The increasing need to manage individuals with a cluster of diseases, such as T2DM in the primary care setting (Witty, 20202), places primary care as a key service provider for person-centred care. The escalation of therapy in T2DM, including insulin initiation, is an example of a decision requiring a person-centred approach and was identified amongst the empirical literature. This study aimed to explore the experiences and views of general practitioners (GPs) to understand insulin initiation in the primary care setting.
Within a critical realist ontology and constructionist episteme, semi-structured interviews with a ‘travelling’ approach (Kvale, 2007) were co-produced with a purposive sample of 16 general practitioners (GPs), recruited using a snowballing technique, from South Yorkshire, UK. GPs related their experiences about managing T2DM patients and considering insulin initiation. A two-stage analysis was used: an initial reflexive thematic analysis, including identification of tensions, followed by narrative structural analysis.
Reflexive thematic analysis constructed GPs in positive and negative stances towards patients, in person-centred (PC) or doctor-centred (DC) approaches to patients, staff, resources and delivering a chronic disease management service. Insulin initiation was infrequent across the GPs and an instrumentality attitude indicated GP expected adequate resources to deliver it. Thematically generated findings confirmed the literature with doctor-centred (DC) attitudes to adherence/engagement to self-care, such as insulin as failure and blame towards patients, and the distal GP.
Narrative structural analysis provided an alternative lens to explore thematically derived tensions. GPs were constructed to hold PC or DC attitudinal stances, towards patients, staff or even service delivery, that may indicate an instrumentality when GPs believed a disease-centred objectives. They would shift from DC or PC stances or vice versa stances or mindsets driven by often unresolved tensions.
Reflective practitioners may consider using the concept of PC or DC to understand their own person-centredness, being aware of the biomedical bias of healthcare in a primary care setting.
