. Performing such a study would be challenging. To avoid cross-over effects, investigations need to focus on whole teams within diabetes care. Who has the greatest impact on patients’ learning and thus the most important effect on outcomes? For instance, the patient might meet a nurse and a doctor in which one focuses on staff while the other focuses on the patient’s learning. Further investigation is needed in this area. Is it methodologically possible within a clinical setting to demonstrate an association between an individual professional’s understanding of different aspects of care and measurable patient outcomes such as blood glucose or HbA1c? 4.1. Limitations Because they typically have different ontological and epistemological assumptions, quality criteria between qualitative and quantitative research differ. The quality standards in qualitative research are perhaps even more challenging
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than in quantitative studies in that rigor, subjectivity, and creativity are actively incorporated in the process [37]. The issue in qualitative work is not to be able to replicate a study, but to express clearly how the results have been reached [38]. The use of co-readers is one feasible approach of assuring quality in qualitative research [39]; using quotes from respondents’ for illustrative purposes is another viable approach [40]. Both approaches were used in the present study. The participating health care professionals represent approximately half of those working in the catchment area, a situation that might have led to a selection bias. However, despite the high dropout rate, we still had 169 participants in the study. A sample size of about 20 participants is considered sufficient to detect existing variations of understanding of the phenomenon under study in phenomenographic studies [27]. Data in phenomenographic research are commonly collected using interview techniques. Because we had a large number of informants, we chose to allow the participants to write down their answers to three structured questions. An interview approach, on the other hand, would probably have given opportunities to explore, in greater depth, themes and ask relevant follow-up questions. Coding procedures in the present study were sometimes difficult because of incomplete participant responses. 4.2. Implications for practice Despite numerous CPD courses only a few professionals recognised that successful treatment of diabetes is contingent upon patients’ understanding of their illness and its treatment, or appreciated that patient education is an integral component in health care. Competence in pedagogy is crucial in caring for the chronically ill. The current results support the notion that the health care professional’s understandings of care and of the patient encounter is important to explore and take as a launching pad for CPD courses. The primary care givers’ understanding of care and of the patient encounter might be developed by newer and better pedagogic efforts that work to improve the quality and efficiency of care for the patients [22,23,41]. The present study raises several issues that need to be addressed in future investigations. For instance, is it possible to link an individual professional’s understanding of different aspects of care to measurable patient outcomes?
Acknowledgements The authors are indebted to the health care professionals who participated in the study and to RNT Lisbet Segerros for data collection. Grants were received from The Swedish Council for Social Research No. 97-0077, the Vardal Foundation No. V2001-205, the Research and Development Unit for the Elderly (ANV), Northwest Stockholm County Council, Sweden and Uppsala University.
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Swedish health care professionals’ diverse understandings of diabetes care Inger Holmstro¨ma,*, Christina Halforda, Urban Rosenqvista,b a
b
Department of Public Health and Caring Sciences, Health Services Research, Uppsala University, Uppsala, Sweden The Research and Development Unit for the Elderly (ANV), Northwest Stockholm County Council, Stockholm, Sweden Received 25 January 2002; received in revised form 15 June 2002; accepted 8 July 2002
Abstract Knowledge of health care professionals’ different understandings of diabetes care is important when preparing such professionals in patient education. For patients to manage illness effectively, the actions of health care professionals are crucial. Patients’ understanding of their condition should be taken as the point of departure when creating a learning situation. The professionals’ understandings of diabetes care were mapped using a survey including 169 primary care doctors, nurses, assistant nurses and chiropodists in Stockholm, Sweden. The responses were analysed using a phenomenographic approach. Five understandings were identified: the professionals treat the patients, the professionals give information, the professionals focus relation and organisation, the professionals seek the patient’s agreement, and the professionals focus the patient’s understanding of the situation. Only 20 (12%) of the 169 professional caregivers focused the patient’s understanding. Professionals need to develop their understandings of health care and the professional–patient interaction in order to support the patients’ learning. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Sweden; Diabetes; Patients’ learning; Patient encounter; Phenomenography
1. Introduction A sizeable number of studies exist today suggesting that patients who have knowledge about and comprehend the nature of their illness and its treatment are more likely to succeed in managing their illness [1,2]. Care of diabetes is an excellent example of the intimate relation between understanding one’s illness and illness management. A patient with diabetes who understands the illness and how it can be treated successfully has a documented higher likelihood of attaining near normal blood-glucose levels than a patient who does not have such knowledge [3–5]. However, keeping the blood-glucose levels as low as possible to reduce complications is a fine balancing act for the patient [6–8]. Sufficient time in the professional–patient encounter, easy access to care, good communication and mutual trust and respect are important factors in achieving this goal [3,9,10]. Effective patient education and intervention are obviously needed but evidence suggests that they have been difficult to achieve [11,12]. To be efficacious the professional–patient encounter in diabetes care needs to focus on the individual’s * Corresponding author. Tel.: þ46-18-611-3569; fax: þ46-18-50-6404. E-mail address: [email protected] (I. Holmstro¨m).
