Patient Education and Counseling 94 (2014) 187–192

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Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou

Communication Study

Interaction between diabetes specialist nurses and patients during group sessions about self-management in type 2 diabetes Eva Bostro¨m *, Ulf Isaksson, Berit Lundman, Ulla H. Graneheim, A˚sa Ho¨rnsten Department of Nursing, Umea˚ University, Umea˚, Sweden

A R T I C L E I N F O

A B S T R A C T

Article history: Received 10 January 2013 Received in revised form 20 September 2013 Accepted 26 October 2013

Objective: The aim of this study was to explore the interaction between diabetes specialist nurses (DSNs) and patients with type 2 diabetes (T2D) during group sessions about self-management. Methods: Ten DSNs and 44 patients were observed during group sessions about self-management, and thereafter the observations were analyzed using qualitative content analysis. Results: The interaction was characterized by three themes: becoming empowered, approaching each other from different perspectives, and struggling for authority. The interaction was not a linear process, but rather a dynamic process with distinct episodes that characterized the content of the sessions. Conclusion: It is important to achieve an interaction that is patient-centered, where the DSN is aware of each patient’s individual needs and avoids responding to patients in a normative way. A satisfying interaction may strengthen patients’ self-management, and also may strengthen the DSNs in their professional performance. Practice implications: Authority struggles between patients and DSNs could be a prerequisite for patients to become autonomous and decisive in self-management. DSNs might benefit from an increased awareness about this issue, because they can better support patients if they do not perceive authority struggles as threats to their professional role. ß 2013 Elsevier Ireland Ltd. All rights reserved.

Keywords: Diabetes specialist nurse Interaction Patient Self-management Type 2 diabetes

1. Introduction The diabetes specialist nurse (DSN) in primary care has an important role in educating, supporting, and enabling patients with type 2 diabetes (T2D) to self-manage their illness [1–3]. Diabetes self-management education (DSME) is critical to enable patients to make well-informed decisions about their care, increase their knowledge of diabetes, and acquire problem-solving skills [4]. Furthermore, based on the latest evidence-based standards for improving clinical outcomes and patients’ quality of life, patients’ needs, goals, and life experiences are incorporated into DSME [4,5]. In Sweden, patient education and support of selfmanagement in diabetes care should be prioritized in primary care by health care professionals [6]. Similar recommendations have been made in other countries [4,5], and positive effects on longterm glycemic control and psychological distress have been reported from group education [6,7]. However, it is a common practice to offer only individual counseling in T2D, and group sessions are still infrequently offered in Sweden [8]. Group sessions

* Corresponding author at: Department of Nursing, Umea˚ university, 90187 Umea˚, Sweden. Tel.: +46 90 7869270. E-mail address: [email protected] (E. Bostro¨m). 0738-3991/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pec.2013.10.010

benefit from the group dynamics, whereby laypersons strengthen each other and become empowered through collaboration [9]. Interaction as a concept is often used interchangeably with communication in the nursing literature, and it has been suggested that one of the concepts cannot be described, defined, and understood without the other [10]. In a review of the concepts communication and interaction, it has been stated that, while communication is always happening when people meet, interaction is a process of cognition and action by the participants [10]. In this paper, we will use the concept interaction to label the active, context-related process that occurs between individuals with the aim of understanding each other [10]. In a review, Shattell [11] argued that nurses commonly interact with patients in a way in which patients risk loss of autonomy and self-esteem, and therefore, improved nurse–patient interaction is central to quality of care. Watson [12] agreed that interaction is a central concern for clinical practice and needs to be further investigated to avoid lessthan-satisfactory interaction. Patients have requested an interaction that is more supportive and patient centered [13,14], whereas DSNs have described difficulties with patient-centeredness, as it might threaten their role as experts [15,16]. It has also been found that misunderstandings concerning illness and treatment are common. Even patients who adhere to treatment regimens do not always know why or how they could benefit from them [17].

