I S S U E S A N D IN N O V A T I O N S IN N U R S I N G P R A C T I C E

Diabetes care: practice nurse roles, attitudes and concerns

Tim Kenealy
New Zealand
MBChB FRNZCGP

HRC Training Fellow, Department of General Practice and Primary Health Care, University of Auckland, Auckland,

Bruce Arroll
New Zealand

BSc MBChB MHSc PhD FRNZCGP FAFPHM

Associate Professor, Department of General Practice and Primary Health Care, University of Auckland, Auckland,

Helen Kenealy

BHB

Medical Student, University of Auckland, Auckland, New Zealand

Barbara Docherty

RGON ADN

Director, Primary Health Care Nursing, Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand

David Scott

MBChB FRNZCGP

Diabetologist, Diabetes Project Trust, Auckland, New Zealand

Robert Scragg

MBChB PhD FAFPHM

Senior Lecturer, Department of Community Health, University of Auckland, Auckland, New Zealand

David Simmons

MD FRACP

Professor of Rural Health, Department of Rural Health, University of Melbourne, Shepparton, Victoria, Australia

Submitted for publication 18 March 2003 Accepted for publication 15 March 2004

Correspondence: Tim Kenealy, Department of General Practice and Primary Health Care, University of Auckland, Private Bag 92019, Auckland, New Zealand. E-mail: [email protected]

KENEALY T., ARROLL B., KENEALY H., DOCHERTY B., SCOTT D., SCRAGG R.

Journal of Advanced Nursing 48(1), 6875 Diabetes care: practice nurse roles, attitudes and concerns Background. Practice nurses (PNs) are the largest group of nurses providing primary care for patients with diabetes in New Zealand, and changes in the health system are likely to have a substantial effect on their roles. To inform the development of a new primary health care nursing structure and evaluate the new role associated with this, it will be important to have data on current practice nurse roles. Aims. The aim of this paper is to report a study to compare the diabetes-related work roles, training and attitudes of practice nurses in New Zealand surveyed in 1990 and 1999, to consider whether barriers to practice nurse diabetes care changed through that decade, and whether ongoing barriers will be addressed by current changes in primary care. Methods. Questionnaires were mailed to all 146 PNs in South Auckland in 1990 and to all 180 in 1999, asking about personal and practice descriptions, practice organization, time spent with patients with diabetes, screening practices,
& SIMMONS D. (2004)

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components of care undertaken by practice nurses, difculties and barriers to good practice, training in diabetes and need for further education. The 1999 questionnaire also asked about nurse prescribing and inuence on patient quality of life. Results. More nurses surveyed in 1999 had postregistration diabetes training than those in 1990, although most of those surveyed in both years wanted further training. In 1999, nurses looked after more patients with diabetes, without spending more time on diabetes care than nurses in 1990. Nevertheless, they reported increased involvement in the more complex areas of diabetes care. Respondents in 1999 were no more likely than those in 1990 to adjust treatment, and gave a full range of opinion for and against proposals to allow nurse prescribing. The relatively low response rate to the 1990 survey may lead to an underestimate of changes between 1990 and 1999. Conclusions. Developments in New Zealand primary care are likely to increase the role of primary health care nurses in diabetes. Research and evaluation is required to ascertain whether this increasing role translates into improved outcomes for patients. Keywords: practice nurse, diabetes, role changes, education, nurse prescribing, survey

Introduction
In New Zealand, important concurrent changes are taking place in diabetes care, the role of practice nurses (PNs), and the whole structure and delivery of primary health care. Concern about an epidemic of diabetes in New Zealand (Simmons 1996a, 1996b) prompted production of a national strategy in 1997 (Ministry of Health 1997), which placed primary health care at the centre of diabetes detection and management. Despite the changes being created by reformers, many at government level, there is no published description of the diabetes care currently provided by PNs or other nurses working in primary health care. This paper offers a baseline description that will contribute to later efforts to evaluate the impact of the reforms. Primary health care in New Zealand is currently delivered principally by general practices consisting of PNs, general medical practitioners (GPs) and support staff. There was at least one PN in 94% of general practices in 1999 (Kenealy et al. 2002a, 2002c). General practice provides sole medical care for over 60% of all patients with diabetes across all ethnic groups (Simmons et al. 1994). Care of a person with diabetes is commonly divided between a PN and GP, although the roles overlap considerably and the division of labour varies between practices. Nevertheless, a new payment to primary health care providers for a diabetes annual review is likely to encourage devolvement of diabetes care from GPs to PNs (Health Funding Authority 2000). General practices have typically been owned and run by GPs. Since 1970, the government has subsidised PN salaries

