Trends in the primary healthcare nursing workforce in managing diabetes from two sample surveys in 2006–2008 and 2016 in Auckland, New Zealand
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The changing role of the primary care nurse has been largely driven by increasing numbers of people with chronic care conditions and escalating costs of secondary healthcare.[[1]] The latter has forced many countries to introduce health reforms to increase capacity in primary care, largely through developing and increasing numbers of primary or family care nurses, and shifting tasks from general practitioners (GPs) to nurses.[[2]] In New Zealand, practice nursing originated in 1970 following a government subsidy scheme to partially fund salaries to incentivise GPs to provide primary care in rural areas, extended to urban areas in 1974 by popular demand.[[3,4]] Based on the primary care model in the United Kingdom, practice nurses (PNs) were employed by GPs but centrally funded[[5]] to carry out administrative duties and perform tasks such as immunising children. A key difference in New Zealand is that general practices are private enterprises and charge a fee-for-service.[[6]]
Several health reforms, which usually involved the centralisation or decentralisation of funding, have occurred in New Zealand since the adoption of a free public healthcare system in 1938[[5]] to improve equity and access of primary care for all New Zealanders.[[5,7]] The first major reform in 1983 included a population-based funding formula and the establishment of 14 regional Area Health Boards.[[5]] In 1993, these were reduced to four Regional Health Authorities and then reconstructed into 23 regional Crown Health Enterprises with a separate public health agency.[[8]] A major health reform in 2001 encouraged general practices to join a not-for-profit Primary Health Organisation (PHO) to initiate a new model of primary healthcare (PHC), improve access for all and reduce health inequities.[[9]] Funding was provided for PNs to undertake education and training to develop expertise and reimburse general practices for nurse consultations.[[5,9]] This funding was expected to encourage more autonomy, extend nursing roles (including prescribing for nurse specialists and nurse practitioners), increase capacity in managing people with long term conditions and reduce the burden on secondary healthcare services.[[9]]
A recent reform in 2022 aimed to recentralise administration under Te Whatu Ora – Health New Zealand and work in partnership with the newly established Te Aka Whai Ora – Māori Health Authority to re-establish a people-centred, equitable, accessible and cohesive national healthcare system.[[10,11]] A public health agency and locality networks have been formed to shape policy, oversee the provision of PHC, reduce inequities in funding and ensure that the health needs of Māori communities are met.[[11]] Improvements are expected in utilising local community health services and digital technology with electronic patient record sharing between all healthcare providers and patients to support self-management and better serve communities by providing more flexibility and increasing consulting hours.[[11]]
The aims of the two surveys were to examine trends between 2006–2008 and 2016 by comparing numbers of PHC nurses, their education and knowledge of diabetes, assessments and care provided during diabetes consultations and how valued nurses felt in their management of diabetes patients.
Methods
Two representative cross-sectional surveys were carried out in 2006–2008 and 2016 among PHC nurses in Auckland to document demographic, educational and work-related characteristics, and to describe their role in the community management of diabetes.
View Figures 1–4, Table 1.
Participants
Lists of all practice, district and specialist nurses who provide general practice and community care were constructed to ensure that both surveys were representative.[[14,15]] Of the total nurses, 26% (n=287) and 24% (n=336) were randomly selected and agreed to participate in each survey, achieving response rates of 86% and 73%, respectively (Figure 1).
Data collection
Participants completed a self-administered questionnaire providing biographical information and general practice or clinic details about diabetes patients registered and their diabetes management processes. All nurses also completed a telephone survey that assessed their knowledge of diabetes, best management practices and their provision of diabetes care. At the end of each telephone interview, nurses provided the number of diabetes patients they had consulted on a randomly selected day they had worked over the past week, and information was ascertained about diabetes patients consulted. Information was provided for 86% of the 308 patients consulted in 2006–2008 and 166 (37%) randomly selected from the 452 patients consulted in 2016. The lower numbers and proportion of patients sampled in the latter survey was due to the large numbers of diabetes patients consulted and time constraints for participants. Participants responded to almost all the questions.
Variables and outcome measures
Between-survey comparisons included: 1) the biographical characteristics of the PHC nursing workforce, 2) diabetes knowledge held by nurses, 3) adherence to best diabetes management practices, 4) patient demographic characteristics, and 5) diabetes management and care provided during nurse consultations.
Ethical considerations
Appropriate ethics approvals were granted for each survey by the Northern Regional Ethics Committee (NTX/05/10/128) and The University of Auckland Human Participants Ethics Committee (014713) in 2006–2008 for 2016, respectively. All participants consented before the telephone interview. All information related to patient consultations was collected anonymously. Adherence to the STROBE guidelines has been followed in conducting the study and reporting findings.
Survey questionnaire
Both questionnaires were adapted and extended from a survey administered to PNs in South Auckland in 1999.[[16]] New demographic questions were modelled on the five yearly New Zealand Census questionnaires. Questionnaires are included in Appendices 1 and 2. All questionnaires were piloted individually among a small number of nurses from each nurse group for face and content validity, and to ensure questions met the aims of the studies. A fixed response was required for the majority of questions that were either numerical, dichotomous, multiple choice or Likert scores, and a small number were short or open-ended. All responses to knowledge questions that differed from the pre-determined correct responses and open-ended responses were recorded in writing and systematically coded prior to analyses to decrease potential random measurement error.
Data analysis
Between-survey comparisons were made by combining all three groups of nurses sampled (practice, district and specialists) using weighted proportions to ensure representation for each group. Results mostly reflect PNs, who accounted for 75% and 88% of the total weighted proportions for each survey. All statistical analyses were carried out using SAS (SAS Institute, Cary, NC, 2013) and SUDAAN (version 11.0, Research Triangle Institute, 2012) and have been previously described.[[17]] For weighted survey comparisons and respective patients consulted, univariate analyses PROC FREQ and PROC UNIVARIATE were used to generate frequencies and p-values from the Wald Chi-Square value. PROC CROSSTAB and PROC REGRESS in SUDAAN were utilised to compare patient variables and management practices between surveys and to correct for clustering effects for nurses who consulted more than one patient.
Results
Trends in numbers and characteristics of primary care nurses
Over time there has been a significant increase in numbers of PNs, while the proportions of district and specialist nurses have approximately halved (Table 1). There was a significant increase in younger nurses aged <40 years, and although the workforce continues to be mostly female (97%), there was a significant increase in male district nurses (4% to 13%) and a small increase in male PNs (1% to 3%)—subgroup data not shown. In 2016, significantly fewer nurses were NZ European, more were Asian and similar proportions were Māori and Pacific compared with nurses in 2006–2008 (Table 1).
Practice details and management of diabetes
Significantly more nurses worked part-time in 2016 (73%) compared with 67% in 2006–2008, and 80% had attended five or more hours of specific diabetes education in the previous five years. This had not significantly changed between surveys (Table 1). Significantly more nurses in 2016 compared with 2006–2008 worked in general practice or Accident and Medical clinics (91% and 83%), in larger practices based on the number of physicians (47% and 36%), had their own room or office for administrative work (62% and 37%) and were able to email patients (80% and 45%). However, fewer nurses consulted patients at home in 2016 (9%) compared with 17% in 2006–2008 (Table 1).
Education and knowledge of diabetes
Significantly more PHC nurses in 2016 undertook post-graduation education (62%) and referred to guidelines on the management of type 2 diabetes (74%) compared with 49% and 50%, respectively, in 2006–2008. Most nurses in 2016 reported having the knowledge to discuss laboratory results (97%) and advise patients on making lifestyle changes (81%) compared with 92% and 70% of nurses, respectively, in 2006–2008. In contrast, only 37% of nurses felt sufficiently knowledgeable to offer advice to patients about their medications in 2016, although this was significantly more than the 29% of nurses surveyed in 2006–2008.
Slightly less nurses in 2016 (87%) rated their knowledge of best practice as at least “good” compared with 92% of nurses in 2006–2008 (Table 1). More nurses knew that type 1 diabetes was an autoimmune condition (23%) and understood the underlying pathology of type 2 diabetes (42%) in 2016 compared with 13% and 28% of nurses, respectively, in 2006–2008 (Figure 2).
Trends in management and care provided
Significantly more nurses addressed serum glucose levels, medications, foot care and smoking cessation and knew of patient’s microalbuminuria and retinal screening status in 2016 than nurses in 2006–2008 (Figure 3). However, the proportion of nurses who provided nutritional and physical activity advice and education remained unchanged—data not shown. Significantly more nurses in 2016 routinely consulted patients, conducted diabetes annual review (DAR) independently of doctors (48% versus 27%) and reported increased support in reviewing patients with diabetes compared with nurses in 2006–2008 (Figure 4).
Nurses feeling valued and supported
Despite the improvements in knowledge and management practices in 2016 compared with 2006–2008, fewer nurses felt valued, felt their suggestions were taken seriously or felt supported in their overall diabetes management activities (Figure 4).