experiences and adapt the learning pace to the patient [5,13,14]. However, diabetes care has often been ‘‘checklist driven’’ via clinical guidelines and has focused on technical advice [3]. Furthermore, patients have raised complaints against such standardised textbook approaches [3,10]. Traditional patient education has had little or no effect on patients’ understanding of their condition and thus in the treatment of diabetes [3,5,15,16]. Few studies have demonstrated a clear link between continuous professional development (CPD) courses for health care professionals and clinical outcomes for patients [12,17]. Consequently, a need exists for a new and qualitatively different competence development for professionals working in diabetes care. Contemporary theories of competence and its development have shown that competence is the result of how people understand their work [18]. A beginning step in the process of competence development within this field would be to show and establish the understandings, or conceptions, that health care professionals bring with them in diabetes care and patient education. The purpose of this study then was to identify, in one catchment area in Stockholm, Sweden, the various understandings health care professionals have of the core aspects of diabetes care and how such understandings are disbursed. The baseline results are part of a larger study
0738-3991/$ – see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 7 3 8 - 3 9 9 1 ( 0 2 ) 0 0 2 1 2 - 4
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designed to develop communication skills of health care professionals working in the general practices of the catchment area in question. The pedagogic framework for this development is based on phenomenographic theories of learning [19,20].
2. Method 2.1. Mapping health care professionals’ understanding of diabetes care In 1996, all (23) health care centres (HCCs) in one catchment area in Stockholm, Sweden were invited to participate in a programme intended to provide information about diabetes and diabetes care. Of the 23 invited centres, 20 accepted (one centre rejected the invitation and two did not reply) to take part in the study. The participants were general practitioners (GPs), nurses, assistant nurses and chiropodists. We decided to study the group of professionals as a whole, as they were working in teams and all had substantial influence over diabetes care carried out at the various health centres. The health care professionals from the 20 centres were invited to attend specially arranged information meetings about the project. In these meetings the participants were asked to write down their responses to the following questions: What do you think is the central feature(s) of diabetes care? Give a concrete example. What do you find difficult to deal with regarding diabetes care? Give a concrete example. When do you think you have been successful regarding diabetes care? Give a concrete example. The first two questions are derived from Dall’Alba [21] and all three have been used in our previous research [22,23]. Through seeking descriptions of concrete situations, the focus was maintained on the professionals’ work-related experiences and not on how the professionals would like things to be or thought they ought to be [21]. In addition to their responses to these three questions, the participants were asked to provide their name, profession, diabetes-related education and the average number of appointments with patients with diabetes that they encounter each month. Most patients with diabetes treated at the health centres have Type 2 diabetes. 2.2. Phenomenographic analysis Qualitative methods are increasingly used within health care research [20,24] because they allow the investigation of research questions of a qualitative character (e.g. emphasis is given to human thoughts and experiences). Data for qualitative research often consist of interview material, but could also consist of written material, participant observation or video recordings [24,25]. The choice of a particular qualitative method for data collection and analysis largely
depends on the research question posed and the theoretical framework adopted. The theoretical framework for this project was phenomenographic theories of learning and competence development. Hence, a phenomenographic analysis of the participants’ written answers was performed. Phenomenography is a qualitative research approach in which the main goal is to describe the essential variation in the understanding or ways of experiencing a given phenomenon [26]. Ways of understanding or experiencing is also referred to as ‘‘conceptions’’ or ‘‘views.’’ The phenomenographic approach has been developed over the past 20 years and has been used extensively to investigate learning and teaching. More recently, however, the approach has been used in health care research [21,27]. In this study we wish to identify different understandings that health care professionals have of diabetes care and relate these to each other in an outcome space, representing the logical relations between the experiences health care professionals have in encountering patients with diabetes [23]. The various understandings, which are dynamic and context specific, are judged to be fundamental to the way in which we act, understand, form our beliefs and experience our world [20]. The present analysis was performed by one of the authors (CH) with the principal author (IH) as co-reader. When opinions differed between authors with respect to classification of responses into categories and assigning labels to categories, we returned to the text and consulted the third author (UR) until agreement was reached on categorisation. Each category should be labelled as closely to the data as possible [28]. In accordance with Sandberg, the analysis was carried out in five steps [29]. Step 1: To master a general knowledge of the material the texts were read several times. No predetermined categories or theories were used at this stage of the analysis. Step 2: In this step the what aspects (i.e. the content and goal of diabetes care and the perspective of the health care professionals) were examined. The professionals described the different aspects of diabetes care (e.g. patients’ blood-glucose). Step 3: In this third step, the how aspect (i.e. the process of attaining the primary goal of diabetes care) was studied. The respondents’ responses were then sorted into themes; for example, one theme was measures: the professionals’ role in the treatment explained as medical knowledge, to medically treat, control, prevent, etc. Step 4: In this phase, each survey was again studied as a whole unit. The ‘what’ and ‘how’ aspects of the respondents’ responses were examined iteratively. Using this technique, several variations of understanding emerged. Step 5: In the final step the variations of understanding were related to each other by identifying and describing the logical relations between them. 3. Results Twenty of the 23 invited centres participated in the survey. Approximately 50% of the health care professionals
