Nurses and Doctors Struggle to Warn Diabetes Patients of Hidden Heart Danger

People living with type 2 diabetes face a two- to four-fold increased risk of cardiovascular disease, yet many of them never fully grasp that their diabetes and their heart are locked in the same dangerous story. A new qualitative study from northern Sweden, published in Nursing Open, offers an unusually candid look at why that message so often fails to land. By interviewing 14 healthcare professionals, including eight diabetes specialist nurses and six physicians working across nine primary healthcare centres in both urban and sparsely populated rural areas, researchers uncovered a portrait of clinicians who feel deeply responsible for communicating cardiovascular risk but who are simultaneously undermined by uncertainty, loneliness and a healthcare system that gives them neither the time nor the teamwork to do the job properly.

The study, conducted between 2022 and 2023 using a constructivist grounded theory approach, did not simply ask clinicians to describe their routines. Researchers used semi-structured interviews lasting 45 to 60 minutes, supplemented with hypothetical patient vignettes that allowed participants to reason through realistic cases without feeling personally exposed. Data collection and analysis ran in parallel, with each interview transcribed verbatim and coded line by line using constant comparison, a process supported by MAXQDA software. From this iterative analysis a core category emerged that captures the entire dilemma: healthcare professionals are striving to enhance cardiovascular risk awareness in their patients while balancing responsibility and uncertainty.

That balancing act begins with assessment itself. The clinicians described monitoring HbA1c, blood pressure, lipid levels and lifestyle habits, but they openly admitted that it was difficult to know which parameter best reflected a patient’s true cardiovascular risk. Some focused primarily on blood sugar; others prioritised cholesterol before turning their attention to glycaemic control. Almost all relied on risk visualisation tools from the Swedish national diabetes register, and physicians additionally used standardised instruments such as SCORE2 to classify risk as high or low. Yet the tools cut both ways. Some professionals refrained from formal risk assessment altogether because navigating multiple systems was perceived as time-consuming and cumbersome, meaning that cardiovascular risk in those cases went inadequately communicated.

Even when assessment succeeded, translation into understanding proved far harder. Participants described painstaking efforts to identify what each patient actually knew, asking individuals to explain in their own words why they were attending the visit and what they understood about their disease. They built step-by-step visual pictures, used metaphors and explanatory models to illustrate blood sugar and lipid levels, and checked comprehension by asking patients to recount what had been agreed. One diabetes nurse explained the stakes bluntly: poorly adapted information is wasted, so she tried to be clear about risks of vision changes, stroke, heart attack and kidney failure without wrapping the message too vaguely. Notably, some clinicians communicated microvascular complications while hesitating over macrovascular ones, sometimes splitting the risk message across different moments in the same visit.

The emotional dimension of this work emerged as perhaps the most striking finding. Clinicians reported genuine frustration and even feelings of failure when they could not reach certain patients, and some described the painful necessity of prioritising those willing to attempt change over those who were not, a decision one nurse called very difficult to make. Patients who expressed shame at missing treatment targets posed a particular challenge, as did patients perceived as fearful, overwhelmed by information, or struggling with mental health difficulties, in whose cases some professionals admitted avoiding risk discussions altogether. The clinicians walked a constant tightrope between encouragement and demand, wanting to convey seriousness without resorting to scare tactics or blame, and recognising that fear alone rarely produces sustainable lifestyle change.

Trust emerged as the currency that made any of this possible. Participants described building professional yet personal relationships, drawing on their own experiences, offering advice anchored in the patient’s actual life, and reinforcing progress to instil hope. Continuity was identified as crucial, because trust accumulates over repeated encounters rather than single appointments. Yet the organisational reality worked against this ideal. Many patients received only one visit per year instead of the guideline-recommended two, appointments became checklist-oriented and conveyor-belt-like, and limited time for follow-up questions hindered meaningful dialogue. Some clinicians encouraged patients to write down questions for their next visit as a workaround, a small and telling adaptation to systemic shortage.

Beneath the individual struggles lay a deeper structural problem: the diabetes team, in any meaningful sense, often did not exist. Diabetes specialist nurses described feeling alone in carrying overall responsibility for patients with type 2 diabetes, absorbing duties that would ordinarily fall to physicians because of chronic doctor shortages. Patients rarely met a physician in a planned manner, and nurses and doctors sometimes applied different strategies to the same patient, creating uncertainty about how treatment and risk communication should proceed. Some nurses admitted they did not always trust the clinical decisions of the physicians they worked with. Both professions called for shared responsibility, a common working model, structured diabetes-focused meetings and greater consensus, so that patients would hear consistent information from every member of the team.

The study’s authors argue that these findings reframe cardiovascular risk communication not as a simple transfer of information but as an ongoing, dynamic dialogue shaped in real time by the tension between objective medical data and patients’ subjective interpretations. Risk calculators and visual tools, however sophisticated, proved insufficient on their own to raise awareness or change behaviour, which helps explain why patients so often report not receiving or not understanding risk information. The researchers suggest that person-centred communication requires more than adapting facts to individual patients; it demands creating shared meaning about what risk actually signifies for a particular life, listening to patient narratives and addressing emotional and existential concerns before expecting behavioural change to follow.

The implications reach well beyond northern Sweden. The authors acknowledge limitations, including recruitment difficulties that forced reliance on snowball and convenience sampling, a predominantly female participant pool, and digital interviews that may have limited rapport, but they note that similar themes emerged across participants of varying age, sex, experience and setting, suggesting robust consistency. Their recommendations are pointed: healthcare systems must provide clinicians with the time, continuity, staffing and team structures without which even the most skilled communicator cannot succeed, and future research should explore collaboratively with patients how cardiovascular risk can be conveyed without vagueness or threat. Until then, the professionals on the front line of the diabetes epidemic will continue doing what this study documents so vividly: shouldering an enormous communicative burden alone, hoping their words reach patients before a heart attack makes the message unmistakably clear.

Subject of Research: Cardiovascular risk communication to people with type 2 diabetes in primary healthcare

Article Title: Primary Healthcare Professionals' Perspectives on Cardiovascular Risk Communication to Persons With Type 2 Diabetes: A Grounded Theory Study

Article References: Stenlund, A.-L., Hellström Ängerud, K., Lilja, M., Otten, J., & Jutterström, L. (2026). Primary Healthcare Professionals' Perspectives on Cardiovascular Risk Communication to Persons With Type 2 Diabetes: A Grounded Theory Study. Nursing Open, 13(9), Article e70828. https://doi.org/10.1002/nop2.70828

Image Credits: AI Generated

DOI: 10.1002/nop2.70828

Keywords: type 2 diabetes, cardiovascular risk, risk communication, primary healthcare, grounded theory, diabetes specialist nurses, person-centred care, patient self-management, healthcare teams, Sweden, qualitative research, HbA1c