Discussion
Numbers of PNs have significantly increased between surveys (Figure 1), which mirrors the national increase from 5,600 (12%) of the total nursing workforce in 2010,[[18]] to 7,713 (14%) in 2019.[[19]] The PHC nursing workforce continues to be over-represented by women (97%). Although there was a small (1%) increase in male nurses between surveys, it continues to lag behind the 8% of male registered nurses in New Zealand.[[19]] PNs were younger in 2016 and 32% were aged <40 years, compared with 20% in 2007–2008. In contrast, numbers of specialist nurses decreased between surveys, and 58% were aged over 50 years in 2016 compared with 43% in 2006–2008, reflecting a lack of recruitment. In the latter survey, more nurses had gained diabetes experience in primary care than within a hospital setting,[[15]] consistent with increasing numbers and size of general practices.[[15,20]]
Nurse education and knowledge of diabetes
Significantly more PHC nurses in 2016 had undertaken post-graduate education, attended specific diabetes educational sessions or conferences[[15]] and were more knowledge about the underlying pathology of type 1 and 2 diabetes compared with nurses in 2006–2008. Despite this, knowledge of type 1 diabetes among nurses remains low in New Zealand and internationally.[[21]] Clinically, more nurses were aware of best management guidelines for people with type 2 diabetes. Nurses who had attended specific diabetes education in the past 5 years were more likely to report feeling sufficiently knowledgeable to advise patients on their test results, required lifestyle changes and medications,[[22]] and educate patients in primary care, which is associated with improved outcomes.[[23]]
Although nurses had increased their knowledge over time of diabetes-related complications, including stroke (which is a proxy for in-depth diabetes knowledge) and major risk factors, less than 20% of nurses could state that hypertension, smoking or dyslipidaemia were also major risk factors for diabetes-related complications.[[22]] Similar gaps in nurses’ knowledge were highlighted in a recent review of 28 studies reporting that most nurses knew retinopathy was a microvascular complication, but very few knew about peripheral neuropathy and its associated clinical implications.[[24]] Knowledge gaps on medications remain, as only 37% of nurses reported having sufficient knowledge to advise patients about their medications, mimicking a report from the United Kingdom where PNs reported lacking knowledge required for initiating insulin.[[25]]
Practice details and management
PHC nurses increasingly work more autonomously. Most work in larger general practices or clinics, and almost twice the proportion of nurses in 2016 compared with 2006–2008 had their own offices for administrative work.[[15]] Significantly more nurses in 2016 routinely consulted patients, conducted DAR independently of doctors (following trends in the UK[[26]]), manage patient’s serum glucose, conduct cardiovascular assessments and foot examinations (indicating reduced barriers in providing care[[27]]), educate patients on reducing their risk of diabetes-related complications and follow-up on screening, referrals and test results.[[28]] These trends indicate increasing capacity and autonomy in managing patients with chronic conditions and are consistent with global trends,[[2]] although the increased support only extended to conducting DAR, not general diabetes management, and may reflect resistance to changing traditional models of primary care identified in a Canadian survey.[[29]] The proportion of nurses who provided nutritional and physical activity education remained the same over time, despite a significant increase in patients’ mean BMIs,[[17]] reflecting the many challenges and barriers engaging patients about lifestyle changes in an obesogenic environment.
Clinical implications
Despite nurses consulting more diabetes patients in 2016,[[17]] gaining knowledge of diabetes and best management practices, fewer nurses reported feeling valued or supported or that their suggestions were taken seriously in their overall diabetes management activities. Fewer nurses reported having support from dietitians or diabetes specialist nurses compared with nurses in 2006–2008, although more were supported by podiatrists and chronic care management nurses.[[30]] This contrasted with nurses who conducted DAR, where most felt supported in 2016,[[30]] and follows global trends where specific management tasks have shifted from GPs to nurses.[[2,26]] Nurses in 2016 reported feeling less valued than nurses in 2006–2008, which may reflect the younger cohort of nurses or structural and organisational changes. Salary gaps continue to widen between practice and hospital-based nurses,[[31]] and structural and organisational barriers reduce opportunities for career development and leadership roles in primary care.[[32,33]]
International context
Increasing the development and capacity of primary care nurses in New Zealand reflects global trends in offering more tangible career opportunities to further attract and nurture talented nurses.[[34]] Over the past 15 years, primary care nurses have become better educated, skilled, more confident and achieved similar or better health outcomes for patients with chronic conditions as GPs in a review of 18 randomised controlled trials.[[1]] Patients have also reported increased satisfaction after consulting a nurse compared with a GP, which could be attributed to longer consultations and more frequent follow-up care.[[1]] An Australian PN-led intervention achieved similar health outcomes and increased satisfaction for patients with type 2 diabetes, hypertension and ischemic heart disease as GPs, and was advantageous for both groups.[[35]] More recently, an Australian in-depth interview-based qualitative study of multidisciplinary primary care providers, which included PNs, reported improved communication and collaboration across primary and secondary care, improved patient self-care practices among people with chronic conditions and reduced hospital admissions.[[36,37]] An integrated model of care between secondary and primary care for diabetes patients with complex needs reduced the burden on secondary care services.[[38]] Similarly, in Estonia, health reforms designed to expand family (primary) care included a four-fold increase in primary care nurses and led to increased nurse consultations, patient access and attendance and reduced hospital admissions.[[39]] A review of 213 PHC teams, which included nurses in Italy, reported improved communication within and across health professionals that could potentially improve outcomes for people with type 2 diabetes.[[40]] In North America, advanced PNs educated to a Masters level, with collective prescribing rights, were increasingly and independently managing elderly patients, and able to meet their varied health needs in a range of rural and urban community settings.[[41]]
Despite progress in increasing capacity among primary care nurses in some countries, other developed countries lag behind. An evaluation of a shared model of primary care between PNs and GPs in the Netherlands highlighted the need for increased training and support for PNs to transition from a largely protocol-driven model of care to sharing management and decision making with GPs.[[42]] Nurses found it particularly difficult to integrate decision making, coaching and goal setting with patients with chronic conditions into the traditional protocol-based care model.[[42]] Similarly, in the United Kingdom, PNs reported needing increased support when incorporating psychological interventions to engage patients with diabetes to improve self-management behaviours.[[43]]
Strengths and limitations
A major strength of the surveys was the random selection of nurses from complete lists of all nurse groups who provide diabetes care in the community and the high response rates. Limitations included the cross-sectional design of the surveys that limited examining trends in qualifications, knowledge, experience, autonomy and career pathway progression from the same cohort of nurses. It is possible a proportion of nurses were in both surveys, although responses were analysed independently. Nurses may have over-reported post-graduate qualifications, experience and their perceived knowledge and confidence in educating patients on key practice points. It is possible that type 1 errors may have occurred due to the number of comparisons made between surveys. However, knowledge was tested during the telephone interview and correlated with self-reported levels.[[22]] Demographic findings correlated with national nursing survey results[[19]] and those reported from international surveys.[[24,44]]
Conclusion
PNs in New Zealand have significantly increased their post-graduate qualifications, knowledge of diabetes, independence and capacity in the community management of people with diabetes. Designated diabetes nurses are increasingly incorporated into the typical general practice model of care. This follows the global trend in shifting the management of people with chronic care conditions from GPs to primary care nurses, increasing the capacity of the community-based nursing workforce, and reducing the burden and escalating costs associated with secondary healthcare provision. Despite increasing diabetes knowledge and autonomy, too few nurses had received sufficient diabetes education. Nurses lacked knowledge about type 1 and 2 diabetes and best medication management practices and felt less valued and supported in their overall management of diabetes. These findings, and those from international reports, indicate that undergraduate and post-graduate educational institutions need to expand their curriculum on diabetes and its management. Extending government funding for post-graduate PHC nursing education and support for nurses to undertake diabetes education will help mitigate gaps in knowledge and practice.
View Appendices.
Summary
Abstract
Aim
To examine trends in the primary healthcare nursing workforce and their community management of diabetes.
Method
Two representative surveys were carried out in 2006–2008 and 2016 among all primary healthcare nurses in Auckland. Nurses were randomly selected, and 26% (n=287) and 24% (n=336) completed a self-administered questionnaire and telephone survey. Biographical information, knowledge of diabetes, how valued nurses felt and diabetes care for patients was provided.
Results
Between surveys, numbers of practice nurses have significantly increased, and specialist nurse numbers decreased, while district nurse numbers remained the same. In 2016, practice nurses were younger, more ethnically diverse, more likely to undertake education and had increased knowledge of diabetes and diabetes-related complications (including stroke) compared to nurses in 2006–2008. More nurses consulted patients, conducted foot examinations, addressed serum glucose, medication management, tobacco use and followed up care independently of doctors. In 2016, only 37% of nurses felt sufficiently knowledgeable to discuss medications with patients, <20% could state that hypertension, smoking and dyslipidaemia were major risk factors for complications, and less nurses felt valued.