in general practice to provide GPs with nursing assistance. The PN work role is, therefore, typically moulded around that of the GP, and the patients who attend the GP on a given day. This has resulted in few nursing decisions being made by nurses for nurses and has ultimately hindered progress in professional development for PNs at a national level or in advanced nursing practice. PN roles, training and competency vary considerably and there is no benchmark to assess the competence of any PN in providing diabetes care. Health reforms since 2001 have signalled a major role for primary health care (PHC) nurses (King 2001). This has resulted in a national education framework for primary health care nursing that is presently moving through the endorsement requirements of the Nursing Council of New Zealand. The framework includes a new nurse practitioner pathway at clinical masters level, which will allow nurse prescribing. All nurses working in primary health care, including PNs, will work under the auspices of primary health care nursing at a postgraduate level and have associated competencies that will be required for annual practising certicates. The requirement for postgraduate training in future contracts for PNs nursing services will ensure advanced nursing roles in disease management, including diabetes. A new government primary health care strategy is using funding to direct general practices to become part of new primary health organizations that are funded by capitation (payment to the organization) rather than fee-for-service (payment to the doctor) (King 2001). This reorganization also seems likely to support the developing role of a qualied
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PHC nurse, who may run diabetes mini-clinics (which are still unusual in New Zealand) and may, increasingly, take on the role of diabetes case-manager. Many of these changes would make primary health care in New Zealand more like that in the United Kingdom (UK). In this paper, along with a description of current PN diabetes care, we describe changes that have taken place since 1990, when a survey was undertaken as part of a major study of diabetes in South Auckland (Wilson et al. 1994, Simmons et al. 2000). To evaluate the new PHC nurse role it is important to consider published data on current PN roles and historical changes in this role.

all PNs working in South Auckland was obtained from a commercial mail-list company and also supplemented by telephoning each practice. A total of 213 PNs were initially identied, of whom 33 proved ineligible (six retired, 27 left the practice), leaving 180 PNs eligible. The commercial list contained only 775% of those on the nal list. The questionnaires were posted in November 1999 and responses were not anonymous. Non-responders were phoned after 2 weeks, followed by a second mail-out and a nal phone call.

Questionnaires
The 1990 questionnaire consisted of a total of 104 closed and open questions. In 1999, it was shortened and updated to address current interests. The 1999 questionnaire contained a total of 76 closed and open questions, including 66 previously asked. Both questionnaires enquired about personal and practice descriptions, practice organization, time spent with patients with diabetes, screening practices, components of care undertaken by PNs, difculties in and barriers to good practice, training in diabetes and need for further education. In 1999, additional questions were asked about PN attitudes to nurse prescribing and their expectations of inuencing patient quality and quantity of life. We can provide copies of the questionnaires on request. Techniques used to improve response rate in both 1990 and 1999 included multiple contacts, different methods of contact, attention to presentation of the questionnaire and the offer to enter respondents into a prize draw (Sibbald et al. 1994, Deehan et al. 1997, Young & Ward 1999).

The study
Aims
The aims of the study were: to describe the diabetes-related work roles, training and attitudes of PNs in New Zealand, comparing 1990 with 1999; and to consider whether barriers to PN diabetes care changed through that decade, and whether ongoing barriers may be addressed by current changes in primary care.

Design
A longitudinal survey design was used, with questionnaires being distributed to all South Auckland PNs in 1990 and 1999.

