Stepping up: a nurse-led model of care for insulin initiation for people with type 2 diabetes

Abstract

The Stepping Up model allowed technical care to be embedded within generalist whole-person care, supported clinicians and practice system to overcome clinical inertia and supported patients to make the timely transition to insulin. Testing of the model's effectiveness is now underway.

Metaphors of Interdisciplinary Collaboration to Overcome the Theory-Practice Gap when Transitioning from RN to Advanced Practice Nurses

“…According to one APN, "they [physicians] are very happy to leave us to our own devices and I think they are sometimes a little bit unhappy…when we…ask them to look at things we are not happy about, and that can cause conflict [7]. Within the traditional workplace hierarchy in primary care, the physician (GP) leading the practice assumes ultimate accountability for decisions made by the nurse [8]. GPs were found to question if APNs have sufficient education to be autonomous and accountable [9].…”

“…Many NPs were found reluctant to fully utilise prescribing rights because they considered themselves to be nurses first and did not wish to be perceived as elitist and acting like a physician [14]. When practicing within environments micromanaged by a physician, nurses were found to doubt their care decisions and seek clarification for simple matters [7]- [8], [11]- [15]. This unnecessary interplay between nurse and physician resulted in incidences of overt client requests being overlooked [16].…”

“…This unnecessary interplay between nurse and physician resulted in incidences of overt client requests being overlooked [16]. Other studies reported the development of protocols as a means of avoiding omissions and explicitly delimiting the APN"s duties [7], [8], [10]- [17]. One nurse expressed that "it was tick the boxes, spit out the care plan, spit out the health assessment… We are not dealing with the patient as a holistic person" [16].…”

“…Whereas physicians may enjoy handing over what they perceive to be mundane duties, tensions regarding the cost of APNs and anxieties around recouping this expense were evident [10], [16]. APNs reported being in a constant battle to be recognised professionally by their colleagues and clients [8], [12], [14]- [17], [20]- [22] and also by other nursing staff [7]. To gain respect from GPs, APNs displayed skills that were more medically oriented; however, these skills were not accepted by their less qualified nursing colleagues who themselves felt undervalued and overworked.…”

“…According to one physician, APNs were "a waste of money" because they always asked for a second opinion [18]. Other GPs viewed APNs as effectively providing continuity of care to vulnerable clients and this view was supported by many chronically ill clients [8], [11]- [12], [14]- [16], [20]. Yet, clients did not recognize the interactions between the APN and GP as professional cooperation.…”