Diabetes Specialist Nurses Research Articles

Training in flexible intensive insulin management improved glycaemic control and quality of life in type 1 diabetes

(2002) BMJ 325, 746. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. ....

Specialist nurses in diabetes mellitus.

The patient with diabetes has many different learning needs relating to diet, monitoring, and treatments. In many health care systems specialist nurses provide much of these needs, usually aiming to empower patients to self-manage their diabetes. The present review aims to assess the effects of the involvement of specialist nurse care on outcomes for people with diabetes, compared to usual care in hospital clinics or primary care with no input from specialist nurses. To assess the effects of diabetes specialist nurses / nurse case manager in diabetes on the metabolic control of patients with type 1 and type 2 diabetes mellitus. We carried out a comprehensive search of databases including the Cochrane Library, MEDLINE and EMBASE to identify trials. Bibliographies of relevant papers were searched, and hand searching of relevant publications was undertaken to identify additional trials (Date of last search November 2002). Randomised controlled trials and controlled clinical trials of the effects of a specialist nurse practitioner on short and long term diabetic outcomes were included in the review. Three investigators performed data extraction and quality scoring independently; any discrepancies were resolved by consensus. Six trials including 1382 participants followed for six to 12 months were included. Two trials were in adolescents. Due to substantial heterogeneity between trials a meta-analysis was not performed. Glycated haemoglobin (HbA1c) in the intervention groups was not found to be significantly different from the control groups over a 12 month follow up period. One study demonstrated a significant reduction in HbA1c in the presence of the diabetes specialist nurse/nurse case manager at 6 months. Significant differences in episodes of hypoglycaemia and hyperglycaemia between intervention and control groups were found in one trial. Where reported, emergency admissions and quality of life were not found to be significantly different between groups. No information was found regarding BMI, mortality, long term diabetic complications, adverse effects, or costs. The presence of a diabetes specialist nurse / nurse case manager may improve patients' diabetic control over short time periods, but from currently available trials the effects over longer periods of time are not evident. There were no significant differences overall in hypoglycaemic episodes, hyperglycaemic incidents, or hospital admissions. Quality of life was not shown to be affected by input from a diabetes specialist nurse/nurse case manager.

Diabetes services in the UK: third national survey confirms continuing deficiencies

Aims: To determine the current level of diabetes services and to compare the results with previous national surveys. Methods: A questionnaire was mailed to all paediatricians in the UK identified...

Documenting diabetes care: the diabetes nurse specialists' perspective.

Diabetes Nurse Specialists (DNSs) are often the hub of the communications network for the entire diabetes multiprofessional health care team, patients and their families. Frequently they liaise between primary and secondary care and have a key role in the provision of a 'seamless service'. To work effectively and efficiently they need a foolproof system of documentation and communication. The aim of the study was to investigate the means by which DNSs document patient care in order to provide baseline information about ongoing record-keeping practices. The study comprised a cross-sectional survey in which data were obtained by questionnaire. All DNSs in the UK registered with the British Diabetic Association were invited to participate in the study. A 70.3% response rate was achieved (n = 545). The results indicated that manual profession-specific records were used by 65.3% of DNSs, 21.1% used shared/integrated records, 12.8% used computerized records and only 0.7% made use of patient-held records. Whilst almost all DNSs felt that a good record-keeping system was essential in providing 'seamless care' to patients, not all felt their system was efficient. Of those using a computerized system 65.7% rated it as efficient, compared with only 28.1% of those using a profession-specific system and 26.1% of those using a manual shared system. A high percentage of DNSs (65.9%) felt that the provision of 'seamless care' was hindered by communication problems with members of other professional groups. The findings from this study indicate that computers alone cannot bridge the gap between primary and secondary care, but 'seamless care' may become more of a reality with computerized record-keeping systems and participation by all members of the multidisciplinary team.

Review: The dark ages of diabetes

At the time of Queen Elizabeth's coronation in 1953, diabetes was still relatively uncommon. In the young the situation was profoundly depressing. Those whose lives had been saved by insulin in the previous 30 years were now succumbing to blindness, kidney failure and heart attacks for which there was no treatment. Clinics were poorly organised, patchily distributed and, except in major cities, run by general physicians with no training in the management of chronic disease. Yet, in the five years after the coronation, the seeds of many future advances including the delineation of diabetic angiopathy, photocoagulation and diabetes specialist nurses were sown by pioneers whose work went largely unrecognised at the time.