Conclusion
Practice nurses have increased their capacity in diabetes management following global trends and require more support in meeting the complex healthcare needs of people with diabetes.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Trends in the primary healthcare nursing workforce in managing diabetes from two sample surveys in 2006–2008 and 2016 in Auckland, New Zealand
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The changing role of the primary care nurse has been largely driven by increasing numbers of people with chronic care conditions and escalating costs of secondary healthcare.[[1]] The latter has forced many countries to introduce health reforms to increase capacity in primary care, largely through developing and increasing numbers of primary or family care nurses, and shifting tasks from general practitioners (GPs) to nurses.[[2]] In New Zealand, practice nursing originated in 1970 following a government subsidy scheme to partially fund salaries to incentivise GPs to provide primary care in rural areas, extended to urban areas in 1974 by popular demand.[[3,4]] Based on the primary care model in the United Kingdom, practice nurses (PNs) were employed by GPs but centrally funded[[5]] to carry out administrative duties and perform tasks such as immunising children. A key difference in New Zealand is that general practices are private enterprises and charge a fee-for-service.[[6]]
Several health reforms, which usually involved the centralisation or decentralisation of funding, have occurred in New Zealand since the adoption of a free public healthcare system in 1938[[5]] to improve equity and access of primary care for all New Zealanders.[[5,7]] The first major reform in 1983 included a population-based funding formula and the establishment of 14 regional Area Health Boards.[[5]] In 1993, these were reduced to four Regional Health Authorities and then reconstructed into 23 regional Crown Health Enterprises with a separate public health agency.[[8]] A major health reform in 2001 encouraged general practices to join a not-for-profit Primary Health Organisation (PHO) to initiate a new model of primary healthcare (PHC), improve access for all and reduce health inequities.[[9]] Funding was provided for PNs to undertake education and training to develop expertise and reimburse general practices for nurse consultations.[[5,9]] This funding was expected to encourage more autonomy, extend nursing roles (including prescribing for nurse specialists and nurse practitioners), increase capacity in managing people with long term conditions and reduce the burden on secondary healthcare services.[[9]]
A recent reform in 2022 aimed to recentralise administration under Te Whatu Ora – Health New Zealand and work in partnership with the newly established Te Aka Whai Ora – Māori Health Authority to re-establish a people-centred, equitable, accessible and cohesive national healthcare system.[[10,11]] A public health agency and locality networks have been formed to shape policy, oversee the provision of PHC, reduce inequities in funding and ensure that the health needs of Māori communities are met.[[11]] Improvements are expected in utilising local community health services and digital technology with electronic patient record sharing between all healthcare providers and patients to support self-management and better serve communities by providing more flexibility and increasing consulting hours.[[11]]
The aims of the two surveys were to examine trends between 2006–2008 and 2016 by comparing numbers of PHC nurses, their education and knowledge of diabetes, assessments and care provided during diabetes consultations and how valued nurses felt in their management of diabetes patients.
Methods
Two representative cross-sectional surveys were carried out in 2006–2008 and 2016 among PHC nurses in Auckland to document demographic, educational and work-related characteristics, and to describe their role in the community management of diabetes.
View Figures 1–4, Table 1.
Participants
Lists of all practice, district and specialist nurses who provide general practice and community care were constructed to ensure that both surveys were representative.[[14,15]] Of the total nurses, 26% (n=287) and 24% (n=336) were randomly selected and agreed to participate in each survey, achieving response rates of 86% and 73%, respectively (Figure 1).
Data collection
Participants completed a self-administered questionnaire providing biographical information and general practice or clinic details about diabetes patients registered and their diabetes management processes. All nurses also completed a telephone survey that assessed their knowledge of diabetes, best management practices and their provision of diabetes care. At the end of each telephone interview, nurses provided the number of diabetes patients they had consulted on a randomly selected day they had worked over the past week, and information was ascertained about diabetes patients consulted. Information was provided for 86% of the 308 patients consulted in 2006–2008 and 166 (37%) randomly selected from the 452 patients consulted in 2016. The lower numbers and proportion of patients sampled in the latter survey was due to the large numbers of diabetes patients consulted and time constraints for participants. Participants responded to almost all the questions.
Variables and outcome measures
Between-survey comparisons included: 1) the biographical characteristics of the PHC nursing workforce, 2) diabetes knowledge held by nurses, 3) adherence to best diabetes management practices, 4) patient demographic characteristics, and 5) diabetes management and care provided during nurse consultations.
Ethical considerations
Appropriate ethics approvals were granted for each survey by the Northern Regional Ethics Committee (NTX/05/10/128) and The University of Auckland Human Participants Ethics Committee (014713) in 2006–2008 for 2016, respectively. All participants consented before the telephone interview. All information related to patient consultations was collected anonymously. Adherence to the STROBE guidelines has been followed in conducting the study and reporting findings.
Survey questionnaire
Both questionnaires were adapted and extended from a survey administered to PNs in South Auckland in 1999.[[16]] New demographic questions were modelled on the five yearly New Zealand Census questionnaires. Questionnaires are included in Appendices 1 and 2. All questionnaires were piloted individually among a small number of nurses from each nurse group for face and content validity, and to ensure questions met the aims of the studies. A fixed response was required for the majority of questions that were either numerical, dichotomous, multiple choice or Likert scores, and a small number were short or open-ended. All responses to knowledge questions that differed from the pre-determined correct responses and open-ended responses were recorded in writing and systematically coded prior to analyses to decrease potential random measurement error.
Data analysis
Between-survey comparisons were made by combining all three groups of nurses sampled (practice, district and specialists) using weighted proportions to ensure representation for each group. Results mostly reflect PNs, who accounted for 75% and 88% of the total weighted proportions for each survey. All statistical analyses were carried out using SAS (SAS Institute, Cary, NC, 2013) and SUDAAN (version 11.0, Research Triangle Institute, 2012) and have been previously described.[[17]] For weighted survey comparisons and respective patients consulted, univariate analyses PROC FREQ and PROC UNIVARIATE were used to generate frequencies and p-values from the Wald Chi-Square value. PROC CROSSTAB and PROC REGRESS in SUDAAN were utilised to compare patient variables and management practices between surveys and to correct for clustering effects for nurses who consulted more than one patient.
Results
Trends in numbers and characteristics of primary care nurses
Over time there has been a significant increase in numbers of PNs, while the proportions of district and specialist nurses have approximately halved (Table 1). There was a significant increase in younger nurses aged <40 years, and although the workforce continues to be mostly female (97%), there was a significant increase in male district nurses (4% to 13%) and a small increase in male PNs (1% to 3%)—subgroup data not shown. In 2016, significantly fewer nurses were NZ European, more were Asian and similar proportions were Māori and Pacific compared with nurses in 2006–2008 (Table 1).
Practice details and management of diabetes
Significantly more nurses worked part-time in 2016 (73%) compared with 67% in 2006–2008, and 80% had attended five or more hours of specific diabetes education in the previous five years. This had not significantly changed between surveys (Table 1). Significantly more nurses in 2016 compared with 2006–2008 worked in general practice or Accident and Medical clinics (91% and 83%), in larger practices based on the number of physicians (47% and 36%), had their own room or office for administrative work (62% and 37%) and were able to email patients (80% and 45%). However, fewer nurses consulted patients at home in 2016 (9%) compared with 17% in 2006–2008 (Table 1).
Education and knowledge of diabetes
Significantly more PHC nurses in 2016 undertook post-graduation education (62%) and referred to guidelines on the management of type 2 diabetes (74%) compared with 49% and 50%, respectively, in 2006–2008. Most nurses in 2016 reported having the knowledge to discuss laboratory results (97%) and advise patients on making lifestyle changes (81%) compared with 92% and 70% of nurses, respectively, in 2006–2008. In contrast, only 37% of nurses felt sufficiently knowledgeable to offer advice to patients about their medications in 2016, although this was significantly more than the 29% of nurses surveyed in 2006–2008.
Slightly less nurses in 2016 (87%) rated their knowledge of best practice as at least “good” compared with 92% of nurses in 2006–2008 (Table 1). More nurses knew that type 1 diabetes was an autoimmune condition (23%) and understood the underlying pathology of type 2 diabetes (42%) in 2016 compared with 13% and 28% of nurses, respectively, in 2006–2008 (Figure 2).
Trends in management and care provided
Significantly more nurses addressed serum glucose levels, medications, foot care and smoking cessation and knew of patient’s microalbuminuria and retinal screening status in 2016 than nurses in 2006–2008 (Figure 3). However, the proportion of nurses who provided nutritional and physical activity advice and education remained unchanged—data not shown. Significantly more nurses in 2016 routinely consulted patients, conducted diabetes annual review (DAR) independently of doctors (48% versus 27%) and reported increased support in reviewing patients with diabetes compared with nurses in 2006–2008 (Figure 4).
Nurses feeling valued and supported
Despite the improvements in knowledge and management practices in 2016 compared with 2006–2008, fewer nurses felt valued, felt their suggestions were taken seriously or felt supported in their overall diabetes management activities (Figure 4).