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In diabetes care, the DSN has an important task to support patient self-management. Studies among nurses and patients have to some extent reported interaction and clinical encounters as unsatisfying for both parties [14,18,19]. This paper is one report from the larger nurse-led intervention project, DIVA 2, designed as a randomized trial with the goal of supporting selfmanagement among patients with T2D and evaluating the effects of patient-centered support on metabolic improvements among patients [20] and also to explore the DSNs’ experiences of practicing patient-centered care. It is a qualitative study focused on DSNs’ interaction with patients during group sessions. Observations of clinical encounters and interaction aimed to support self-management of patients with T2D may add value to the existing knowledge about the quality of nurse–patient interaction. 1.1. Aim The aim of this study was to explore the interaction between diabetes specialist nurses and patients with type 2 diabetes during group sessions about self-management within a patientcentered intervention. The research questions that guided the observations and the analysis concerned how patients’ autonomy, needs, and values, and their personal understandings of and preferences for self-management were highlighted and communicated. 2. Methods 2.1. Design This is a qualitative observational study as a part of a larger intervention project (DIVA 2) [20]. 2.1.1. The workshop for DSNs The intervention was preceded by a 20-h preparatory workshop for the DSNs that included training in patient-centered support and role-playing. The DSNs were given information about guidelines on patient education in T2D. Professionals’ and patients’ various perspectives of disease and illness, patient-centered care, and patient empowerment were highlighted. During the intervention, which constituted six forthcoming group sessions for patients, the DSNs were encouraged to focus more on patients’ understandings of the illness, and encourage the patients to discuss everything they wanted to relate to their illness, while medical diabetes facts were conveyed only when requested. Each session, had a theme: the image of the disease, the meaning of the diagnosis, the illness integration over time, the space of illness management in daily life, views on responsibilities for selfmanagement, and lastly, the patients’ future prospects for life with an illness like T2D [21]. 2.2. Setting

patients (29 men, 15 women) between 45 and 76 years old (median = 64) and diagnosed with T2D within the last two years participated in this study. 2.4. Observations The observations reported in this study were performed during the fifth session, the topic of which was patients’ views on their responsibilities for self-management. The observations focused on interaction, actions and reactions during the group sessions. The participants were informed in advance about the observational study and the audiotape recording. Each observation lasted between 54 and 79 min (median = 64). The observer (EB) was positioned at the side of the group, with a clear view of the participants around the table. The observer had a ‘‘participant as observer’’ role [22], determined by participants’ knowledge about the purpose of the observation. The observer in this study participated in the social situation, but had a peripheral role and strived for a low level of interaction; if addressed, she referred to the DSN. During the observations, the observer wrote down field notes about the time and occurrences in the room and made further notes to elaborate on their meanings. 2.5. Analysis The tape-recorded material was transcribed verbatim and analyzed using qualitative content analysis [23] conducted in several steps. First, all text material—such as field notes, memos, and transcribed recorded text—was merged, read, and discussed to get a sense of the whole. Meaning units responding to the aim were identified and condensed, with the core meaning preserved. The condensed text was coded, sorted, and abstracted into subthemes and themes. The analysis was mainly performed by the first author, but with continuous supervision by the co-authors. One of the supervisors analyzed parts of the data together with the first author, and thereafter the interpretations were continuously discussed with all co-authors in all steps, such as coding, and grouping of codes and interpretative levels of themes, to ensure trustworthiness. The co-authors were all senior researchers and well experienced in qualitative research and qualitative content analysis. The results are illustrated with quotations. 2.6. Ethical considerations All participants gave consent after being informed about the purpose of the study and their right to withdraw. Confidentiality was assured. The Regional Ethical Review Board (Dnr 06-126M) approved the study. 3. Results

Nine primary health care centers (PHCs) in three communities of northern Sweden participated in the current study. The observations of the group sessions took place at the PHCs.

The result showed that the interaction was characterized by the three themes becoming empowered, approaching each other from different perspectives, and struggling for authority. Themes and subthemes are presented in Table 1 and illustrated by quotations in the text.

2.3. Participants

3.1. Becoming empowered

Ten DSNs, all women, managing the diabetes clinics at the PHCs, participated in the study. All were registered nurses and had 4–21 years of experience in diabetes care (median = 9). Eight DSNs had a post-graduate education in primary health care nursing, and nine had an additional university education in diabetes care. The DSNs led nine groups with 3–6 patients each. Forty-four Swedish-speaking

This theme was characterized by the empowerment of both DSNs and patients. They became empowered through engaging, enabling, and relating to one another and sharing views on patients’ self-management. The DSNs and patients saw each other as partners, both with important knowledge to contribute to the interaction.