Association of British Clinical Diabetologists (ABCD): survey of specialist diabetes care services in the UK, 2000. 2. Workforce issues, roles and responsibilities of diabetes specialist nurses.

To examine the provision and role of diabetes specialist nurses (DSNs), and the content of patient education programmes in the UK. A postal survey of secondary care providers of diabetes services in the UK in 2000. Following two reminders, a 77% response rate demonstrated 2.5 (median) whole time equivalent DSNs per 250 000 population, with only 13% of centres meeting the recommended staffing level of four per 250 000 population. The vast majority carried out work both in hospital and in the community, the proportion a reflection of who employed and managed staff. There was a wide variation in the qualifications required and the nursing gradings of DSNs, and regional variation in the number of grade I nurses, with the greatest proportion based in the South-east of England. The vast majority (96%) provided patient education, and where it existed (in 60% of responses), were the major providers of a patient help line (90%). Although key providers of patient education, there had been no specific education for this task in over 20% of responses. There was broad consistency in the topics covered at educational sessions, although advice on footwear (76%) and home urine glucose monitoring (73%) were least frequently documented. The issuing of literature and cards for patient use was also very variable. Over 25% of bids for diabetes service improvement were for additional DSNs, but only 48% of these were successful. There has been an improvement in staffing levels of DSNs over the last 10 years but the numbers are many fewer than recommended in national strategy documents, with evidence that despite expansion being given a high profile, such efforts are often unsuccessful. There was also evidence of considerable variation in the qualifications and gradings of DSNs throughout the UK and indeed in their day-to-day roles, and the content of patient education programmes. This suggests the need for a nationally co-ordinated approach to training and recruitment.

Improvements in the provision of hospital diabetes services in an English region 1988-98.

To investigate the changes in provision of hospital-based services for patients with diabetes in an English region over a 10-year period. Questionnaires were completed by lead clinicians in hospitals in the Northern region of England in 1988 and repeated in 1998. Information was sought on diabetes service provision including the staff and their working practices. Data are presented to demonstrate changes during the 10 years. During a 10-year period the number of consultants providing specialized diabetes services increased from 16 to 25 (to become one per 126 240 population). Their outpatient sessions changed from 34 to 55.5 per week, with a decrease in nonspecialists providing diabetes services. Reductions occurred in registrar numbers providing sessions from 23 to 15 and senior house officers from 16 to 14. Increases occurred in other health care professionals: diabetes specialist nurses from 19 to 30.3 whole time equivalents (WTEs); dieticians from 16 to 32.3 WTEs and chiropodists from 8 to 23 WTEs. The numbers of specialized clinics and units providing services from diabetes care centres increased. Improved facilities in clinics and access to laboratory tests were available to all units. Diabetes registers came into use in 12 of 16 units, but there have been difficulties in providing funding. 'Out-of-hours' advice has moved towards advising their patients to see their general practitioners or the accident and emergency department of the hospitals. The number of diabetes professional staff and the provision of specialized diabetes services have increased during a 10-year period in the Northern region of England. However, they still fall far short of recommended staffing levels and services are far from comprehensive in most districts.

Diabetes education and professional roles

The National Service Framework (England) for diabetes has been developed from the principles of the NHS Plan1 which highlights the needs for services to be patient centered as well as delivered as locally as possible. This presents a challenge for those of us providing diabetes services to try and develop our services for those with diabetes so that the health care system that they are trying to navigate through during their life with diabetes does not confuse them and that they don't have to see any more health care professionals than they need to. The review article on page 180 of this edition of Practical Diabetes International by Worth and Vyas starts addressing this problem by considering the integration of the role of the specialist/advanced dietitian further into that of a diabetes educator. They highlight the need for healthcare professionals to extend their roles to provide seamless diabetes education. A number of diabetes specialist nurses will already be developing or have developed ‘advanced’ skills in the dietetic management of diabetes either to ensure that their patients get all the information they need from a single visit to a diabetes services or because they cannot get access to specialist dietetic time in sufficient amounts! So, as two of the key roles in diabetes education start to emerge, what challenges does that bring to the world of diabetes care in the UK? Those reading this in the US, Australia and Canada will not be surprised by the concept. They have Certified Diabetes Educator organsiations and accreditation systems which support the work suggested by Worth and colleagues. But we often hear in conversation with our colleagues working within these systems that the scope of practice (starting/adjusting insulin for example) will still depend on the professional regulation of the ‘certified educator’. Perhaps a different model is necessary for the UK – a registered diabetes care advisor? A further dilemma that faces us in the UK (and across the world) is that with increasing numbers of people with diabetes, the increasing complexity of their care requirements and the recognition of the need for structured education to facilitate effective disease self management, will we have enough health care professionals to deliver services in the way we current deliver them? The potential roles identified by Worth et al. in the ‘scope of the educator’ lists a number of activities that may be delivered by either health care technicians, generic health care workers or the person with diabetes themselves! Whilst the numbers of doctors and nurses are at last on the increase in the UK, there may still not be sufficient to deliver care within the current models of care. The numbers of dietitians and podiatrists are not rising and in some areas, diminishing2 – leading us all to consider two things urgently. Firstly, if we are only going to have a few dietitians and podiatrists, how best should that resource be used to help people with diabetes? Secondly, what or how should the care gap that is now developing be filled? Should the role of a diabetes educator be developed from the population of unregistered health care support workers? In Portsmouth, as in other areas, the role of a foot care assistant has now developed (through training and job evaluation) into that of a specialist diabetes foot care advisor. This person is now assisting with the running of education workshops for those with newly diagnosed Type 2 diabetes – and it will not be long until the role is that of specialist diabetes self care advisor for those people with Type 2 diabetes. The new challenges that we face require new ways of delivering services and new roles for those who deliver them. Practical Diabetes International would welcome views and experiences of readers!