Discussion
Numbers of PNs have significantly increased between surveys (Figure 1), which mirrors the national increase from 5,600 (12%) of the total nursing workforce in 2010,[[18]] to 7,713 (14%) in 2019.[[19]] The PHC nursing workforce continues to be over-represented by women (97%). Although there was a small (1%) increase in male nurses between surveys, it continues to lag behind the 8% of male registered nurses in New Zealand.[[19]] PNs were younger in 2016 and 32% were aged <40 years, compared with 20% in 2007–2008. In contrast, numbers of specialist nurses decreased between surveys, and 58% were aged over 50 years in 2016 compared with 43% in 2006–2008, reflecting a lack of recruitment. In the latter survey, more nurses had gained diabetes experience in primary care than within a hospital setting,[[15]] consistent with increasing numbers and size of general practices.[[15,20]]
Nurse education and knowledge of diabetes
Significantly more PHC nurses in 2016 had undertaken post-graduate education, attended specific diabetes educational sessions or conferences[[15]] and were more knowledge about the underlying pathology of type 1 and 2 diabetes compared with nurses in 2006–2008. Despite this, knowledge of type 1 diabetes among nurses remains low in New Zealand and internationally.[[21]] Clinically, more nurses were aware of best management guidelines for people with type 2 diabetes. Nurses who had attended specific diabetes education in the past 5 years were more likely to report feeling sufficiently knowledgeable to advise patients on their test results, required lifestyle changes and medications,[[22]] and educate patients in primary care, which is associated with improved outcomes.[[23]]
Although nurses had increased their knowledge over time of diabetes-related complications, including stroke (which is a proxy for in-depth diabetes knowledge) and major risk factors, less than 20% of nurses could state that hypertension, smoking or dyslipidaemia were also major risk factors for diabetes-related complications.[[22]] Similar gaps in nurses’ knowledge were highlighted in a recent review of 28 studies reporting that most nurses knew retinopathy was a microvascular complication, but very few knew about peripheral neuropathy and its associated clinical implications.[[24]] Knowledge gaps on medications remain, as only 37% of nurses reported having sufficient knowledge to advise patients about their medications, mimicking a report from the United Kingdom where PNs reported lacking knowledge required for initiating insulin.[[25]]
Practice details and management
PHC nurses increasingly work more autonomously. Most work in larger general practices or clinics, and almost twice the proportion of nurses in 2016 compared with 2006–2008 had their own offices for administrative work.[[15]] Significantly more nurses in 2016 routinely consulted patients, conducted DAR independently of doctors (following trends in the UK[[26]]), manage patient’s serum glucose, conduct cardiovascular assessments and foot examinations (indicating reduced barriers in providing care[[27]]), educate patients on reducing their risk of diabetes-related complications and follow-up on screening, referrals and test results.[[28]] These trends indicate increasing capacity and autonomy in managing patients with chronic conditions and are consistent with global trends,[[2]] although the increased support only extended to conducting DAR, not general diabetes management, and may reflect resistance to changing traditional models of primary care identified in a Canadian survey.[[29]] The proportion of nurses who provided nutritional and physical activity education remained the same over time, despite a significant increase in patients’ mean BMIs,[[17]] reflecting the many challenges and barriers engaging patients about lifestyle changes in an obesogenic environment.
Clinical implications
Despite nurses consulting more diabetes patients in 2016,[[17]] gaining knowledge of diabetes and best management practices, fewer nurses reported feeling valued or supported or that their suggestions were taken seriously in their overall diabetes management activities. Fewer nurses reported having support from dietitians or diabetes specialist nurses compared with nurses in 2006–2008, although more were supported by podiatrists and chronic care management nurses.[[30]] This contrasted with nurses who conducted DAR, where most felt supported in 2016,[[30]] and follows global trends where specific management tasks have shifted from GPs to nurses.[[2,26]] Nurses in 2016 reported feeling less valued than nurses in 2006–2008, which may reflect the younger cohort of nurses or structural and organisational changes. Salary gaps continue to widen between practice and hospital-based nurses,[[31]] and structural and organisational barriers reduce opportunities for career development and leadership roles in primary care.[[32,33]]
International context
Increasing the development and capacity of primary care nurses in New Zealand reflects global trends in offering more tangible career opportunities to further attract and nurture talented nurses.[[34]] Over the past 15 years, primary care nurses have become better educated, skilled, more confident and achieved similar or better health outcomes for patients with chronic conditions as GPs in a review of 18 randomised controlled trials.[[1]] Patients have also reported increased satisfaction after consulting a nurse compared with a GP, which could be attributed to longer consultations and more frequent follow-up care.[[1]] An Australian PN-led intervention achieved similar health outcomes and increased satisfaction for patients with type 2 diabetes, hypertension and ischemic heart disease as GPs, and was advantageous for both groups.[[35]] More recently, an Australian in-depth interview-based qualitative study of multidisciplinary primary care providers, which included PNs, reported improved communication and collaboration across primary and secondary care, improved patient self-care practices among people with chronic conditions and reduced hospital admissions.[[36,37]] An integrated model of care between secondary and primary care for diabetes patients with complex needs reduced the burden on secondary care services.[[38]] Similarly, in Estonia, health reforms designed to expand family (primary) care included a four-fold increase in primary care nurses and led to increased nurse consultations, patient access and attendance and reduced hospital admissions.[[39]] A review of 213 PHC teams, which included nurses in Italy, reported improved communication within and across health professionals that could potentially improve outcomes for people with type 2 diabetes.[[40]] In North America, advanced PNs educated to a Masters level, with collective prescribing rights, were increasingly and independently managing elderly patients, and able to meet their varied health needs in a range of rural and urban community settings.[[41]]
Despite progress in increasing capacity among primary care nurses in some countries, other developed countries lag behind. An evaluation of a shared model of primary care between PNs and GPs in the Netherlands highlighted the need for increased training and support for PNs to transition from a largely protocol-driven model of care to sharing management and decision making with GPs.[[42]] Nurses found it particularly difficult to integrate decision making, coaching and goal setting with patients with chronic conditions into the traditional protocol-based care model.[[42]] Similarly, in the United Kingdom, PNs reported needing increased support when incorporating psychological interventions to engage patients with diabetes to improve self-management behaviours.[[43]]
Strengths and limitations
A major strength of the surveys was the random selection of nurses from complete lists of all nurse groups who provide diabetes care in the community and the high response rates. Limitations included the cross-sectional design of the surveys that limited examining trends in qualifications, knowledge, experience, autonomy and career pathway progression from the same cohort of nurses. It is possible a proportion of nurses were in both surveys, although responses were analysed independently. Nurses may have over-reported post-graduate qualifications, experience and their perceived knowledge and confidence in educating patients on key practice points. It is possible that type 1 errors may have occurred due to the number of comparisons made between surveys. However, knowledge was tested during the telephone interview and correlated with self-reported levels.[[22]] Demographic findings correlated with national nursing survey results[[19]] and those reported from international surveys.[[24,44]]
Conclusion
PNs in New Zealand have significantly increased their post-graduate qualifications, knowledge of diabetes, independence and capacity in the community management of people with diabetes. Designated diabetes nurses are increasingly incorporated into the typical general practice model of care. This follows the global trend in shifting the management of people with chronic care conditions from GPs to primary care nurses, increasing the capacity of the community-based nursing workforce, and reducing the burden and escalating costs associated with secondary healthcare provision. Despite increasing diabetes knowledge and autonomy, too few nurses had received sufficient diabetes education. Nurses lacked knowledge about type 1 and 2 diabetes and best medication management practices and felt less valued and supported in their overall management of diabetes. These findings, and those from international reports, indicate that undergraduate and post-graduate educational institutions need to expand their curriculum on diabetes and its management. Extending government funding for post-graduate PHC nursing education and support for nurses to undertake diabetes education will help mitigate gaps in knowledge and practice.
View Appendices.
Summary
Abstract
Aim
To examine trends in the primary healthcare nursing workforce and their community management of diabetes.
Method
Two representative surveys were carried out in 2006–2008 and 2016 among all primary healthcare nurses in Auckland. Nurses were randomly selected, and 26% (n=287) and 24% (n=336) completed a self-administered questionnaire and telephone survey. Biographical information, knowledge of diabetes, how valued nurses felt and diabetes care for patients was provided.
Results
Between surveys, numbers of practice nurses have significantly increased, and specialist nurse numbers decreased, while district nurse numbers remained the same. In 2016, practice nurses were younger, more ethnically diverse, more likely to undertake education and had increased knowledge of diabetes and diabetes-related complications (including stroke) compared to nurses in 2006–2008. More nurses consulted patients, conducted foot examinations, addressed serum glucose, medication management, tobacco use and followed up care independently of doctors. In 2016, only 37% of nurses felt sufficiently knowledgeable to discuss medications with patients, <20% could state that hypertension, smoking and dyslipidaemia were major risk factors for complications, and less nurses felt valued.
