Relational coordination amongst health professionals involved in insulin initiation for people with type 2 diabetes in general practice: an exploratory survey
Jo-Anne Manski-Nankervis, Irene Blackberry, Doris Young, David O'Neal, Elizabeth Patterson, John Furler, Jo-Anne Manski-Nankervis, Irene Blackberry, Doris Young, David O'Neal, Elizabeth Patterson, John Furler
Abstract
Background: The majority of people with type 2 diabetes (T2D) receive their care in general practice and will eventually require initiation of insulin as part of their management. However, this is often delayed and frequently involves referral to specialists. If insulin initiation is to become more frequent and routine within general practice, coordination of care with specialist services may be required. Relational coordination (RC) provides a framework to explore this. The aim of this study was to explore RC between specialist physicians, specialist diabetes nurses (DNEs), generalist physicians in primary care (GPs) and generalist nurses (practice nurses (PNs)) and to explore the association between RC and the initiation of insulin in general practice, and the belief that it is appropriate for this task to be carried out in general practice.
Methods: A survey was distributed to a convenience sample of specialist physicians, DNEs, GPs and practice nurses. We collected data on demographics, models of care and RC in relation to insulin initiation. We expected that RC would be higher between specialists than between specialists and generalists. We expected higher RC between specialists and generalists to be associated with insulin initiation in general practice and with the belief that it is appropriate for insulin initiation to be carried out in general practice. We used descriptive statistics and non-parametric tests to explore these hypotheses.
Results: 179 health professionals returned completed surveys. Specialists reported higher RC with each other and lower RC with PNs. All groups except PNs reported their highest RC with DNEs, suggesting the potential for DNEs to serve as boundary spanners. Lower RC with specialists was reported by those working within a general practice model of care. Health professionals who felt that a general practice model was appropriate reported lower communication with specialist physicians and higher shared knowledge with GPs.
Conclusion: Given the need for coordination between specialist and generalist care for the task of insulin initiation, this study's results suggest the need to build relationships and communication between specialist and generalist health professional groups and the potential for DNE's to play a boundary spanner role in this process.
Figures
![Figure 1](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4224690/bin/12913_2014_515_Fig1_HTML.jpg)
![Figure 2](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4224690/bin/12913_2014_515_Fig2_HTML.jpg)
References
- Wagner EH. The role of patient care teams in chronic disease management. Br Med J. 2000;320(7234):569. doi: 10.1136/bmj.320.7234.569.
- Torres S, Dominguez LM. Collaborative practice: How we get from coordination to the integration of skills and knowledge. In: Sheehy C, McCarthy M, editors. Advanced Practice Nursing: Emphasizing common roles. Philadelphia: F.A. Davis Company; 1998. pp. 218–240.
- Yarnall KSH, Ostbye T, Krause KM, Pollack KI, Gradison M, Michener JL. Family physicians as team leaders: “Time” to share the care. Prev Chronic Dis. 2009;6(2):1–6.
- Heckscher C, Rubinstein SA, Flynn L, Erhardt N, Boniface M. Collaboration and the quality of health care delivery. 2008.
- Australian Institute of Health and Welfare (AIHW) National health priority areas. 2013.
- Penfornis A, San-Galli F, Cimino L, Huet D. Current insulin therapy in patients with type 2 diabetes: results of the ADHOC survey in France. Diabetes Metab. 2011;37(5):440–445. doi: 10.1016/j.diabet.2011.03.001.
- Britt H, Miller GC, Charles J, Henderson J, Bayram C, Valenti L, Harrison C, Pan Y, O’Halloran J, Zhang C, Fahridin S. General practice activity in Australia 2010–11. Sydney: Sydney University Press; 2011.
- Jaakkimainen L, Baiju RS, Kopp A. Sources of physician care for people with diabetes. In: Hux JE, editor. Diabetes in Ontario. Toronto: Institute for Clinical Evaluative Sciences (ICES); 2003. pp. 181–192.
- Davis TME, Davis WA, Bruce DG. Glycaemic levels triggering intensification of therapy in type 2 diabetes in the community: the Fremantle Diabetes Study. Med J Aust. 2006;184:325–328.
- Calvert MJ, McManus RJ, Freemantle N. Management of type 2 diabetes with multiple oral hypoglycaemic agents or insulin in primary care: retrospective cohort study. Br J Gen Pract. 2007;57(539):455–460.
- Harris SB, Kapor J, Lank CN, Willan AR, Houston T. Clinical inertia in patients with T2DM requiring insulin in family practice. Canadian Fam Physician Médecin De Famille Canadien. 2010;56(12):e418–e424.
- Britt H, Miller GC, Charles J, Henderson J, Bayram C, Valenti L, Pan Y, Harrison C, Fahridin S, O’Halloran J. General Practice Activity in Australia 2008–09. Canberra: AIHW; 2009.