E. Bostro¨m et al. / Patient Education and Counseling 94 (2014) 187–192 Table 1 Themes and sub-themes of the interaction between DSNs and patients. Themes

Sub-themes

Becoming empowered

Engaging and enabling Relating and sharing

Approaching each other from different perspectives

Objectifying and individualizing Focusing on facts and emotions

Struggling for authority

Governing and subordinating Being vague and taking over Questioning and justifying

3.1.1. Engaging and enabling The DSNs engaged with the patients and tried to enable them by identifying possibilities for discussing alternatives and asking about individual strengths. One nurse suggested: ‘‘It sounds like [you] need a lot of strength to do that.’’ The DSNs also asked questions about ‘‘how’’ things could be done, and were engaged and showed genuine interest by summarizing the patients’ answers and following them up: ‘‘How do you feel about engagement and motivation?’’ and ‘‘What is it that hinders you in your self-management of diabetes?’’ The DSNs waited for and encouraged patients to present their perspectives on the illness and their possibilities for self-management. Supporting patients through engagement in their lives was empowering for the DSNs themselves. The patients were engaged in and decided on solutions for self-management and described in detail that having a plan for their daily living was vital for success: ‘‘We all have responsibility for our own lives, and making a plan or structure makes it more possible to take responsibility for the illness.’’ Having common goals for the patients’ future self-management seemed to empower the DSNs as well. The patients had opportunities to discuss different alternatives and independently reflect with one another. They seemed to be relaxed and willing to tell others about their capabilities as well as obstacles to self-management. 3.1.2. Relating and sharing The DSNs and patients were relating to each other and sharing views and goals. By listening to and following up on the patients’ stories, the DSNs strengthened their achieved goals and suggested further self-management goals that both patients and DSNs could accept. The patients’ capabilities were discussed, and together the patients and DSNs reflected about various solutions for successful self-management. The DSNs encouraged and motivated the patients to manage the demands of the illness in daily life, which was expressed, for example, as follows: ‘‘But when you are working in the barn, that’s exercise as well, isn’t it?’’ In the interaction characterized by relating and sharing, the patients shared with the DSNs the benefits they perceived about lifestyle changes they had made: ‘‘I think that if you change some parts and feel better, then you suffer less from the illness.’’ Patients and DSNs related to each other when they reflected on a subject and exchanged thoughts and ideas, for example, getting insight into what would happen if the patients kept on living as before. When the participants related and shared one another’s opinions, the patients had room to describe their motives for self-management, such as ‘‘wanting to see the grandchildren grow up’’ or ‘‘understanding the severity of the diagnosis.’’ 3.2. Approaching each other from different perspectives This theme was characterized by DSNs and patients approaching each other from different perspectives, such as the ‘‘objective’’ versus ‘‘subjective’’ perspective. The subthemes objectifying and individualizing, and focusing on facts and emotions, were identified.