Setting
South Auckland had a population of 341,721 according to the 1996 census, with 53% being European, 17% New Zealand Maori, 16% Pacic Polynesian, 8% Asian and 6% other and unknown ethnicities (Statistics New Zealand 1997). The population in the area increased by 23% between the 1991 and 2001 censuses (http://www.statistics.govt.nz). The area includes some of the most economically deprived people in New Zealand and is relatively under-served by health care providers.

Ethical considerations
Both studies received approval from the appropriate ethics committees. Responses were anonymous, but questionnaires were tagged with a temporary identication code to track non-responders, who were followed-up by letter and then by telephone. Consent to participate was implied by return of a completed questionnaire.

Data analysis
SPSS 11.0 software was used to analyse the data. All results reported refer to respondents only. Only data from questions that were unchanged from 1990 to 1999 were directly compared. Means were compared by t-test. Equal variance was assumed when comparing years since graduation of PNs in 1990 and 1999, but was not assumed for all other comparisons. Proportions were compared using Pearsons chi-square test, and the MannWhitney U-test was used to

Participants
All PNs working in South Auckland at the time of the surveys were considered eligible for the studies. In 1990, a list of PNs working in South Auckland was compiled from Auckland Area Health Board records and updated by telephoning each practice. A total of 146 PNs were identied. In 1999, a list of
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compare scale rankings. Statistical signicance was set at P 005 and all tests were two-tailed.

Results
In 1990, responses were received from 86 PNs in 51 practices and in 1999 from 155 PNs in 77 practices, giving response rates of 59% and 86%, respectively (v2 3096, d.f. 1, P < 00001). Table 1 describes the nurses and the general practices in which they worked. Practice sizes increased from 1990 to 1999, as judged by the number of GPs per practice. Similarly, the total number of PNs per practice grew, due to an increase in the number working part-time, although the mean number of hours worked was essentially unchanged. PNs surveyed in 1999 had more years of experience since registration or graduation and had worked longer in their current practice than those in 1990. In 1990, 148% of PNs had postregistration education in diabetes compared with 471% in 1999 (v2 23929, d.f. 1, P < 00001), although it is notable that nearly all nurses in both years wanted more education. Of the 59 PNs in 1999 who gave a description of their education, 49 said that they had attended diabetes education sessions run by staff working in outpatient clinics at local hospitals. In 1999, 73 PNs reported past experience in diabetes care, including 53 while working on medical wards, 22 on surgical wards, seven as district nurses and ve in care of older people. It was not possible to count the exact number of organizations or providers of education, but it was clear that there was a wide range of educators and minimal co-ordination between them, with subsequent fragmentation of diabetes education.

Those PNs surveyed in 1999 who had any postregistration diabetes education were compared with those who had not. It was found that they had more years of postregistration experience [241 (SE 124) vs. 194 (SE 120), t 2683, d.f. 151, P 0008]; were more likely to regularly spend time with established patients (76% vs. 59%, v2 4914, d.f. 1, P 0027); were more likely to feel that their workload allowed for positive health promotion (79% vs. 58% P 0007); and were more likely to be involved in foot care (61% vs. 40%, v2 7339, d.f. 1, P 0021). Nevertheless, they were also more likely to perceive nancial, educational and other barriers to regular patient attendance and achieving good diabetes control (78% vs. 60%, v2 5339, d.f. 1, P 0021), and to say that they experienced difculties in educating some groups of patients (78% vs. 60%, v2 5134, d.f. 1, P 0023). However, there were no statistically signicant differences in hours involved in diabetes care per week, methods used for diabetes screening, and likelihood of being involved in education about diet, weight, hypoglycaemia, blood testing, sick days, insulin injections, adjusting treatment or taking blood pressure. Similar analyses comparing part-time and full-time PNs showed no signicant differences. Table 2 shows that about one-third of PNs in both 1990 and 1999 prompted their GPs to screen for diabetes. Of the respondents to the 1999 survey who did not prompt, 146% commented that they did not need to, 101% did it themselves and 124% said they would do it for high risk patients. PNs were asked an open-ended question about which patient groups warrant screening for diabetes. Suggestions from the nurses surveyed in 1999 were Pacic Island people (471%), Maoris (297%), obese or overweight people (196%), those with a family history of