Journeys of a lifetime

AbstractThis paper is based on the Janet Kinson Lecture, given at the Diabetes UK Annual Professional Conference 2001. The lifelong nature of living with diabetes can be likened to a journey, during which a number of events may occur and need to be dealt with. Using the analagies of ‘hijack’ (the diagnosis of diabetes), ‘breakdown’ (the need for hospital admission), and ‘refuelling and servicing’ (consultations for routine care and surveillance), the paper describes and discusses these key issues in diabetes care. The paper also discusses ‘transport policy’ (the influences of political level on the provision of diabetes care) and highlights some important issues for ‘navigators’ (diabetes specialist nurses). Finally, it suggests a new, alternative ‘transport infrastructure’ (a programme of training for diabetes health professionals). Copyright © 2002 John Wiley & Sons, Ltd.

The renal diabetic nurse specialist...a luxury or an essential player?

Diabetic Nephropathy is the single largest cause of Chronic Renal Failure. As the number of patients referred to a nephrologist increase, the needs of many diabetic nephropaths are not being met. The post of Renal Diabetes Nurse Specialist (DNS) was instituted in September 1999 to organise the management of and to meet all aspects of need of this group of patients. The role currently incorporates a daily ward round with the aim of reviewing all patients at least once during every admission to hospital. Ward-based teaching with the patients occurs and six nurse-led clinics covering all modalities are now in place and run alongside the Nephrologist. Patients are either referred directly to the nurse-led clinic or are approached by the renal DNS whilst the patient is in the nephrology clinic. 71.4% of our diabetic patients have an improvement in their HbA1c after 21 months of working closely with the Renal DNS and multidisciplinary team. The average HbA1c at the beginning was 9.7%; the average is now 8%. It is clear that the role is being continuously stretched to its absolute limit. Our aim is to develop a broader service over time and we will, in the near future be employing a renal nurse with an interest in diabetes to work alongside the DNS for six months to particularly learn about the needs of our in-patients.

Association of British Clinical Diabetologists (ABCD) survey of secondary care services for diabetes in the UK, 2000. 1. Methods and major findings.

To examine the provision, and variations in, secondary care diabetes services in the UK. A postal survey of all 238 identified secondary care providers of diabetes services in 2000. Following two reminders, a 77% response rate was achieved. Major deficiencies in core staffing levels were recorded, with 36% of services provided by only one consultant physician with an interest in diabetes. The provision of diabetes specialist nurses was less than recommended in 87% of responses, whereas podiatry and dietetic support was unavailable in 3% and 27% of responses, respectively. Diabetes registers were not present in 28%, and a co-ordinated retinopathy screening programme unavailable in 26% of responses. Key biochemical measurements were unavailable in 9% (microalbuminuria) to 18% (HDL-cholesterol) of responses. A 'Well-Resourced Service' score was devised taking account of levels of personnel, facilities and specialized clinical services. There was a significant geographical variation in this score (P < 0.001), with the lowest score (least well-resourced services) in the Eastern NHS Region of England, and the highest score in the North-west NHS Region of England. The 'Well-Resourced Service' score was also significantly lower (P < 0.05) where there were less than two whole-time consultant physicians providing diabetes services. In contrast to other aspects of service provision, availability of dieticians and a combined diabetes-ophthalmology service had declined since 1990. Of 245 recorded bids for resources and service improvements for diabetes care, the success rate overall was 44%, and lowest where bids were made for dietetic and podiatry support. There is presently a major shortfall in provision of secondary care diabetes services throughout the UK, with evidence that there is significant regional variation and less facilities and resources where there are less than two consultants providing specialized diabetes services. On average bids for service improvements were only successful in < 50% of cases, most usually where the service was relatively better provided for. Considerable development and investment are required nationally to ensure equitable access to specialized diabetes services, a vital component in reducing adverse diabetes outcomes.