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3.2.1. Objectifying and individualizing The DSNs used expressions that were interpreted as objectifying the care and the patients—for example, referring to the illness as ‘‘it’’, referring to the patients in collective terms, and striving for standardized blood glucose results. The DSNs leaned forward to the patients and showed an eagerness to persuade the patients using motives from a biomedical view. They also spoke to the patient in the ‘I’ form: ‘‘It depends a lot on how much engagement I have or how motivated I feel, right?’’ The DSNs urged the patients to establish routines and choose the right priorities: ‘‘Should I take care of the laundry first before I go out for a walk?’’ The more the DSNs emphasized the ‘I’ perspective and stressed the disease severity and the patients’ responsibility, the more the patients distanced themselves from the DSNs and instead reflected the illness from an individual personal perspective, referring to personal and social obstacles to self-management. The patients pronounced and requested others’ responsibility and engagement, for example, those of society, professionals, and relatives, and explained selfmanagement as a process and something they had to grow into. Patients expressed that if they had the opportunity to prioritize self-management, they would already have changed their life situation and thereby affected their future. One patient looked dejected when he expressed, ‘‘If you think about it [having diabetes] every day, then it will be difficult, so it is better if you forget about it between the pills. Then it won’t be a problem.’’ 3.2.2. Focusing on facts and emotions The DSNs emphasized facts about the severity of the disease as a truth, and delineated common symptoms and general treatment goals: ‘‘Generally, the same goal value for blood sugar applies to all [patients].’’ The DSNs presented the pros and cons of having the disease and avoiding disease progression. A pro, for example, was the opportunity to become a ‘‘healthier person’’, and a con was living with the risk of complications. Sometimes the DSNs remained focused on topics concerning diet, values, and selftesting, rather than responding to problems expressed by the patients. However, when DSNs tried to problematize the progressive disease by discussing the patients’ futures, patients expressed conflicting emotions: ‘‘I have no tests or medications, and I think I feel good, but maybe I do not understand how bad it is.’’ Patients commonly emphasized the feeling that, despite having T2D, they ought to live as normally as possible and take the illness for what it is as of today. They seemed troubled when they expressed that having more knowledge about diabetes could be more frightening than comforting to them. 3.3. Struggling for authority The DSNs’ and the patients’ struggle for authority characterized this theme. The DSNs governed the sessions and justified themselves in the interaction, while the patients subordinated themselves. When the DSNs became vague, however, the patients became directive and took over the session. 3.3.1. Governing and subordinating The DSNs governed the interaction by pronouncing the need for patients to have annual check-ups and by setting a template about what was normally expected of the patients concerning their training and food intake: ‘‘If you go to a birthday party once in two months and eat cream cake, it will not appear on the blood sample test.’’ They informed the patients about disease complications, without asking if the patients were interested in or receptive to this issue. The DSNs also governed the interaction by gazing at one patient at a time, thereby excluding the others, and by confronting and asking short and distinct questions about their self-management: ‘‘How many fruits do you eat per day, then?’’ They also made

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proposals and provided solutions to identified problems without asking for the patients’ opinions. The patients often interacted in a subordinate way, assuring the DSN with head nods and asking questions that followed the DSN’s agenda, agreeing and responding to the DSN: ‘‘Sometimes when I’m taking a sweet, then I remember your lesson and I see you [the DSN] in front of me.’’ Patients tried to gently resist, by expressing that their daily living was more important than controls and training: ‘‘Sometimes birthday parties are very important in many ways, aren’t they?’’ Another patient added, ‘‘Yes, what happens if you have birthday parties too seldom?’’ 3.3.2. Being vague and taking over The interaction was sometimes characterized by the DSNs’ vagueness and avoidance of sensitive topics, which resulted in a loss of focus on diabetes care and self-management. At times, the DSNs became quiet and started to browse through their papers, and they seemed to lose their moderator role. In such moments, the patients took over the meeting and sought alliance with one another. By having an equal understanding and giving support to each other, the patients found their own answers to problems. The patients sometimes agreed with the DSNs’ advice about selfmanagement, but simultaneously underlined the difficulty of implementing it. They declared that they made their own decisions at home: ‘‘It is a matter of having your own courage, to determine. You cannot decide for me. If I want a cookie, I’ll have a small one.’’ In such situations, the patients expressed reservations toward the DSN by crossing their arms, avoiding eye contact, and becoming reticent. 3.3.3. Questioning and justifying The patients sometimes questioned the care, and DSNs justified it. In such situations, the patients looked angry and resolute. They revealed difficulties in their contacts with other health care professionals, expressed ironically, for example, as: ‘‘I didn’t have time to take a breath before the doctor dismissed me’’ and ‘‘Is it okay with the doctors present only every second week?’’ The patients shook their heads, expressed perceptions of mistreatment concerning advice about treatment and lifestyle changes, and stated negative attitudes toward health care professionals. The DSNs justified and defended themselves and other professionals: ‘‘You cannot always rely on us to take the initiative. If you have concerns, then you can call.’’ The DSNs sometimes looked troubled and referred the problem to those in higher positions, instead of problematizing it further. The DSNs in general tried to justify shortcomings in the health care services and minimized colleagues’ inadequate behavior. 4. Discussion and conclusion 4.1. Discussion The main findings revealed that the interaction between DSNs and patients is a dynamic process varying between becoming empowered, approaching each other from different perspectives, and struggling for authority. This study raises an important question of how interaction between professionals and patients takes place, particularly in lifestyle-related diseases such as T2D, where self-management is crucial. The discussion will be based on the three themes that were found in the results. In the theme ‘‘becoming empowered’’, an empowering and patient-centered interaction was observed in the data. In accordance with the descriptions of several authors [24–27], the interaction concerned addressed patients’ difficulties, confirming and enabling them and engaging their thoughts and ideas about living with the illness. The patients and the DSNs encouraged and related to one another, based on a continuous relationship involving both parties in the care, which involved negotiation.

