How do people with Type 2 diabetes and healthcare professionals understand and manage decision-making involving risks

Introduction: This grounded theory study explores how patients and clinicians negotiate and manage decision-making involving risks associated with Type 2 diabetes. The purpose of the study was to improve person-centred care by developing an understanding of what is effective when communicating about risks to people with diabetes. The concept of _risk literacy_ was explored with patients in how they use information on risk to make decisions about managing their diabetes.

Methods: A qualitative approach based on case studies (n=6) involving a person with diabetes and a practice nurse, was undertaken in three local general practices. Grounded theory methodology was used to investigate the perspectives of nurses and patients managing risk of diabetes complications.

Results: • Patients live with uncertainty which impacts on their behaviour and how they manage risk, often within personal time-frames

• Diabetes creates a social risk for patients which has to be managed in their daily lives

• Practice nurses balance the tensions of formal and informal risk management in order to meet professional and organisational requirements as well as the expectations of patients

• Effective risk communication may be enhanced by the quality of the nurse-patient relationship and the use of patient decision-making aids, visual metaphors and narratives involving _similar others_

Discussion: Risk literacy in the context of the current study, related to how patients chose to incorporate risk into their social lives/situations and how practice nurses mediated a clinical imperative to help patients achieve prescribed metabolic outcomes and reduce acute and long-term complications of diabetes.

Risk had temporal (time-mediated) properties for patients in terms of reflecting on the past - why they may have developed diabetes and how things could have been different and their perceptions of the possible future. How patients viewed their future was influenced by their exposure to others with diabetes. For patients, diabetes had both physical and social consequences in terms of avoiding long-term complications, but at the same time they were trying to reduce the impact diabetes had on their daily social lives. At times, because of the demands of patients and the practice (relating to the Quality and Outcomes Framework) the nurses could feel powerless, isolated, potentially exposed (for example, ‘ad-hoc prescribing’) and become fatalistic about the potential outcomes for patients.