Conclusion
Practice nurses have increased their capacity in diabetes management following global trends and require more support in meeting the complex healthcare needs of people with diabetes.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Trends in the primary healthcare nursing workforce in managing diabetes from two sample surveys in 2006–2008 and 2016 in Auckland, New Zealand
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The changing role of the primary care nurse has been largely driven by increasing numbers of people with chronic care conditions and escalating costs of secondary healthcare.[[1]] The latter has forced many countries to introduce health reforms to increase capacity in primary care, largely through developing and increasing numbers of primary or family care nurses, and shifting tasks from general practitioners (GPs) to nurses.[[2]] In New Zealand, practice nursing originated in 1970 following a government subsidy scheme to partially fund salaries to incentivise GPs to provide primary care in rural areas, extended to urban areas in 1974 by popular demand.[[3,4]] Based on the primary care model in the United Kingdom, practice nurses (PNs) were employed by GPs but centrally funded[[5]] to carry out administrative duties and perform tasks such as immunising children. A key difference in New Zealand is that general practices are private enterprises and charge a fee-for-service.[[6]]
Several health reforms, which usually involved the centralisation or decentralisation of funding, have occurred in New Zealand since the adoption of a free public healthcare system in 1938[[5]] to improve equity and access of primary care for all New Zealanders.[[5,7]] The first major reform in 1983 included a population-based funding formula and the establishment of 14 regional Area Health Boards.[[5]] In 1993, these were reduced to four Regional Health Authorities and then reconstructed into 23 regional Crown Health Enterprises with a separate public health agency.[[8]] A major health reform in 2001 encouraged general practices to join a not-for-profit Primary Health Organisation (PHO) to initiate a new model of primary healthcare (PHC), improve access for all and reduce health inequities.[[9]] Funding was provided for PNs to undertake education and training to develop expertise and reimburse general practices for nurse consultations.[[5,9]] This funding was expected to encourage more autonomy, extend nursing roles (including prescribing for nurse specialists and nurse practitioners), increase capacity in managing people with long term conditions and reduce the burden on secondary healthcare services.[[9]]
A recent reform in 2022 aimed to recentralise administration under Te Whatu Ora – Health New Zealand and work in partnership with the newly established Te Aka Whai Ora – Māori Health Authority to re-establish a people-centred, equitable, accessible and cohesive national healthcare system.[[10,11]] A public health agency and locality networks have been formed to shape policy, oversee the provision of PHC, reduce inequities in funding and ensure that the health needs of Māori communities are met.[[11]] Improvements are expected in utilising local community health services and digital technology with electronic patient record sharing between all healthcare providers and patients to support self-management and better serve communities by providing more flexibility and increasing consulting hours.[[11]]
The aims of the two surveys were to examine trends between 2006–2008 and 2016 by comparing numbers of PHC nurses, their education and knowledge of diabetes, assessments and care provided during diabetes consultations and how valued nurses felt in their management of diabetes patients.
Methods
Two representative cross-sectional surveys were carried out in 2006–2008 and 2016 among PHC nurses in Auckland to document demographic, educational and work-related characteristics, and to describe their role in the community management of diabetes.
View Figures 1–4, Table 1.
Participants
Lists of all practice, district and specialist nurses who provide general practice and community care were constructed to ensure that both surveys were representative.[[14,15]] Of the total nurses, 26% (n=287) and 24% (n=336) were randomly selected and agreed to participate in each survey, achieving response rates of 86% and 73%, respectively (Figure 1).
Data collection
Participants completed a self-administered questionnaire providing biographical information and general practice or clinic details about diabetes patients registered and their diabetes management processes. All nurses also completed a telephone survey that assessed their knowledge of diabetes, best management practices and their provision of diabetes care. At the end of each telephone interview, nurses provided the number of diabetes patients they had consulted on a randomly selected day they had worked over the past week, and information was ascertained about diabetes patients consulted. Information was provided for 86% of the 308 patients consulted in 2006–2008 and 166 (37%) randomly selected from the 452 patients consulted in 2016. The lower numbers and proportion of patients sampled in the latter survey was due to the large numbers of diabetes patients consulted and time constraints for participants. Participants responded to almost all the questions.
Variables and outcome measures
Between-survey comparisons included: 1) the biographical characteristics of the PHC nursing workforce, 2) diabetes knowledge held by nurses, 3) adherence to best diabetes management practices, 4) patient demographic characteristics, and 5) diabetes management and care provided during nurse consultations.
Ethical considerations
Appropriate ethics approvals were granted for each survey by the Northern Regional Ethics Committee (NTX/05/10/128) and The University of Auckland Human Participants Ethics Committee (014713) in 2006–2008 for 2016, respectively. All participants consented before the telephone interview. All information related to patient consultations was collected anonymously. Adherence to the STROBE guidelines has been followed in conducting the study and reporting findings.
Survey questionnaire
Both questionnaires were adapted and extended from a survey administered to PNs in South Auckland in 1999.[[16]] New demographic questions were modelled on the five yearly New Zealand Census questionnaires. Questionnaires are included in Appendices 1 and 2. All questionnaires were piloted individually among a small number of nurses from each nurse group for face and content validity, and to ensure questions met the aims of the studies. A fixed response was required for the majority of questions that were either numerical, dichotomous, multiple choice or Likert scores, and a small number were short or open-ended. All responses to knowledge questions that differed from the pre-determined correct responses and open-ended responses were recorded in writing and systematically coded prior to analyses to decrease potential random measurement error.
Data analysis
Between-survey comparisons were made by combining all three groups of nurses sampled (practice, district and specialists) using weighted proportions to ensure representation for each group. Results mostly reflect PNs, who accounted for 75% and 88% of the total weighted proportions for each survey. All statistical analyses were carried out using SAS (SAS Institute, Cary, NC, 2013) and SUDAAN (version 11.0, Research Triangle Institute, 2012) and have been previously described.[[17]] For weighted survey comparisons and respective patients consulted, univariate analyses PROC FREQ and PROC UNIVARIATE were used to generate frequencies and p-values from the Wald Chi-Square value. PROC CROSSTAB and PROC REGRESS in SUDAAN were utilised to compare patient variables and management practices between surveys and to correct for clustering effects for nurses who consulted more than one patient.
Results
Trends in numbers and characteristics of primary care nurses
Over time there has been a significant increase in numbers of PNs, while the proportions of district and specialist nurses have approximately halved (Table 1). There was a significant increase in younger nurses aged <40 years, and although the workforce continues to be mostly female (97%), there was a significant increase in male district nurses (4% to 13%) and a small increase in male PNs (1% to 3%)—subgroup data not shown. In 2016, significantly fewer nurses were NZ European, more were Asian and similar proportions were Māori and Pacific compared with nurses in 2006–2008 (Table 1).
Practice details and management of diabetes
Significantly more nurses worked part-time in 2016 (73%) compared with 67% in 2006–2008, and 80% had attended five or more hours of specific diabetes education in the previous five years. This had not significantly changed between surveys (Table 1). Significantly more nurses in 2016 compared with 2006–2008 worked in general practice or Accident and Medical clinics (91% and 83%), in larger practices based on the number of physicians (47% and 36%), had their own room or office for administrative work (62% and 37%) and were able to email patients (80% and 45%). However, fewer nurses consulted patients at home in 2016 (9%) compared with 17% in 2006–2008 (Table 1).
Education and knowledge of diabetes
Significantly more PHC nurses in 2016 undertook post-graduation education (62%) and referred to guidelines on the management of type 2 diabetes (74%) compared with 49% and 50%, respectively, in 2006–2008. Most nurses in 2016 reported having the knowledge to discuss laboratory results (97%) and advise patients on making lifestyle changes (81%) compared with 92% and 70% of nurses, respectively, in 2006–2008. In contrast, only 37% of nurses felt sufficiently knowledgeable to offer advice to patients about their medications in 2016, although this was significantly more than the 29% of nurses surveyed in 2006–2008.
Slightly less nurses in 2016 (87%) rated their knowledge of best practice as at least “good” compared with 92% of nurses in 2006–2008 (Table 1). More nurses knew that type 1 diabetes was an autoimmune condition (23%) and understood the underlying pathology of type 2 diabetes (42%) in 2016 compared with 13% and 28% of nurses, respectively, in 2006–2008 (Figure 2).
Trends in management and care provided
Significantly more nurses addressed serum glucose levels, medications, foot care and smoking cessation and knew of patient’s microalbuminuria and retinal screening status in 2016 than nurses in 2006–2008 (Figure 3). However, the proportion of nurses who provided nutritional and physical activity advice and education remained unchanged—data not shown. Significantly more nurses in 2016 routinely consulted patients, conducted diabetes annual review (DAR) independently of doctors (48% versus 27%) and reported increased support in reviewing patients with diabetes compared with nurses in 2006–2008 (Figure 4).
Nurses feeling valued and supported
Despite the improvements in knowledge and management practices in 2016 compared with 2006–2008, fewer nurses felt valued, felt their suggestions were taken seriously or felt supported in their overall diabetes management activities (Figure 4).