This finding is in line with Aujoulat and colleagues [24], who found that the empowering encounter was based on a continuous relationship involving both parties in the care and negotiated with each patient, reinforcing psychosocial skills for patients’ selfmanagement. Empowerment can be viewed theoretically and as a goal or process [25], where the latter concerns enabling the patients’ capabilities, finding common solutions, sharing decision-making, and relating to others as partners in care, leading to autonomous informed decisions among patients [26,27]. According to Holmstro¨m and Ro¨ing [28], empowerment can be seen as a broader concept of patient-centeredness, because it places greater demands on the professionals to enable the patients’ own capabilities. In this study, we found that when the DSNs highlighted patients’ possibilities and strengths for, and obstacles to, selfmanagement, and when patients started to reflect independently, the DSNs seemed to become empowered as well. Some authors have argued that nurses have to understand empowerment both theoretically and practically and perceive it themselves as a prerequisite to enabling and empowering others [29]. Further knowledge of how to implement empowering approaches may help professionals maintain a satisfying interaction, so they simultaneously avoid being caught between different perspectives of the disease/illness. In the theme ‘‘approaching each other from different perspectives’’, the DSNs emphasized the disease and objectified patients, expounding the disease severity and management, while patients eagerly tried to emphasize their perspectives, describing their life situations and emotions. The DSNs often focused on food intake and blood glucose values while the patients focused on social concerns and how they were feeling. DSNs and patients having different perspectives on chronic illness and diabetes has also been described by other authors [18,30,31]. Toombs [32] argued that professionals view patients’ diseases more from a naturalistic perspective, emphasizing biomedical values, while patients view their illnesses from a natural perspective, focusing on daily life and function. DSNs have been described by patients as having a onesided disease perspective, exaggerating the disease and prioritizing routines [13] and emphasizing the disease over the patients’ life-world perspective [30]. Being aware of these different perspectives in the interaction may help health care professionals, who are reported to lack sufficient counseling skills, to encourage patient self-management in primary health care [33]. In the theme ‘‘struggling for authority’’, the interaction was characterized as the DSNs’ governing. The patients’ participation was seldom encouraged, implying that both parties struggled for their own authority. If the interaction between the DSNs and the patients is unsatisfying—that is, when both parties disagree both explicitly and implicitly about goals for self-management—the patients’ autonomy may be less supported, and a collaborative responsibility between DSNs and patients may be difficult to achieve [34]. We found that the DSNs often had an informative approach, setting the agenda of what was expected of the patients, while patients distanced themselves from the DSNs. It has been reported that professionals’ governing and lecturing about longterm goals for self-management and warning patients may inspire a reaction opposite to the one desired. Furthermore, patients having a day-by-day plan for self-management may be questioned and regarded by professionals as non-compliance [35]. At times the patients questioned the diabetes care, and took control over the interaction, which have been interpreted as a necessary part of a process toward becoming autonomous, empowered, and responsible for self-management. Paterson and colleagues [3] have described self-management as a movement through: passive compliance, naive experimentation, rebellion, and active control. Rebellion should be seen as a benefit and something health care professionals might view as a prerequisite to patients’ taking