Time to reflect – what makes a difference in diabetes care?1

AbstractDiabetes care is constantly evolving in response to new developments, innovative research, and the national agenda. The development of new technical advances, such as pen devices and glucose monitors, as well as the implementation of new working practices, has led to significant improvement in the management of diabetes. If, however, too much emphasis is placed on the advantages offered by these new advances, it is often easy to overlook or fail to recognise what makes a real difference to patients in the self‐management of diabetes. It is, therefore, essential to constantly reappraise and develop the provision of diabetes care, to ensure the best possible service for patients. The diabetes nurse specialist (DNS) plays a major part in shaping the future of diabetes care. How changes in care are translated into tangible benefits for patients depends largely on the dedication and commitment of the DNS, whose important role in the planning and implementation of diabetes care continues to increase and expand. The role of the DNS extends much further than simply providing medical care. DNSs are key contributors both to patient education and in ensuring that help and support is available to enable patients to feel more confident about managing their diabetes. Copyright © 2001 John Wiley &amp; Sons, Ltd.

Empowering patients: how to implement a diabetes passport in hospital care

The purpose was to ascertain the views of patients with diabetes and patient care teams on the introduction of a recently developed diabetes passport in order to plan effective implementation. A semi-qualitative study by eight semi-structured focus group discussions with patient care teams and patients in four Dutch hospitals was organised. In total 29 patients participated (range five to nine per hospital). Patient care teams ranged from four to six participants. Each team included at least one specialised diabetic nurse and an internist. Taped views were transcribed and coded on the basis of a structured checklist. Various potential barriers to the implementation of the diabetes passport were found. Although patients recognized the diabetes passport as a handy tool, most of them expected starting problems and little co-operation from the internists; in this respect they rely more on the diabetes specialist nurse (DSN). Internists had mixed feelings about the diabetes passport. Lack of motivation and lack of time were important perceived barriers. The specialised diabetes nurses had the highest expectations of the diabetes passport and perceived themselves as those who would effectuate implementation. The main potential barriers to effective implementation of the diabetes passport were found in setting the agenda of the passport and fitting it into the organization of diabetes care. These barriers need to be considered when implementing the passport. The DSN could play an important part in its implementation.

‘Diabetic holiday stump syndrome’?!

Sir, It was nice to see two original articles and a leading article in Practical Diabetes International (March 2001) on the subject of ‘Diabetic holiday foot syndrome’.1-3 One of these reports was from our own unit, 1 and we thought readers might be interested in the most recent events in the life of case 1. Having had a below-knee amputation following three separate episodes of ‘holiday ulceration’ (Spain, Morocco, and finally Blackpool!), he made a good recovery and mobilised successfully with a prosthesis. Feeling so well, he recently went on holiday again to Spain, and took with him a ‘swimming prosthesis’. This however caused friction and soft tissue trauma to his stump, resulting in severe cellulitis, but no ulceration. He required antibiotics and increased doses of insulin for several days, following which he recovered and returned to the use of his original prosthesis. We suggest that this is a further twist in the tale of lower-limb holiday risks for diabetic patients, and we suggest the name ‘diabetic holiday stump syndrome’! Geoffrey Gill Consultant Physician and Reader in Medicine*, Karen Noblett Diabetes Specialist Nurse*, * Walton Diabetes Centre, University Hospital Aintree, Liverpool L9 1AE, UK.