Table 1 Practice nurses and their practices, comparing 1990 with 1999 1990 (n 86) Years since graduation Range Mean (SE ) Years as a nurse, mean (SE ) n Years as a practice nurse, mean (SE ) n Postregistration diabetes education, % (n) Want more diabetes education, % (n) PNs in practice part-time, mean (SE ) n PNs in practice full-time, mean (SE ) n Total PNs in practice, mean (SE ) n Hours worked per week, mean (SE ) n Years in current practice, mean (SE ) n Number of GPs in PNs practice, mean (SE ) n Practice has computerized patient information, % (n) n, Number of valid responses. 2004 Blackwell Publishing Ltd, Journal of Advanced Nursing, 48(1), 6875 71 1999 (n 155) Statistics t 2283, d.f. 235, P 0023 140 185 (097) 136 (079) Not asked 148 (81) 923 (79) 22 (022) 080 (014) 31 (024) 280 (114) 38 (042) 27 (023) 355 (76) 143 216 (087) Not asked 81 (052) 471 (153) 882 (144) 30 (028) 10 (010) 40 (029) 299 (076) 57 (051) 37 (025) 929 (154)

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153

82 82 82 81 80 82

154 154 154 151 153 144

v2 23929, d.f. 1, P < 00001 v2 0760, d.f. 1, P 038 t 2154, d.f. 23297, P 0032 t 1230, d.f. 17269, P 022 t 2598, d.f. 22996, P 001 t 1393, d.f. 15148, P 017 t 2874, d.f. 22788, P 0004 t 2989, d.f. 21502, P 0003 v2 86744, d.f. 1, P < 00001

T. Kenealy et al. Table 2 Practice nurse involvement in diabetes care, expressed in terms of percentage of valid responses (number of valid responses) except where stated otherwise 1990 (n 86) Prompt doctor to screen for diabetes Screening methods used (multiple answers allowed) Urine glucose Capillary blood glucose metre Fructosamine Random blood glucose Fasting glucose 2 hours after glucose load Glucose tolerance test Haemoglobin A1c Involved in care of patients with diabetes Interview new patients with diabetes prior to GP consultation Regularly spend time with established patients Workload allows positive health promotion Hours per week spent in diabetes care, mean (SE ) n Work includes (multiple answers allowed) Diet education Home glucose testing Adjustment of treatment Hypoglycaemia Sick days Education/support for family Weight control Injection technique Explaining what diabetes is Foot care Blood pressure measurement Involvement is one-to-one with patient Involvement is with patient and family Importance of having family member present Not important Moderate Very important 321 (78) 658 (73) 151 (73) 671 (73) 849 (73) 534 (73) 151 (73) 575 (73) Not asked 802 (81) 413 (80) 825 (80) 747 (75) 23 (057) 30 857 810 175 238 127 492 778 95 508 397 714 932 15 (63) (63) (63) (63) (63) (63) (63) (63) (63) (63) (63) (73) (64) 1999 (n 155) 386 (145) 415 (135) 763 (135) 304 (135) 770 (135) 504 (135) 111 (135) 474 (135) 459 (135) 793 (150) 288 (153) 675 (151) 680 (150) 29 (040) 73 906 (128) 914 (128) 156 (128) 383 (128) 320 (128) 602 (128) 805 (128) 258 (128) 773 (128) 516 (128) 867(128) 984 (127) 224 (58) 38 (5) 392 (51) 569 (74) Statistics v2 0946, d.f. 1, P 033 v2 11165, d.f. 1, P 0001 v2 71711, d.f. 1, P < 00001 v2 26072, d.f. 1, P < 00001 v2 1832, d.f. 1, P 018 v2 0177, d.f. 1, P 067 v2 0678, d.f. 1, P 041 v2 1944, d.f. 1, P 016 v2 0027, d.f. 1, P 087 v2 3705, d.f. 1, P 0054 v2 5893, d.f. 1, P 0015 v2 1063, d.f. 1, P 030 t 0926, d.f. 588, P 036 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 v2 104, d.f. 1, P 030 4356, d.f. 1, P 0037 0105, d.f. 1, P 075 3969, d.f. 1, P 0046 8274, d.f. 1, P 0004 2060, d.f. 1, P 015 0188, d.f. 1, P 066 6867, d.f. 1, P 0009 13813, d.f. 1, P 0002 2389, d.f. 1, P 012 6596, d.f. 1, P 001 3818, d.f. 1, P 0051 839, d.f. 1, P 0004