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employed at the health care centres in the catchment area in Stockholm took part in the introductory meetings. Roughly, 90% (or 169) of those persons who participated responded to the written survey items described above. Of the 169 respondents, 65 were doctors, 63 were nurses and 29 were assistant nurses or chiropodists; the occupation(s) of the remaining 12 respondents was unspecified. Gender distribution within the occupational groups closely followed the national pattern in Sweden, with almost 95% of the nurses, all of the assistant nurses and chiropodists and approximately half of the GPs being female. A majority of the health care professionals had previously attended specific diabetes training programmes, which ranged from single-day courses to extensive 10-week course. About 40% of the respondents were encountering between 5 and 10 diabetes patients per month (range 0–110 patient encounters per month). 3.1. Understanding of diabetes care The analysis of the participants’ responses identified five categories that describe the essential features of the variations in understanding in diabetes care. Within these five categories of understanding, the respondents delineated their unique understanding of diabetes care in terms of the purpose of care, as well as the nature of the relationship between the patient and the health care professional and the kind of knowledge upon which treatment was conceived to be based. Each respondent could embrace more than one understanding and interrelations and overlapping between categories do exist. However, in the results reported below we focus on the respondents’ main understanding of diabetes care. The five categories of understanding are described below though details about a particular category are not included. The quotes are given to illustrate each category. 3.1.1. Understanding A: the professionals treat the patient Understanding A reflects the belief that health care professionals envision treatment and its result in terms of primary medical facts. They inform or give advice to the patient. Recommendations, even in individual lifestyle-related questions, are based solely on the professionals’ view of what is ‘right’ or ‘wrong’—the patient’s individual perspective is largely ignored. The professionals are the active agents when it comes to diagnosis and treatment. The difficulties encountered are often described in terms of ‘‘they do not do as I tell them,’’ and to succeed with care in terms of ‘‘I managed to change the patients’ life style.’’ The patient is described in passive terms, expected to accept the prescribed treatment and follow recommendations without questioning the professional’s advice (i.e. patient compliance): ‘‘advice about diet, life style and diabetes itself. Follow-up in these matters and complimentary treatment with tablets and insulin, follow-up and control according to complications and prevent these, as eye- and kidney-failure. . .’’
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3.1.2. Understanding B: the professionals give information In contrast to understanding A, understanding B emphasises the importance of patients having an awareness and understanding of treatment principles. Patient participation is sometimes described in general terms, as patients being able to ‘‘manage their treatment.’’ Participation is described as an understanding of treatment principles, acknowledging the fact that patients make day-to-day decisions about medical treatment, allowing improvising on lifestyle-related issues. In most cases, however, there is no mention as to how patients develop knowledge of this kind. Some respondents talk of ‘‘making patients understand’’ treatment. The health care staff describe themselves as consultants or advisors to patients, with a responsibility for helping patients develop knowledge that allows them to take responsibility for treatment decisions: ‘‘to reach the patient with ‘the message’ and make the patient change his/her behaviour.’’ However, the health care professionals present only that information and knowledge that they find relevant to the patient: ‘‘to give the patient knowledge about the disease so that he or she might have control over treatment and understand the three-way connection insulin-diet exercise.’’ 3.1.3. Understanding C: the professionals’ focus on relation and organisation Understanding C, unlike A and B, focuses the organisational aspects of the consultation and/or the establishment of a good emotional contact between professional and patient during the consultation. Organisational aspects refer to allocating sufficient time to discuss treatment plans with patients or ensuring that patients are offered continuity of care: ‘‘arrange sufficient time for the patient. Continuity regular visits—check-ups. . .’’ Establishing a good relation between professional and patient is an important goal for some professionals. The quality of communication or the emotional content of the consultation should be ‘good’ or one in which there is a mutual sense of trust: ‘‘good contact with the patient and mutual confidence.’’ The outcomes of the encounter are also described in emotional terms: ‘‘the patient feels well both physically and psychologically.’’ However, nor the meaning of good contact neither feels well is described more in-depth. 3.1.4. Understanding D: the professionals seek the patient’s agreement Unlike A–C, the emphasis in understanding D is on collaboration between health care professionals and patients, i.e. professional–patient concordance in problem identification, diagnosis, and treatment. Collaboration is used in general terms in some cases, but in most cases it denotes co-operation in establishing goals for treatment. The meaning of working jointly is not always clear, however: ‘‘to sit down together with the patient and get a description of life conditions . . . with departure from the description and lab results form the individual diabetes treatment.’’ This view might imply that professionals, with help of