Discussion
Numbers of PNs have significantly increased between surveys (Figure 1), which mirrors the national increase from 5,600 (12%) of the total nursing workforce in 2010,[[18]] to 7,713 (14%) in 2019.[[19]] The PHC nursing workforce continues to be over-represented by women (97%). Although there was a small (1%) increase in male nurses between surveys, it continues to lag behind the 8% of male registered nurses in New Zealand.[[19]] PNs were younger in 2016 and 32% were aged <40 years, compared with 20% in 2007–2008. In contrast, numbers of specialist nurses decreased between surveys, and 58% were aged over 50 years in 2016 compared with 43% in 2006–2008, reflecting a lack of recruitment. In the latter survey, more nurses had gained diabetes experience in primary care than within a hospital setting,[[15]] consistent with increasing numbers and size of general practices.[[15,20]]
Nurse education and knowledge of diabetes
Significantly more PHC nurses in 2016 had undertaken post-graduate education, attended specific diabetes educational sessions or conferences[[15]] and were more knowledge about the underlying pathology of type 1 and 2 diabetes compared with nurses in 2006–2008. Despite this, knowledge of type 1 diabetes among nurses remains low in New Zealand and internationally.[[21]] Clinically, more nurses were aware of best management guidelines for people with type 2 diabetes. Nurses who had attended specific diabetes education in the past 5 years were more likely to report feeling sufficiently knowledgeable to advise patients on their test results, required lifestyle changes and medications,[[22]] and educate patients in primary care, which is associated with improved outcomes.[[23]]
Although nurses had increased their knowledge over time of diabetes-related complications, including stroke (which is a proxy for in-depth diabetes knowledge) and major risk factors, less than 20% of nurses could state that hypertension, smoking or dyslipidaemia were also major risk factors for diabetes-related complications.[[22]] Similar gaps in nurses’ knowledge were highlighted in a recent review of 28 studies reporting that most nurses knew retinopathy was a microvascular complication, but very few knew about peripheral neuropathy and its associated clinical implications.[[24]] Knowledge gaps on medications remain, as only 37% of nurses reported having sufficient knowledge to advise patients about their medications, mimicking a report from the United Kingdom where PNs reported lacking knowledge required for initiating insulin.[[25]]
Practice details and management
PHC nurses increasingly work more autonomously. Most work in larger general practices or clinics, and almost twice the proportion of nurses in 2016 compared with 2006–2008 had their own offices for administrative work.[[15]] Significantly more nurses in 2016 routinely consulted patients, conducted DAR independently of doctors (following trends in the UK[[26]]), manage patient’s serum glucose, conduct cardiovascular assessments and foot examinations (indicating reduced barriers in providing care[[27]]), educate patients on reducing their risk of diabetes-related complications and follow-up on screening, referrals and test results.[[28]] These trends indicate increasing capacity and autonomy in managing patients with chronic conditions and are consistent with global trends,[[2]] although the increased support only extended to conducting DAR, not general diabetes management, and may reflect resistance to changing traditional models of primary care identified in a Canadian survey.[[29]] The proportion of nurses who provided nutritional and physical activity education remained the same over time, despite a significant increase in patients’ mean BMIs,[[17]] reflecting the many challenges and barriers engaging patients about lifestyle changes in an obesogenic environment.
Clinical implications
Despite nurses consulting more diabetes patients in 2016,[[17]] gaining knowledge of diabetes and best management practices, fewer nurses reported feeling valued or supported or that their suggestions were taken seriously in their overall diabetes management activities. Fewer nurses reported having support from dietitians or diabetes specialist nurses compared with nurses in 2006–2008, although more were supported by podiatrists and chronic care management nurses.[[30]] This contrasted with nurses who conducted DAR, where most felt supported in 2016,[[30]] and follows global trends where specific management tasks have shifted from GPs to nurses.[[2,26]] Nurses in 2016 reported feeling less valued than nurses in 2006–2008, which may reflect the younger cohort of nurses or structural and organisational changes. Salary gaps continue to widen between practice and hospital-based nurses,[[31]] and structural and organisational barriers reduce opportunities for career development and leadership roles in primary care.[[32,33]]
International context
Increasing the development and capacity of primary care nurses in New Zealand reflects global trends in offering more tangible career opportunities to further attract and nurture talented nurses.[[34]] Over the past 15 years, primary care nurses have become better educated, skilled, more confident and achieved similar or better health outcomes for patients with chronic conditions as GPs in a review of 18 randomised controlled trials.[[1]] Patients have also reported increased satisfaction after consulting a nurse compared with a GP, which could be attributed to longer consultations and more frequent follow-up care.[[1]] An Australian PN-led intervention achieved similar health outcomes and increased satisfaction for patients with type 2 diabetes, hypertension and ischemic heart disease as GPs, and was advantageous for both groups.[[35]] More recently, an Australian in-depth interview-based qualitative study of multidisciplinary primary care providers, which included PNs, reported improved communication and collaboration across primary and secondary care, improved patient self-care practices among people with chronic conditions and reduced hospital admissions.[[36,37]] An integrated model of care between secondary and primary care for diabetes patients with complex needs reduced the burden on secondary care services.[[38]] Similarly, in Estonia, health reforms designed to expand family (primary) care included a four-fold increase in primary care nurses and led to increased nurse consultations, patient access and attendance and reduced hospital admissions.[[39]] A review of 213 PHC teams, which included nurses in Italy, reported improved communication within and across health professionals that could potentially improve outcomes for people with type 2 diabetes.[[40]] In North America, advanced PNs educated to a Masters level, with collective prescribing rights, were increasingly and independently managing elderly patients, and able to meet their varied health needs in a range of rural and urban community settings.[[41]]
Despite progress in increasing capacity among primary care nurses in some countries, other developed countries lag behind. An evaluation of a shared model of primary care between PNs and GPs in the Netherlands highlighted the need for increased training and support for PNs to transition from a largely protocol-driven model of care to sharing management and decision making with GPs.[[42]] Nurses found it particularly difficult to integrate decision making, coaching and goal setting with patients with chronic conditions into the traditional protocol-based care model.[[42]] Similarly, in the United Kingdom, PNs reported needing increased support when incorporating psychological interventions to engage patients with diabetes to improve self-management behaviours.[[43]]
Strengths and limitations
A major strength of the surveys was the random selection of nurses from complete lists of all nurse groups who provide diabetes care in the community and the high response rates. Limitations included the cross-sectional design of the surveys that limited examining trends in qualifications, knowledge, experience, autonomy and career pathway progression from the same cohort of nurses. It is possible a proportion of nurses were in both surveys, although responses were analysed independently. Nurses may have over-reported post-graduate qualifications, experience and their perceived knowledge and confidence in educating patients on key practice points. It is possible that type 1 errors may have occurred due to the number of comparisons made between surveys. However, knowledge was tested during the telephone interview and correlated with self-reported levels.[[22]] Demographic findings correlated with national nursing survey results[[19]] and those reported from international surveys.[[24,44]]
Conclusion
PNs in New Zealand have significantly increased their post-graduate qualifications, knowledge of diabetes, independence and capacity in the community management of people with diabetes. Designated diabetes nurses are increasingly incorporated into the typical general practice model of care. This follows the global trend in shifting the management of people with chronic care conditions from GPs to primary care nurses, increasing the capacity of the community-based nursing workforce, and reducing the burden and escalating costs associated with secondary healthcare provision. Despite increasing diabetes knowledge and autonomy, too few nurses had received sufficient diabetes education. Nurses lacked knowledge about type 1 and 2 diabetes and best medication management practices and felt less valued and supported in their overall management of diabetes. These findings, and those from international reports, indicate that undergraduate and post-graduate educational institutions need to expand their curriculum on diabetes and its management. Extending government funding for post-graduate PHC nursing education and support for nurses to undertake diabetes education will help mitigate gaps in knowledge and practice.
View Appendices.
Summary
Abstract
Aim
To examine trends in the primary healthcare nursing workforce and their community management of diabetes.
Method
Two representative surveys were carried out in 2006–2008 and 2016 among all primary healthcare nurses in Auckland. Nurses were randomly selected, and 26% (n=287) and 24% (n=336) completed a self-administered questionnaire and telephone survey. Biographical information, knowledge of diabetes, how valued nurses felt and diabetes care for patients was provided.
Results
Between surveys, numbers of practice nurses have significantly increased, and specialist nurse numbers decreased, while district nurse numbers remained the same. In 2016, practice nurses were younger, more ethnically diverse, more likely to undertake education and had increased knowledge of diabetes and diabetes-related complications (including stroke) compared to nurses in 2006–2008. More nurses consulted patients, conducted foot examinations, addressed serum glucose, medication management, tobacco use and followed up care independently of doctors. In 2016, only 37% of nurses felt sufficiently knowledgeable to discuss medications with patients, <20% could state that hypertension, smoking and dyslipidaemia were major risk factors for complications, and less nurses felt valued.