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responsibility for their self-management—a challenge, rather than a threat. The DSNs struggled for their authority by governing and holding on to an expert role in the interaction, also described earlier [15,16]. Redman [36] argued that harm can be avoided and self-management supported by an interaction where confidence is inspired and oppressive messages and controlling behaviors are avoided. 4.2. Conclusion DSNs must be aware of each patient’s individual needs and avoid responding to the patients in a normative way. DSNs benefit from becoming aware of their own shortcomings in interactions, such as being too informative, and instead focusing more on listening and relating to, and encouraging, patients. A satisfying interaction could strengthen the patients so that they make wellinformed decisions about their self-management, and also strengthen the DSNs in their professional role performance. 4.3. Practice implications This study suggests that group sessions in the form described here, which is not a common form of diabetes care in Sweden, rather an innovative approach, may be beneficial, but DSNs need professional supervision to handle a patient-centered self-management support and interaction. In clinical practice, DSNs and patients would benefit from seeing each other as partners, sharing different experiences as a common resource. Emphasizing patient matters enable and empower patients in their self-management of chronic illness. It is important to remember that authority struggles among patients may be a prerequisite to becoming autonomous. DSNs can support patients more adequately if they do not perceive authority struggles as threats against their professional role. The results from this study may be of relevance in other contexts of chronic illness where nurses’ interaction concerning self-management is important. 4.4. Methodological discussion The observations took place at the fifth of six sessions, since responsibility for self-management was the topic. The participants’ acquaintance with one another before the observation was a benefit. Observations are difficult, and using videotapes for corroboration of the interaction may be a help. In this study, the field notes complemented the transcription, describing the participants’ positions and movements, conversation, expressions. The observer was at the time for the data collection a PhD student and an experienced primary health care nurse, but having limited experience of observations. Therefore, observations and notes taken were carefully discussed with the main supervisor (the last author) before and after the various observations. Four authors were senior researchers, two with extensive experience of diabetes care. Only one observer was present during the group sessions, which raise a question as to whether everything important was captured. The observer was conscious of her own role in being a part of and influencing the interaction [37]. To obtain trustworthiness, the whole research group discussed themes and subthemes, resulting in a consolidation of the findings. Acknowledgments We acknowledge with thanks funding provided by the Swedish Diabetes Association, Strategic Research Program in Care Science; the Department of Nursing, Umea˚ University; and the Faculty of Medicine, Umea˚ University. The authors declare no conflicts of interest.