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information from the patient, view their task as a process of determining goals for treatment. In this case, patients take on a passive role, as in understandings A and B. Yet, it could also be interpreted to mean that the central aspect of this understanding is that the patient is active in formulating the goal for treatment: ‘‘dialogue between staff and the patient in which they together decide optimal treatment regimens and goals and quality of life together. . .’’ thus, as in C, the dialogue implies a focus on the relational aspects of the encounter. 3.1.5. Understanding E: the professionals’ focus on the patients’ understanding of the situation The focus in understanding E is on the importance of patients’ understanding of their current situation, the illness, and its treatment. Most respondents described responsibility in rather general terms as patients ‘‘taking responsibility for their own health.’’ Examples of self-care include selfimprovement care as changing eating habits, learning to take insulin injections, and self-control of blood-glucose levels, i.e. what patients do or how they act. The profession-patient role is more or less explicit, and should be in order to ‘‘support the patient or be a support for help to self-help.’’ This means that, unlike A–D, the professionals’ role is described as supporting the patient in seeking knowledge relevant for the unique patient in his or her own context. Accordingly, doing a good job with a successful outcome implies that ‘‘the patient has taken responsibility of the illness and its treatment and thereby accepted the illness with self-controls and feels comfortable in doing it.’’ 3.2. The distribution of participant responses A little more than half (87 of 169) of the participants described the core aspect of diabetes care in terms of medically treating the patient (Table 1). Twenty of the respondents described the patients’ understanding, and thus learning, as the central aspect of the encounter. None of the 20 health care centres included all five understandings of the core aspects of diabetes care among their staff though as many as four variations of understanding were noted in seven of the Table 1 Variations in the understandings (A–E) of diabetes care among 169 Swedish health care professionals Understandings A–E A The professionals treat the patient B The professionals give information C The professionals’ focus on relation and organisation D The professionals seek the patient’s agreement E The professionals’ focus on the patients’ understanding of the situation Incomplete answers Total
Number of Answers answers (%) 87 34 9
51.5 20.1 5.3
10 20
5.9 11.8
9
5.3
169
100
centres. The staff of one centre had only two variations of understanding (A and B), variations that focused on only the professionals’ role in health care.
4. Discussion and conclusions This study shows that there are five qualitatively different understandings of diabetes care among Swedish health care professionals. The study also demonstrated how health care professionals describe their ways of relating to patients with diabetes. Understandings A and B, which focus on the professionals, were the most common understandings reported in our study. Understandings D and E, with focus on agreement with the patient and the patients’ understanding, have the patient, not the professional, in focus, whereas understanding C is something in between A and B, and D and E. Only 30 (17.8%) of 169 professionals tended to focus their understandings on the patient and the patient’s understanding of illness and treatment. This is noteworthy as there is a well know association between the patients’ understanding of their illness and the likelihood of attaining good control of blood glucose [4,30]. The results are consistent with a phenomenographic asthma management study in which only a few of the participants (all GPs) focused on the patient’s entire life situation [27]. Focus on staff and procedures are, according to Benner, the very first step of professional development from novice to expert [31]. The concept of patient-centeredness [32] that has been discussed in recent years [33] is not explicitly reflected in the way most participants in this study expressed their understanding of diabetes care. To treat (understanding A) and inform (understanding B) the patient are important aspects of diabetes care. However, the professional practice will be carried out in different ways depending on whether the professionals see this as their only professional task, or as a part of the larger project of supporting the patients’ learning and reflection. The professionals who were willing to attend the introductory meetings and complete the survey are likely to be individuals who have a greater interest in diabetes care than those who did not attend these meetings. The distribution of the health care professionals’ different understandings of the phenomenon of diabetes care is especially noteworthy because of this possibility. The result raises the issue of how well health care educational programmes prepare students and professionals for dealing with the chronically ill and in supporting the patient’s learning process. Nursing and medical education still largely rely on a prescriptive model based on medical facts [3,34]. Such an approach, we believe, might be counter-productive to students’ learning process and in their application of this approach when encountering patients. Teachers and persons in supervisory positions in health care education have to consider which views of the health care practice they communicate to their students, especially when such beliefs are known to influence the opinions and professional role of those being educated [35].