- Baker IDI Heart & Diabetes Institute . Diabetes: The Silent Pandemic and its Impact on Australia. Melbourne: Baker IDI Heart & Diabetes Institute; 2012.
- Rizza RA, Vigersky RA, Rodbard HW, Ladenson PW, Young WF, Surks MI, Kahn R, Hogan PF. A model to determine workforce needs for endocrinologists in the United States until 2020. Diabetes Care. 2003;26(5):1545–1552. doi: 10.2337/diacare.26.5.1545.
- Health Workforce Australia . Health Workforce 2025 - Volume 3 - Medical Specialties. 2012.
- Russell A, Baxter KA, Askew DA, Tsai J, Ware RS, Jackson C. Model of care for the managment of complex type 2 diabetes managed in the community by primary care physicians with specialist support: an open controlled trial. Diabet Med. 2013;30(9):1112–1121. doi: 10.1111/dme.12251.
- The Stepping Up Investigators . Stepping up to insulin: A cluster randomised trial of team based transition to insulin in primary care for patients with poorly controlled type 2 diabetes. Melbourne: General Practice and Primary Health Care Academic Centre; 2011.
- O’Neal D, Initiation Study Group . Initiation Study: A pilot study examining a model of care for initiating patients with Type 2 diabetes on a basal +/− prandial insulin regimen in primary care with adjunct Continuous Glucose Monitoring. 2011.
- van Avendonk MJP, Gorter KJ, van den Donk M, Rutten GEHM. Insulin therapy in type 2 diabetes is no longer a secondary care activity in the Netherlands. Prim Care Diabetes. 2009;3(1):23–28. doi: 10.1016/j.pcd.2008.10.007.
- Australian Practice Nurses Association (APNA): CPD and national registration for practice nurses.. [30/6/2013]; Available from: Accessed 6/11/2014.
- Australian Diabetes Educators Association (ADEA) National standards of practice for diabetes educators. Weston, ACT: Australian Diabetes Educators Association; 2003.
- The Royal Australian College of General Practitioners and Diabetes Australia . Guidelines for Type 2 diabetes. East Melbourne: The Royal Australian College of General Practitioners; 2014. Australian General Practice Management of type 2 diabetes 2014-2015.
- Pullon S. Competence, respect and trust: key features of successful interprofessional nurse-doctor relationships. J Interprof Care. 2008;22(2):133–147. doi: 10.1080/13561820701795069.
- Gittell JH. Relational coordination: Guidelines for theory, measurement and analysis. Waltham, MA: Brandeis University; 2011.
- Gittell JH. Coordinating mechanisms in care provider groups: relational coordination as a mediator and input uncertainty as a moderator of performance effects. Manag Sci. 2002;48(11):1408–1426. doi: 10.1287/mnsc.48.11.1408.268.
- Gittell JH, Godfrey M, Thistlethwaite J. Interprofessional collaborative practice and relational coordination: improving healthcare through relationships. J Interprof Care. 2013;27(3):210–213. doi: 10.3109/13561820.2012.730564.
- Cramm JM, Nieboer AP. Relational coordination promotes quality of chronic care delivery in Dutch disease-management programs. Health Care Manage Rev. 2012;37(4):301–309. doi: 10.1097/HMR.0b013e3182355ea4.
- Gittell JH. Relational coordination: coordinating work through relationships of shared goals, shared knowledge and mutual respect. In: Kyriakidou O, Ozbilgin MF, editors. Relational perspectives in organizational studies. Cheltenham, UK: Edward Elgar; 2006.
- Gittell JH, Gittell JH, Fairfield KM, Bierbaum B, Head W, Jackson R, Kelly M, Laskin R, Lipson S, Siliski J, Thornhill T, Zuckerman J. Impact of relational coordination on quality of care, postoperative pain and functioning, and length of stay: a nine-hospital study of surgical patients. Med Care. 2000;38(8):807–819. doi: 10.1097/00005650-200008000-00005.
- Noel PH, Lanham HJ, Palmer RF, Leykum LK, Parchman ML. The importance of relational coordination and reciprocal learning for chronic illness care within primary care teams. Health Care Manage Rev. 2013;38(1):20–28. doi: 10.1097/HMR.0b013e3182497262.
- Hinami K, Whelan CT, Konetzka RT, Edelson DP, Casalino LP, Meltzer DO. Effects of provider characteristics on care coordination under comanagement. J Hosp Med. 2010;5(9):508–513. doi: 10.1002/jhm.797.
- Lundstrom SL, Edwards K, Knudsen TB, Larsen PV, Reventlow S, Sondergaard J. Relational coordination and organisational social capital association with characteristics of general practice. Int J Fam Med. 2014;2014:618435.