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References [1] Andersson MM, Carlsson B-M, Adolfsson ET, Wikblad K. Diabetessjuksko¨terskans roll i diabetesva˚rden-en tidsstudie. The role of specialist nurses in diabetes care – a time study SFSD, Swedish Federation for nurses in diabetes care; 2009 Available athttp://www.swenurse.se/PageFiles/11390/Diabetessjuksk%C3%B6terskans%20roll%20i%20diabetesv%C3%A5rden%20091207.pdf [accessed 19.11.12]. [2] SBU, Swedish Council on Technology Assessment in Health Care. Patientutbildning vid diabetes: en systematisk litteraturo¨versikt. Patient education in diabetes care: a systematic literature review Stockholm: Swedish Council on Technology Assesment in Health Care; 2009. [3] Paterson B, Thorne S. Developmental evolution of expertise in diabetes selfmanagement. Clin Nurs Res 2000;9:402–19. [4] ADA, American Diabetes Association. National standards for diabetes selfmanagement education. Diabetes Care 2012;35:101–8. [5] IDF. Global guidelines for type 2 diabetes. Clinical Guidelines Task Force; 2012, http://www.idf.org/sites/default/files/IDF%20Guideline%20for%20Type%202% 20Diabetes.pdf [accessed 30.11.12]. [6] National Board of Health and Welfare. Nationella riktlinjer fo¨r diabetesva˚rden 2010: sto¨d fo¨r styrning och ledning. National guidelines for diabetes care: support for governance and management Stockholm: Socialstyrelsen; 2010. [7] Steinsbekk A, Rygg LØ, Lisulo M, Rise MB, Fretheim A. Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis. BMC Health Serv Res 2012;12:213–32. [8] Adolfsson ET, Rosenblad A, Wikblad K. The Swedish National Survey of the Quality and Organization of Diabetes Care in Primary Healthcare—Swed-QOP. Primary Care Diabetes 2010;4:91–7. [9] Heinrich E, Schaper NC, de Vries NK. Self-management interventions for type 2 diabetes: a systematic review. Eur Diab Nurs 2010;7:71–6. [10] Fleischer S, Berg A, Zimmermann M, Wu¨ste K, Behrens J. Nurse–patient interaction and communication: a systematic literature review. J Public Health 2009;17:339–53. [11] Shattell M. Nurse–patient interaction: a review of the literature. J Clin Nurs 2004;13:714–22. [12] Watson J. Commentary on Shattell M (2004) Nurse–patient interaction: a review of the literature. J Clin Nurs 13, 714–22. J Clin Nurs 2005;14:530–2. [13] Ho¨rnsten A˚, Graneheim UH. A lesson to learn – patients’ critiques of diabetes nursing. Int J Adv Nurs 2011;11–22. Available athttp://www.ispub.com/ journal/the-internet-journal-of-advanced-nursing-practice/volume-11number-1/a-lesson-to-learn-patients-critiques-of-diabetes-nursing.html [accessed 19.11.12]. [14] Ho¨rnsten A˚, Lundman B, Selstam EK, Sandstrom H. Patient satisfaction with diabetes care. J Adv Nurs 2005;51:609–17. [15] Adolfsson ET, Smide B, Gregeby E, Fernstrom L, Wikblad K. Implementing empowerment group education in diabetes. Patient Educ Couns 2004;53:319– 24. [16] Bostro¨m E, Isaksson U, Lundman B, Sjo¨lander AE, Ho¨rnsten A˚. Diabetes specialist nurses’ perceptions of their multifaceted role. Eur Diab Nurs 2012;9:39–44. [17] Holmstro¨m IM, Rosenqvist U. Misunderstandings about illness and treatment among patients with type 2 diabetes. J Adv Nurs 2005;49:146–54. [18] Ho¨rnsten A˚, Lundman B, Almberg A, Sandstro¨m H. Nurses’ experiences of conflicting encounters in diabetes care. Eur Diab Nurs 2008;5:64–9. [19] Holmstro¨m I, Halford C, Rosenqvist U. Swedish health care professionals’ diverse understandings of diabetes care. Patient Educ Couns 2003;51:53–8. [20] Jutterstro¨m L. Illness integration, self-management and patient-centred support in type 2 diabetes. Umea˚: Umea˚ University; 2013 [Medical dissertation]. [21] Ho¨rnsten A, Sandstrom H, Lundman B. Personal understandings of illness among people with type 2 diabetes. J Adv Nurs 2004;47:174–82. [22] Adler PA, Adler P. Observational techniques. In: Denzin NK, Lincoln YS, editors. Handbook . of qualitative research. Thousand Oaks, CA: Sage Publications; 1994 [23] Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurs Educ Today 2004;24:105–12. [24] Aujoulat I, d’Hoore W, Deccache A. Patient empowerment in theory and practice: polysemy or cacophony. Patient Educ Couns 2007;66:13–20. [25] Kuokkanen L, Leino-Kilpi H. Power and empowerment in nursing: three theoretical approaches. J Adv Nurs 2000;31:235–41. [26] Zoffmann V, Kirkevold M. Realizing empowerment in difficult diabetes care: a guided self-determination intervention. Qual Health Res 2011;22:103–18. [27] Anderson RM, Funnell MM. Patient empowerment: myths and misconceptions. Patient Educ Couns 2010;79:277–82. [28] Holmstro¨m I, Ro¨ing M. The relation between patient-centeredness and patient empowerment: a discussion on concepts. Patient Educ Couns 2010;79:167– 72. [29] Williams T. Patient empowerment and ethical decision making: the patient/ partner and the right to act. Dimens Crit Care Nurs 2002;21:100–4. [30] Zoffmann V, Kirkevold M. Life versus disease in difficult diabetes care: conflicting perspectives disempower patients and professionals in problem solving. Qual Health Res 2005;15:750–65. [31] Paterson BL. The shifting perspectives model of chronic illness. J Nurs Scholarsh 2004;33:21–6. [32] Toombs SK. The meaning of illness: a phenomenological account of the different perspectives of physician and patient. Dordrecht: Kluwer; 1992.

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[33] Jallinoja P, Absetz P, Kuronen R, Nissinen A, Talja M, Uutela A, et al. The dilemma of patient responsibility for lifestyle change: perceptions among primary care physicians and nurses. Scand J Prim Health Care 2007;25: 244–9. [34] Moser A, Houtepen R, Spreeuwenberg C, Widdershoven G. Realizing autonomy in responsive relationships. Med Health Care Philos 2010;13: 215–23.

[35] Matthews SM, Peden AR, Rowles GD. Patient–provider communication: understanding diabetes management among adult females. Patient Educ Couns 2009;76:31–7. [36] Redman BK. The ethics of self-management preparation for chronic illness. Nurs Ethics 2005;12:360–9. [37] Carolan M. Reflexivity: a personal journey during data collection. Nurse Res 2003;10:7–14.

Interaction between diabetes specialist nurses and patients during group sessions about self-management in type 2 diabetes.

The aim of this study was to explore the interaction between diabetes specialist nurses (DSNs) and patients with type 2 diabetes (T2D) during group se...
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