1. Perceptions of Insulin Therapy in Type 2 Diabetes A Thematic Synthesis
*Kathy Ellis, Henrietta Mulnier & Professor Angus Forbes,
The Florence Nightingale Faculty of Nursing & Midwifery
BACKGROUND: Increasing numbers of patients with type 2 diabetes (T2DM) are starting insulin treatment. Yet many still have suboptimal blood glucose control (Evans et al. 2010, Khunti et al. 2016). Insulin management is increasingly undertaken in primary care by General Practitioners (GPs) and Practice Nurses (PNs). Therefore gaining insight into the perceptions and experiences of patients and primary care healthcare professionals (HCPs) in insulin use may help identify ways to improve insulin-related support for these patients.
METHOD: A systematic literature search was undertaken to identify studies reporting on views and experiences of HCPs and patients in managing insulin. Key themes were identified and findings synthesised broadly based on Thomas & Harden’s (2008) method.
then developed from five analytical themes which identified areas for further research (figure 3).
CONCLUSIONS: Adherence to injecting, managing and adjusting insulin is often poor in T2DM patients. This review reveals the burden experienced by insulin receiving T2DM patients, and the skills needed by primary care HCPs to support them. More research is required to identify ways to improve insulin-related services provided by GPs & PNs and to develop interventions to support patient self-management.
FINDINGS: Thirty-five reports fulfilled the inclusion criteria (figure 1) including qualitative (n=12) and quantitative (n=23) designed studies. From these, 100 coded sub-themes of patients (n=46) & HCPs (n=54) were identified and linked to overarching themes (tables 1 & 2). From these, twelve key themes were linked to insulin use and organized into three domains:
*Kathy Ellis, an Advanced Nurse Practitioner with Whitstable Medical Practice, conducted this review as part of a PhD. She was awarded a Band Trust Research Scholarship by the Florence Nightingale Foundation to support her studies.
AIM: To conduct a thematic synthesis of research to explore experiences and perceptions of insulin treated T2DM patients, and primary HCPs.
patient perceptions, HCP perceptions & HCP-patient relationships (figure 2). A theoretical framework was
INSULIN ADHERENCE IN T2DM
Domain Patient perceptions of insulin use
Insulin beliefs
Social factors
Psychological factors
Hypoglycaemia
Therapy barriers
Domain The HCP-Patient Relationship
Patient & HCP Perspectives of their relationship
Domain 3. Primary Care HCP Experiences
Insulin skills of GPs
Integrated Healthcare
Insight into patient barriers
Explanations for adherence
Figure 2 Key Themes
Patients adjust insulin in various ways, often sub-optimally
Patient goals can be different to those of their HCPs
Skills, systems & attitudes enable GP teams to help patients
HCP understanding of patient perceived barriers
Injecting in public & preventing hypos
Table 2 HCP Experiences of managing insulin
Table 1 Patient perceptions of insulin use
Figure 3 Theoretical Framework
Hypoglycaemia (patient)
“To avoid hypos… I won’t have insulin..”
Avoiding injecting in public (patient)
“If I go out ..I always go and do it [inject] in the toilet. I won’t ever do it outside.”
Insulin titration (clinician)
“So ..the most common thing that happens is people start insulin but after that, they don’t optimise the regime..”
REFERENCES Evans et al. (2010) Insulin usage in T2DM pts. in UK clinical practice: a retrospective cohort-based analysis using the THIN database. British Journal of Diabetes & Vascular Disease 10(4), Khunti et al. (2016) Clinical inertia with regard to intensifying therapy in people with T2DM treated with basal insulin. Diabetes, Obesity and Metabolism 18(4), Thomas & Harden (2008) Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Medical Research Methodology 8:45.