83 (6) 250 (18) 667 (48)

v2 5189, d.f. 2, P 0075

diabetes (155%) and middle-aged (200%) or older (97%) people. Participants in both years identied similar groups whom they had difculty educating. In 1999, the nurses listed Pacic Island people (181%), non-English speakers (110%), Maori (103%), older (45%), Chinese (32%) and Indian (26%) people. The reasons given were patient non-compliance (110%) and disinterested patients (65%). Nurses in the 1999 survey were also asked how big a difference they could make to patient quality of life and length of life, each measured on a seven-point Likert scale ranging from 1 (no difference) to 7 (huge difference). The median scores for both quality and length were 50 (range 17). Nurses with postregistration or postgraduate education in diabetes were signicantly more likely to believe that they could make a difference to quality of life than were those without such education, median 60 (range 27) vs.
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50 (range 17) (MannWhitney U-test 1473, z 2289, P 0022). However, the two groups did not differ statistically in respect of their expectation of making a difference to length of life. Nor was there any signicant difference in the patient length or quality of life scores given by nurses whose workload did or did not provide time for positive health promotion. In 1999, participants were asked, Do you see your role changing with the introduction of nurse prescribing rights? Forty-two (326%) ticked yes and 87 ticked no. An openended question asked them to explain their response. There was a wide range of explanations in each group. These included: opposed in principle to nurse prescribing (6); not intending to take up the option themselves (13); not needed because the current system is satisfactory (6); does not t current role or practice structure (6); doctors or practice would oppose (7); and prescribing would advantage the

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patient (8), the PN (4) or the doctor (1). There were also multiple comments on the need for additional training and support if they were to undertake this role. Six comments reected uncertainty about the mechanisms and long-term implications of nurse prescribing.

Discussion
This study shows an impressive increase between 1990 and 1999 in the proportion of PNs with some postregistration or postgraduate training in diabetes. There was also an impressive increase in PN involvement in the more complex aspects of diabetes care, including initial education about diabetes, sick day management, hypoglycaemia management, glucose self-monitoring and injection technique. Nurses in both 1990 and 1999 reported high levels of giving dietary advice and assisting with weight control. While both groups considered it important to have a family member present during diabetes care and education, the nurses surveyed in 1999 reported achieving this signicantly more often. Increased involvement in complex care was not limited to the nurses who reported additional training. It is interesting to note that nearly all the nurses in both years wanted additional diabetes education. Studies with South Auckland GPs conducted at the same time as the PN surveys found that the number of patients with diabetes per GP increased from a median of 20 in 1990 to 33 in 1999, while the number of GPs per practice increased from a mean of 28 in 1990 to 37 in 1999 (Kenealy et al. 2002a, 2002c). Thus, it seems that in 1999 PNs worked in larger practices, with more patients with diabetes and, although they spent no more hours on diabetic care, they looked after more complex areas of diabetes. It is understandable that the PNs surveyed in 1999 felt less able than those in 1990 to spend time with either new or established patients. It was noted earlier that the role of each PN has been largely moulded around the GPs in their particular practice, which signicantly limits the exibility of PNs to practice as they might ideally wish. A strength of this study is that it reports changes in PN diabetes care over nearly 10 years in the same district. A search, using the terms nurses and diabetes, of CINAHL from 1982 to February 2003 and Medline from 1966 to February 2003 failed to nd a similar study. In both years approximately 80% of respondents said they were involved in diabetes care. However, it must be noted that the proportion of non-responders was higher in 1990 and it is known that people not involved in the type of work being studied are less likely to respond (Sibbald et al. 1994). During education sessions conducted after the 1990 survey, we received many anecdotes from nurses who had not respon-