- Goenka N, Turner B, Vora J. Commissioning specialist diabetes services for adults with diabetes: summary of a diabetes UK task and finish group report. Diabet Med. 2011;28(12):1494–1500. doi: 10.1111/j.1464-5491.2011.03410.x.
- Levich BR. Diabetes management: optimizing roles for nurses in insulin initiation. J Multidiscip Healthc. 2011;4:15–24. doi: 10.2147/JMDH.S16451.
- Cheung NW, Yue DK, Kotowicz MA, Jones PA, Flack JR. A comparison of diabetes clinics with different emphasis on routine care, complications assessment and shared care. Diabet Med. 2008;25(8):974–978. doi: 10.1111/j.1464-5491.2008.02522.x.
- Gruen RL, Weeramanthri TS, Knight SS, Bailie RS. Specialist outreach clinics in primary care and rural hospital settings. Cochrane Database Syst Rev. 2003;4:ᅟ.
- Australian Diabetes Educators Association (ADEA): Australian Diabetes Educators Association;. [6/2/2012]; Available from: .
- Capaldi B. Optimising glycaemic control for patients starting insulin therapy. Nurs Stand. 2007;21(44):49–57. doi: 10.7748/ns2007.07.21.44.49.c4581.
- Royal College of General Practitioners (RCGP) and Department of Health . Guidelines for the appointment of General Practitioners with Special Interests in the Delivery of Clinical Services - Diabetes. 2003.
- Relational Coordination Research Collaborative: Relational coordination survey; [cited 2012 2/6/2012]; Available from: .
- Davies M, Evans R, Storms F, Gomis R, Khunti K, AT.LANTUS Study Group Initiation of insulin glargine in suboptimally controlled patients with type 2 diabetes: sub-analysis of the AT.LANTUS trial comparing treatment outcomes in subjects from primary and secondary care in the UK. Diabetes Obes Metab. 2007;9(5):706–713. doi: 10.1111/j.1463-1326.2006.00652.x.
- Samann A, Lehman T, Hella T, Muller N, Hartmann P, Wolf GB, Muller UA. A retrospective study on the incidence and risk factors of severe hypoglycaemia in primary care. Fam Pract. 2013;30(3):290–293. doi: 10.1093/fampra/cms071.
- Thistlethwaite J, Jackson A, Moran M. Interprofessional collaborative practice: a deconstruction. J Interprof Care. 2013;27(1):50–56. doi: 10.3109/13561820.2012.730075.
- Gandevia B. A history of general practice in Australia. Canadian Fam Physician. 1971;17(10):51–61.
- Piterman L, Koritsas S. Part I. general practitioner-specialist relationship. Intern Med J. 2005;35:430–434. doi: 10.1111/j.1445-5994.2005.00855.x.
- Freidson E. Professional dominance: The social structure of medicine. Chicago: Aldine Publishing Company; 1970.
- Wainwright P. Professionalism and the concept of role extension. In: Hunt G, Wainwright P, editors. Expanding the role of the nurse. Oxford: Blackwell Science; 1994. pp. 3–21.
- Hallam J. Nursing the image. Media, culture and professional identity. London: Routledge; 2000.
- Wicks D. Nurses and doctors at work: rethinking professional boundaries. St Leonards: Allen & Unwin; 1999.
- Stein L. The doctor-nurse game. Arch Gen Psychiat. 1967;16:699–703. doi: 10.1001/archpsyc.1967.01730240055009.
- Hall P. Interprofessional teamwork: professional cultures as barriers. J Interprof Care. 2005;s1:188–196. doi: 10.1080/13561820500081745.
- Davies C. Gender and the professional predicament in nursing. Buckingham: Open University Press; 1995.
- Keleher H, Joyce CM, Parker R, Piterman L. Practice nurses in Australia: current issues and future directions. Med J Aust. 2007;187(2):108–110.
- Greaves CJ, Brown P, Terry RT, Eiser C, Lings P, Stead JW. Converting to insulin in primary care: an exploration of the needs of practice nurses. J Adv Nurs. 2003;42(5):487–496. doi: 10.1046/j.1365-2648.2003.02648.x.
- Alliance AML. 2012 General Practice Nurse National Survey Report. Manuka: Australian Medicare Local Alliance; 2012.
- Gjerberg E, Kjolsrod L. The doctor-nurse relationship: how easy is it to be a female doctor co-operating with a female nurse? Soc Sci Med. 2001;52:189–202. doi: 10.1016/S0277-9536(00)00219-7.
- Long JC, Cunningham FC, Braithwaite J. Bridges, brokers and boundary spanners in collaborative networks: a systematic review. BMC Health Serv Res. 2013;13:158. doi: 10.1186/1472-6963-13-158.
Source: PubMed