Conclusion
Practice nurses have increased their capacity in diabetes management following global trends and require more support in meeting the complex healthcare needs of people with diabetes.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Trends in the primary healthcare nursing workforce in managing diabetes from two sample surveys in 2006–2008 and 2016 in Auckland, New Zealand
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The changing role of the primary care nurse has been largely driven by increasing numbers of people with chronic care conditions and escalating costs of secondary healthcare.[[1]] The latter has forced many countries to introduce health reforms to increase capacity in primary care, largely through developing and increasing numbers of primary or family care nurses, and shifting tasks from general practitioners (GPs) to nurses.[[2]] In New Zealand, practice nursing originated in 1970 following a government subsidy scheme to partially fund salaries to incentivise GPs to provide primary care in rural areas, extended to urban areas in 1974 by popular demand.[[3,4]] Based on the primary care model in the United Kingdom, practice nurses (PNs) were employed by GPs but centrally funded[[5]] to carry out administrative duties and perform tasks such as immunising children. A key difference in New Zealand is that general practices are private enterprises and charge a fee-for-service.[[6]]
Several health reforms, which usually involved the centralisation or decentralisation of funding, have occurred in New Zealand since the adoption of a free public healthcare system in 1938[[5]] to improve equity and access of primary care for all New Zealanders.[[5,7]] The first major reform in 1983 included a population-based funding formula and the establishment of 14 regional Area Health Boards.[[5]] In 1993, these were reduced to four Regional Health Authorities and then reconstructed into 23 regional Crown Health Enterprises with a separate public health agency.[[8]] A major health reform in 2001 encouraged general practices to join a not-for-profit Primary Health Organisation (PHO) to initiate a new model of primary healthcare (PHC), improve access for all and reduce health inequities.[[9]] Funding was provided for PNs to undertake education and training to develop expertise and reimburse general practices for nurse consultations.[[5,9]] This funding was expected to encourage more autonomy, extend nursing roles (including prescribing for nurse specialists and nurse practitioners), increase capacity in managing people with long term conditions and reduce the burden on secondary healthcare services.[[9]]
A recent reform in 2022 aimed to recentralise administration under Te Whatu Ora – Health New Zealand and work in partnership with the newly established Te Aka Whai Ora – Māori Health Authority to re-establish a people-centred, equitable, accessible and cohesive national healthcare system.[[10,11]] A public health agency and locality networks have been formed to shape policy, oversee the provision of PHC, reduce inequities in funding and ensure that the health needs of Māori communities are met.[[11]] Improvements are expected in utilising local community health services and digital technology with electronic patient record sharing between all healthcare providers and patients to support self-management and better serve communities by providing more flexibility and increasing consulting hours.[[11]]
The aims of the two surveys were to examine trends between 2006–2008 and 2016 by comparing numbers of PHC nurses, their education and knowledge of diabetes, assessments and care provided during diabetes consultations and how valued nurses felt in their management of diabetes patients.
Methods
Two representative cross-sectional surveys were carried out in 2006–2008 and 2016 among PHC nurses in Auckland to document demographic, educational and work-related characteristics, and to describe their role in the community management of diabetes.
View Figures 1–4, Table 1.
Participants
Lists of all practice, district and specialist nurses who provide general practice and community care were constructed to ensure that both surveys were representative.[[14,15]] Of the total nurses, 26% (n=287) and 24% (n=336) were randomly selected and agreed to participate in each survey, achieving response rates of 86% and 73%, respectively (Figure 1).
Data collection
Participants completed a self-administered questionnaire providing biographical information and general practice or clinic details about diabetes patients registered and their diabetes management processes. All nurses also completed a telephone survey that assessed their knowledge of diabetes, best management practices and their provision of diabetes care. At the end of each telephone interview, nurses provided the number of diabetes patients they had consulted on a randomly selected day they had worked over the past week, and information was ascertained about diabetes patients consulted. Information was provided for 86% of the 308 patients consulted in 2006–2008 and 166 (37%) randomly selected from the 452 patients consulted in 2016. The lower numbers and proportion of patients sampled in the latter survey was due to the large numbers of diabetes patients consulted and time constraints for participants. Participants responded to almost all the questions.
Variables and outcome measures
Between-survey comparisons included: 1) the biographical characteristics of the PHC nursing workforce, 2) diabetes knowledge held by nurses, 3) adherence to best diabetes management practices, 4) patient demographic characteristics, and 5) diabetes management and care provided during nurse consultations.
Ethical considerations
Appropriate ethics approvals were granted for each survey by the Northern Regional Ethics Committee (NTX/05/10/128) and The University of Auckland Human Participants Ethics Committee (014713) in 2006–2008 for 2016, respectively. All participants consented before the telephone interview. All information related to patient consultations was collected anonymously. Adherence to the STROBE guidelines has been followed in conducting the study and reporting findings.
Survey questionnaire
Both questionnaires were adapted and extended from a survey administered to PNs in South Auckland in 1999.[[16]] New demographic questions were modelled on the five yearly New Zealand Census questionnaires. Questionnaires are included in Appendices 1 and 2. All questionnaires were piloted individually among a small number of nurses from each nurse group for face and content validity, and to ensure questions met the aims of the studies. A fixed response was required for the majority of questions that were either numerical, dichotomous, multiple choice or Likert scores, and a small number were short or open-ended. All responses to knowledge questions that differed from the pre-determined correct responses and open-ended responses were recorded in writing and systematically coded prior to analyses to decrease potential random measurement error.
Data analysis
Between-survey comparisons were made by combining all three groups of nurses sampled (practice, district and specialists) using weighted proportions to ensure representation for each group. Results mostly reflect PNs, who accounted for 75% and 88% of the total weighted proportions for each survey. All statistical analyses were carried out using SAS (SAS Institute, Cary, NC, 2013) and SUDAAN (version 11.0, Research Triangle Institute, 2012) and have been previously described.[[17]] For weighted survey comparisons and respective patients consulted, univariate analyses PROC FREQ and PROC UNIVARIATE were used to generate frequencies and p-values from the Wald Chi-Square value. PROC CROSSTAB and PROC REGRESS in SUDAAN were utilised to compare patient variables and management practices between surveys and to correct for clustering effects for nurses who consulted more than one patient.
Results
Trends in numbers and characteristics of primary care nurses
Over time there has been a significant increase in numbers of PNs, while the proportions of district and specialist nurses have approximately halved (Table 1). There was a significant increase in younger nurses aged <40 years, and although the workforce continues to be mostly female (97%), there was a significant increase in male district nurses (4% to 13%) and a small increase in male PNs (1% to 3%)—subgroup data not shown. In 2016, significantly fewer nurses were NZ European, more were Asian and similar proportions were Māori and Pacific compared with nurses in 2006–2008 (Table 1).
Practice details and management of diabetes
Significantly more nurses worked part-time in 2016 (73%) compared with 67% in 2006–2008, and 80% had attended five or more hours of specific diabetes education in the previous five years. This had not significantly changed between surveys (Table 1). Significantly more nurses in 2016 compared with 2006–2008 worked in general practice or Accident and Medical clinics (91% and 83%), in larger practices based on the number of physicians (47% and 36%), had their own room or office for administrative work (62% and 37%) and were able to email patients (80% and 45%). However, fewer nurses consulted patients at home in 2016 (9%) compared with 17% in 2006–2008 (Table 1).
Education and knowledge of diabetes
Significantly more PHC nurses in 2016 undertook post-graduation education (62%) and referred to guidelines on the management of type 2 diabetes (74%) compared with 49% and 50%, respectively, in 2006–2008. Most nurses in 2016 reported having the knowledge to discuss laboratory results (97%) and advise patients on making lifestyle changes (81%) compared with 92% and 70% of nurses, respectively, in 2006–2008. In contrast, only 37% of nurses felt sufficiently knowledgeable to offer advice to patients about their medications in 2016, although this was significantly more than the 29% of nurses surveyed in 2006–2008.
Slightly less nurses in 2016 (87%) rated their knowledge of best practice as at least “good” compared with 92% of nurses in 2006–2008 (Table 1). More nurses knew that type 1 diabetes was an autoimmune condition (23%) and understood the underlying pathology of type 2 diabetes (42%) in 2016 compared with 13% and 28% of nurses, respectively, in 2006–2008 (Figure 2).
Trends in management and care provided
Significantly more nurses addressed serum glucose levels, medications, foot care and smoking cessation and knew of patient’s microalbuminuria and retinal screening status in 2016 than nurses in 2006–2008 (Figure 3). However, the proportion of nurses who provided nutritional and physical activity advice and education remained unchanged—data not shown. Significantly more nurses in 2016 routinely consulted patients, conducted diabetes annual review (DAR) independently of doctors (48% versus 27%) and reported increased support in reviewing patients with diabetes compared with nurses in 2006–2008 (Figure 4).
Nurses feeling valued and supported
Despite the improvements in knowledge and management practices in 2016 compared with 2006–2008, fewer nurses felt valued, felt their suggestions were taken seriously or felt supported in their overall diabetes management activities (Figure 4).