ded, conrming that they were not involved in diabetes care. Therefore, a comparison of respondents in 1990 and 1999 is likely to underestimate the increase in PN diabetes activity. A weakness of this study is that behaviours are self-reported rather than measured more directly, which would require a more comprehensive study using different methods. The study showed that PNs surveyed in 1999 were staying longer in the same practice than those in 1990. This bodes well for continuity of care for patients. Where doctors are concerned, continuity of care for diabetes leads to signicant lowering of patient HbA1c (Parchman et al. 2002). Many PNs, especially those surveyed in 1999 who had more diabetes training, were conscious of difculties with educating and achieving good diabetes control in some groups of patients. Unfortunately, these patient groups include Maori and Pacic people, who have particularly high rates of diabetes and associated complications (Simmons 1996a, 1996b). Recently, there has been a rapid uptake by PNs of the Early Intervention Training Programme, in which participants learn brief intervention skills and strategies to assist in behavioural change for patients with diabetes. The programme is nurse-led and is unique to New Zealand. From June 1997 to July 1999, 798 PNs and other primary health care nurses were trained in this programme, and a further 3463 were trained from July 1999 to January 2003. It seems that PNs in both years considered it important to involve family members in patient education, but by 1999 they were more able to achieve this. We did not ask which patients they thought would benet from family involvement, nor how they would conduct these sessions. We speculate that the PNs focussed on the families of Maori and Pacic patients, both groups for whom the individual patient illness is often viewed, understood and adequately managed only within the context of the extended family (New Zealand Guidelines Group 2004). Practice nurses were frequently involved in screening for diabetes and between 1990 and 1999 had appropriately decreased the use of tests based on urine glucose and fructosamine. However, for screening in particular, increased use of capillary whole-blood metres may be undesirable due to the wide condence intervals associated with the results that they produce (Kenealy et al. 2002b). It is interesting to note that, in the UK during the 1990s, the role of the PN in diabetes care increased dramatically, and that 71% of practices in a national survey in 1997 had miniclinics for diabetes care, nearly all of which either included or were run by nurses (Carr et al. 1991, Jones & Marsden 1992, Pierce et al. 2000). Furthermore, in the UK, insulin dose adjustment by nurses is commonplace and there is a move to
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What is already known about this topic

Practice nurses in the United Kingdom and other countries have an important role in diabetes care. There is no published information about past, present or future roles of practice nurses in diabetes care in New Zealand. There is no baseline information against which to evaluate developing changes in New Zealand primary care.

What this paper adds

Practice nurses in New Zealand have an important role in diabetes care. The role of practice nurses developed substantially through the 1990s, but was limited by their employment status and the structure and funding of primary care. New changes to health care structures and funding will need to be evaluated against the data presented here.

variety of ad hoc groups. It is notable that none of the training reported in this study was led by primary health-care-based nurses, despite unique differences between primary and secondary nursing functions. In the year 2000, 13 different general groups provided diabetes education to PNs, including diabetes societies, diabetes nurse specialists, pharmaceutical companies and others. New legislation that requires ongoing training for health professionals will be met, for nursing, by competency-based annual practising certicates issued by the Nursing Council of New Zealand. This is a good opportunity to mandate minimum up-skilling on specic topics, such as diabetes, within each re-registration cycle.

Conclusion
Practice nurses surveyed in 1999 reported more diabetes training and more complex diabetes work roles compared with similar nurses in 1990. Nevertheless, they had the same time available for diabetes care and limited control over their own work patterns. Training was found to be episodic, opportunistic and there was no national programme of diabetes education. Ongoing research and evaluation is required to ascertain whether the increasing role of nurses in dealing with diabetes in primary health care translates into improved outcomes for patients. This especially applies to those patients with the greatest needs, whom some PNs currently consider to be their most challenging patients. Such research and ongoing evaluation may be particularly important for nursing and the population as a whole in New Zealand, where suitably qualied primary health care nurses should be compared with the current under-trained and underutilized PNs.