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According to Dall’Alba, it is essential that the medical education system functions to enrich the students’ understanding of medical practice in a variety of ways [21]. The importance of such influences from teachers and supervisors are equally important in other health care educations. If health care professionals are not encouraged to reflect on their actions as ‘‘teachers,’’ it is likely that they will uncritically use the same methods for teaching as they themselves were taught [27]. Because health care professionals’ understanding of care and of the clinical encounter is crucial to the patients’ learning process, the awareness of the essential variation in the understanding of a particular phenomenon needs to be taken into account when developing and implementing educational programmes for health care professionals [27]. Saleh-Stattin showed that effective educational interventions for patients with diabetes were attained when health care professionals used a reflective model based on patients’ lived experiences of diabetes [5]. The need to explore patients’ understanding of their particular illness and take it as the starting point for a learning process should thus be emphasised [36]. We have in two small-scaled studies performed educational interventions where we took the participating health care professionals’ understanding of diabetes care as the starting point for their learning [22,23]. The processes of observing and reflecting seemed to serve as a means for developing a new understanding of the clinical encounter. Participation in those interventions resulted in discoveries that induced the professionals to question their earlier way of working and to focus attention on the patient’s learning process [22,23]. van den Arend et al. noted that patients of doctors with a special interest in diabetes care were able to achieve better glycaemic control in Type 2 diabetes [2]. In the present study we were not able to analyse patient outcomes, which meant that we could not relate these outcomes to the professionals’ diverse understandings of diabetes care. Performing such a study would be challenging. To avoid cross-over effects, investigations need to focus on whole teams within diabetes care. Who has the greatest impact on patients’ learning and thus the most important effect on outcomes? For instance, the patient might meet a nurse and a doctor in which one focuses on staff while the other focuses on the patient’s learning. Further investigation is needed in this area. Is it methodologically possible within a clinical setting to demonstrate an association between an individual professional’s understanding of different aspects of care and measurable patient outcomes such as blood glucose or HbA1c? 4.1. Limitations Because they typically have different ontological and epistemological assumptions, quality criteria between qualitative and quantitative research differ. The quality standards in qualitative research are perhaps even more challenging
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than in quantitative studies in that rigor, subjectivity, and creativity are actively incorporated in the process [37]. The issue in qualitative work is not to be able to replicate a study, but to express clearly how the results have been reached [38]. The use of co-readers is one feasible approach of assuring quality in qualitative research [39]; using quotes from respondents’ for illustrative purposes is another viable approach [40]. Both approaches were used in the present study. The participating health care professionals represent approximately half of those working in the catchment area, a situation that might have led to a selection bias. However, despite the high dropout rate, we still had 169 participants in the study. A sample size of about 20 participants is considered sufficient to detect existing variations of understanding of the phenomenon under study in phenomenographic studies [27]. Data in phenomenographic research are commonly collected using interview techniques. Because we had a large number of informants, we chose to allow the participants to write down their answers to three structured questions. An interview approach, on the other hand, would probably have given opportunities to explore, in greater depth, themes and ask relevant follow-up questions. Coding procedures in the present study were sometimes difficult because of incomplete participant responses. 4.2. Implications for practice Despite numerous CPD courses only a few professionals recognised that successful treatment of diabetes is contingent upon patients’ understanding of their illness and its treatment, or appreciated that patient education is an integral component in health care. Competence in pedagogy is crucial in caring for the chronically ill. The current results support the notion that the health care professional’s understandings of care and of the patient encounter is important to explore and take as a launching pad for CPD courses. The primary care givers’ understanding of care and of the patient encounter might be developed by newer and better pedagogic efforts that work to improve the quality and efficiency of care for the patients [22,23,41]. The present study raises several issues that need to be addressed in future investigations. For instance, is it possible to link an individual professional’s understanding of different aspects of care to measurable patient outcomes?
Acknowledgements The authors are indebted to the health care professionals who participated in the study and to RNT Lisbet Segerros for data collection. Grants were received from The Swedish Council for Social Research No. 97-0077, the Vardal Foundation No. V2001-205, the Research and Development Unit for the Elderly (ANV), Northwest Stockholm County Council, Sweden and Uppsala University.
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