Discussion
Numbers of PNs have significantly increased between surveys (Figure 1), which mirrors the national increase from 5,600 (12%) of the total nursing workforce in 2010,[[18]] to 7,713 (14%) in 2019.[[19]] The PHC nursing workforce continues to be over-represented by women (97%). Although there was a small (1%) increase in male nurses between surveys, it continues to lag behind the 8% of male registered nurses in New Zealand.[[19]] PNs were younger in 2016 and 32% were aged <40 years, compared with 20% in 2007–2008. In contrast, numbers of specialist nurses decreased between surveys, and 58% were aged over 50 years in 2016 compared with 43% in 2006–2008, reflecting a lack of recruitment. In the latter survey, more nurses had gained diabetes experience in primary care than within a hospital setting,[[15]] consistent with increasing numbers and size of general practices.[[15,20]]
Nurse education and knowledge of diabetes
Significantly more PHC nurses in 2016 had undertaken post-graduate education, attended specific diabetes educational sessions or conferences[[15]] and were more knowledge about the underlying pathology of type 1 and 2 diabetes compared with nurses in 2006–2008. Despite this, knowledge of type 1 diabetes among nurses remains low in New Zealand and internationally.[[21]] Clinically, more nurses were aware of best management guidelines for people with type 2 diabetes. Nurses who had attended specific diabetes education in the past 5 years were more likely to report feeling sufficiently knowledgeable to advise patients on their test results, required lifestyle changes and medications,[[22]] and educate patients in primary care, which is associated with improved outcomes.[[23]]
Although nurses had increased their knowledge over time of diabetes-related complications, including stroke (which is a proxy for in-depth diabetes knowledge) and major risk factors, less than 20% of nurses could state that hypertension, smoking or dyslipidaemia were also major risk factors for diabetes-related complications.[[22]] Similar gaps in nurses’ knowledge were highlighted in a recent review of 28 studies reporting that most nurses knew retinopathy was a microvascular complication, but very few knew about peripheral neuropathy and its associated clinical implications.[[24]] Knowledge gaps on medications remain, as only 37% of nurses reported having sufficient knowledge to advise patients about their medications, mimicking a report from the United Kingdom where PNs reported lacking knowledge required for initiating insulin.[[25]]
Practice details and management
PHC nurses increasingly work more autonomously. Most work in larger general practices or clinics, and almost twice the proportion of nurses in 2016 compared with 2006–2008 had their own offices for administrative work.[[15]] Significantly more nurses in 2016 routinely consulted patients, conducted DAR independently of doctors (following trends in the UK[[26]]), manage patient’s serum glucose, conduct cardiovascular assessments and foot examinations (indicating reduced barriers in providing care[[27]]), educate patients on reducing their risk of diabetes-related complications and follow-up on screening, referrals and test results.[[28]] These trends indicate increasing capacity and autonomy in managing patients with chronic conditions and are consistent with global trends,[[2]] although the increased support only extended to conducting DAR, not general diabetes management, and may reflect resistance to changing traditional models of primary care identified in a Canadian survey.[[29]] The proportion of nurses who provided nutritional and physical activity education remained the same over time, despite a significant increase in patients’ mean BMIs,[[17]] reflecting the many challenges and barriers engaging patients about lifestyle changes in an obesogenic environment.
Clinical implications
Despite nurses consulting more diabetes patients in 2016,[[17]] gaining knowledge of diabetes and best management practices, fewer nurses reported feeling valued or supported or that their suggestions were taken seriously in their overall diabetes management activities. Fewer nurses reported having support from dietitians or diabetes specialist nurses compared with nurses in 2006–2008, although more were supported by podiatrists and chronic care management nurses.[[30]] This contrasted with nurses who conducted DAR, where most felt supported in 2016,[[30]] and follows global trends where specific management tasks have shifted from GPs to nurses.[[2,26]] Nurses in 2016 reported feeling less valued than nurses in 2006–2008, which may reflect the younger cohort of nurses or structural and organisational changes. Salary gaps continue to widen between practice and hospital-based nurses,[[31]] and structural and organisational barriers reduce opportunities for career development and leadership roles in primary care.[[32,33]]
International context
Increasing the development and capacity of primary care nurses in New Zealand reflects global trends in offering more tangible career opportunities to further attract and nurture talented nurses.[[34]] Over the past 15 years, primary care nurses have become better educated, skilled, more confident and achieved similar or better health outcomes for patients with chronic conditions as GPs in a review of 18 randomised controlled trials.[[1]] Patients have also reported increased satisfaction after consulting a nurse compared with a GP, which could be attributed to longer consultations and more frequent follow-up care.[[1]] An Australian PN-led intervention achieved similar health outcomes and increased satisfaction for patients with type 2 diabetes, hypertension and ischemic heart disease as GPs, and was advantageous for both groups.[[35]] More recently, an Australian in-depth interview-based qualitative study of multidisciplinary primary care providers, which included PNs, reported improved communication and collaboration across primary and secondary care, improved patient self-care practices among people with chronic conditions and reduced hospital admissions.[[36,37]] An integrated model of care between secondary and primary care for diabetes patients with complex needs reduced the burden on secondary care services.[[38]] Similarly, in Estonia, health reforms designed to expand family (primary) care included a four-fold increase in primary care nurses and led to increased nurse consultations, patient access and attendance and reduced hospital admissions.[[39]] A review of 213 PHC teams, which included nurses in Italy, reported improved communication within and across health professionals that could potentially improve outcomes for people with type 2 diabetes.[[40]] In North America, advanced PNs educated to a Masters level, with collective prescribing rights, were increasingly and independently managing elderly patients, and able to meet their varied health needs in a range of rural and urban community settings.[[41]]
Despite progress in increasing capacity among primary care nurses in some countries, other developed countries lag behind. An evaluation of a shared model of primary care between PNs and GPs in the Netherlands highlighted the need for increased training and support for PNs to transition from a largely protocol-driven model of care to sharing management and decision making with GPs.[[42]] Nurses found it particularly difficult to integrate decision making, coaching and goal setting with patients with chronic conditions into the traditional protocol-based care model.[[42]] Similarly, in the United Kingdom, PNs reported needing increased support when incorporating psychological interventions to engage patients with diabetes to improve self-management behaviours.[[43]]
Strengths and limitations
A major strength of the surveys was the random selection of nurses from complete lists of all nurse groups who provide diabetes care in the community and the high response rates. Limitations included the cross-sectional design of the surveys that limited examining trends in qualifications, knowledge, experience, autonomy and career pathway progression from the same cohort of nurses. It is possible a proportion of nurses were in both surveys, although responses were analysed independently. Nurses may have over-reported post-graduate qualifications, experience and their perceived knowledge and confidence in educating patients on key practice points. It is possible that type 1 errors may have occurred due to the number of comparisons made between surveys. However, knowledge was tested during the telephone interview and correlated with self-reported levels.[[22]] Demographic findings correlated with national nursing survey results[[19]] and those reported from international surveys.[[24,44]]
Conclusion
PNs in New Zealand have significantly increased their post-graduate qualifications, knowledge of diabetes, independence and capacity in the community management of people with diabetes. Designated diabetes nurses are increasingly incorporated into the typical general practice model of care. This follows the global trend in shifting the management of people with chronic care conditions from GPs to primary care nurses, increasing the capacity of the community-based nursing workforce, and reducing the burden and escalating costs associated with secondary healthcare provision. Despite increasing diabetes knowledge and autonomy, too few nurses had received sufficient diabetes education. Nurses lacked knowledge about type 1 and 2 diabetes and best medication management practices and felt less valued and supported in their overall management of diabetes. These findings, and those from international reports, indicate that undergraduate and post-graduate educational institutions need to expand their curriculum on diabetes and its management. Extending government funding for post-graduate PHC nursing education and support for nurses to undertake diabetes education will help mitigate gaps in knowledge and practice.
View Appendices.
Summary
Abstract
Aim
To examine trends in the primary healthcare nursing workforce and their community management of diabetes.
Method
Two representative surveys were carried out in 2006–2008 and 2016 among all primary healthcare nurses in Auckland. Nurses were randomly selected, and 26% (n=287) and 24% (n=336) completed a self-administered questionnaire and telephone survey. Biographical information, knowledge of diabetes, how valued nurses felt and diabetes care for patients was provided.
Results
Between surveys, numbers of practice nurses have significantly increased, and specialist nurse numbers decreased, while district nurse numbers remained the same. In 2016, practice nurses were younger, more ethnically diverse, more likely to undertake education and had increased knowledge of diabetes and diabetes-related complications (including stroke) compared to nurses in 2006–2008. More nurses consulted patients, conducted foot examinations, addressed serum glucose, medication management, tobacco use and followed up care independently of doctors. In 2016, only 37% of nurses felt sufficiently knowledgeable to discuss medications with patients, <20% could state that hypertension, smoking and dyslipidaemia were major risk factors for complications, and less nurses felt valued.
Conclusion
Practice nurses have increased their capacity in diabetes management following global trends and require more support in meeting the complex healthcare needs of people with diabetes.
Author Information
Acknowledgements
Correspondence
Correspondence Email
Competing Interests
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Trends in the primary healthcare nursing workforce in managing diabetes from two sample surveys in 2006–2008 and 2016 in Auckland, New Zealand
The changing role of the primary care nurse has been largely driven by increasing numbers of people with chronic care conditions and escalating costs of secondary healthcare.
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