change the law to sanction this (Craddock & Avery 1998). Perhaps the wide range of roles undertaken by the New Zealand PNs, and the fact that nurses in 1999 were no more likely than those in 1990 to adjust treatment, underlie the ambivalent attitude, in 1999, to the prospect of nurse prescribing rights. Many foresaw practical difculties in their practice or personal difculties because of the training needed and a majority did not anticipate any role change for themselves. It is clear that nurses (in a variety of roles and with appropriate training and systems of care) can improve diabetes care (Bessman 1974, MacKinnon et al. 1989). Nurse case-managers have been effective in primary care in the United States of America (USA) (Aubert et al. 1998) and have been specically advocated for South Auckland (Simmons et al. 2000), where they have already been piloted. Improved glycaemic control has been shown in patients attending a practice where a nurse has dietetic skills (Pringle et al. 1993). PN involvement in diabetes care was shown, in a UK study, to result in better glycosylated haemoglobin levels and the patients were more likely to have their blood pressure, weight, foot examinations and visual acuity documented (Stearn & Sullivan 1993). However, these authors list the specic training requirements needed to achieve reliably positive results, New Zealand PNs have no formalized national educational framework and training is carried out by a wide
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Acknowledgements
Tim Kenealy was funded by a Training Fellowship and Helen Kenealy was funded by a Summer Studentship, both from the Health Research Council of New Zealand, which also funded the 1990 study. Thanks to Alistair Stewart for statistical advice.

Author contributions
Study conception and design TK, BA, HK, DS, RS & DS, Data collection TK & HK, Data analysis TK, HK & BD, Drafting of manuscript TK & BD, Critical revisions of manuscript for important intellectual content TK, BA, HK, BD, DS, RS & DS, Statistical expertise TK, Obtaining funding TK, BA, DS & RS, Supervision TK & BA.

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Nurse roles, attitudes and concerns in diabetes care Parchman M.L., Solomon T., Noel P., Larme A. & Pugh J. (2002) Continuity of care, stages of change for self-management behaviors, and glucose control among patients with type 2 diabetes (Abstract of Distinguished Papers: From the 2001 Meeting of the North American Primary Care Research Group). Journal of Family Practice 51, 263264. Pierce M., Agarwal G. & Ridout D. (2000) A survey of diabetes care in general practice in England and Wales. British Journal of General Practice 50, 542545. Pringle M., Stewart-Evans C., Coupland C., Williams I., Allison S. & Sterland J. (1993) Influences on control in diabetes mellitus: patient, doctor, practice, or delivery of care? British Medical Journal 306, 630634. Sibbald B., Addington-Hall J., Brenneman D. & Freeling P. (1994) Telephone versus postal surveys of general practitioners: methodological considerations. British Journal of General Practice 44, 297300. Simmons D. (1996a) Diabetes and its complications in New Zealand: an epidemiological perspective. New Zealand Medical Journal 109, 245247. Simmons D. (1996b) The epidemiology of diabetes and its complications in New Zealand. Diabetic Medicine 13, 371375. Simmons D., Shaw L., Kenealy T. & Scragg R. (1994) Ethnic differences in diabetes knowledge and education: The South Auckland Diabetes Survey. New Zealand Medical Journal 107, 197200. Simmons D., Kenealy T. & Scott D. (2000) Implementing the South Auckland Diabetes Plan: barriers and lessons. New Zealand Medical Journal 113, 364366. Statistics New Zealand (1997) 1996 Census of Population and Dwellings: Regional Summary. Statistics New Zealand, Wellington. Stearn R. & Sullivan F.M. (1993) Should practice nurses be involved in diabetic care. British Journal of Nursing 2, 952956. Wilson P., Simmons D. on behalf of the South Auckland Community Diabetes Planning Group (1994) The development of community orientated recommendations for diabetes care in south Auckland. New Zealand Medical Journal 107, 456459. Young J. & Ward J. (1999) Improving survey response rates: a meta-analysis of the effectiveness of an advance telephone prompt from a medical peer (letter). Medical Journal of Australia 179, 339.

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