Letter to the Editor

Sir, Salma's story is not an unfamiliar one. Many of us can identify patients with similar backgrounds. A picture emerges of a material figure who from the description of her routine has little time to think about, let alone manage, her diabetes. Language difficulties hinder communication and this complicates existing social and medical issues. What stands out as needing immediate attention is education. Assessing her knowledge and understanding of diabetes will be the first step towards improving diabetic control. Insulin would remove glycaemic control, but the concern is whether Salma can cope with insulin therapy at this point. Before embarking on this, diet and lifestyle need to be addressed and modified, as both factors appear to be pivotal in explaining poor glycaemic control. Given the circumstances it would not be unreasonable to maximise oral hypoglycaemic therapy and consider a trial of a sulphonylurea agent. As insulin resistance is likely, an insulin sensitising agent such as rosiglitazone should be considered. Risk factors for cardiovascular disease should be targeted aggressively and neuropathic symptoms evaluated and treated. The basic problem however would appear to stem from a poor understanding of diabetes. Misconceptions about diabetes are very likely to be well entrenched and education would be the cornerstone of any approach. Patients from ethnic minorities often feel polarised, as their social fabric is completely different. Language problems compound the issue. Local Community Health Workers working in liaison with the Diabetes Specialist Nurses have a lot to offer in this regard. However not all Local Health Authorities employ such practitioners. The onus is therefore on the Diabetes Specialist Nurse, who usually has the best rapport with the patient. To improve communication with members of ethnic minorities, professional interpreters should be involved at every clinic visit if possible. Joint education sessions with the main carers would be useful in reinforcing the advice about lifestyle and diet. Dieticians familiar with Asian diets would be invaluable in formulating a diet plan, and diet sheets and written charts will serve to reinforce dietary principles in a friendlier and less confrontational manner. Salma's mental health needs to be evaluated tactfully at some point. Depression is often not volunteered as a symptom as mental illness is still perceived to carry a social stigma. Salma's case exemplifies the multidisciplinary approach to managing diabetes with contributions from primary, secondary and community care. The solutions may not be simplistic but in the long run individualised plans and structured interaction bring about outcomes that are productive and gratifying. Satyajit Nag Specialist Registrar*, * Diabetes and Endocrinology, Medical Unit 3, Freeman Hospital, Newcastle upon Tyne NE77DN, UK.

What role do nurses play in Type 2 diabetes care in the community: a Delphi study.

To identify the views of nurses on their current and future roles in care in the community for people with Type 2 diabetes. A two-round Delphi study was used to elicit, and assess consensus on opinions from random samples of practice nurses, with a substantial role in the management of diabetes patients and diabetes specialist nurses. Both groups had defined levels of expertise in diabetes care and worked in Great Britain. The study instrument in round one comprised a questionnaire with 10 statement headings inviting opinions on the nursing role in the management and care of people with Type 2 diabetes. In the second round levels of agreement were elicited from responders on collated opinions from round one. The initial questionnaire also included closed questions to obtain a profile of current care delivered. Responders were 97 practice nurses and 69 diabetes specialist nurses with second round response rates of 93% and 86%, respectively. The 47 themes raised could be grouped under headings of clinical practice, responsibility, communication, knowledge, education/experience, rewards, and patients' roles. Many were common to several statements and both nurse groups. The level of agreement on the themes fed back was high, 85% of the 165 items achieved greater than 80% agreement. Agreement occurred for factors relating to clinical effectiveness, audit, knowledge, education and experience. Dissent occurred both within and between individual nurse groups on issues of responsibility, prescribing, service delivery, resources, and patient factors. This Delphi study has identified key areas of consensus on the management of care for people with Type 2 diabetes in the community but also areas in which further work needs to be carried out to understand the differences found. Many of the discordant items relate to the separate roles and associated issues of the two nurse groups.

The paediatric diabetes specialist nurse and diabetes education in childhood

The aim of this study was to identify the job title, work setting, qualifications and training of the paediatric diabetes specialist nurse (PDSN) as well as to examine the composition of the multidisciplinary diabetes team. It also aimed to determine who is involved in diabetes education and to explore the teaching methods, approaches, tools and materials that the PDSN uses in the educational process. A survey design was used. Questionnaires, which combined quantitative and qualitative approaches, were sent to 80 participants from eight opportunistically selected regions of the United Kingdom (UK). Access to names and addresses was gained through the directory of diabetes specialist nurses (DSNs). The selection criteria were nurses working full-time with children with diabetes or having children with diabetes on their caseloads. The overall response rate was 66 (82.5%). The study findings showed that the majority of the respondents were based in both hospital and community, held paediatric qualifications and had undertaken further training to prepare as diabetes specialists. Respondents used a wide range of teaching methods and materials in the educational process. A substantial number of individuals and voluntary organizations were also involved in diabetes education. The findings of this study support the belief that the PDSN, as a member of the multidisciplinary paediatric diabetes team, has a key role in the education of children with diabetes and their parents/carers. However, the importance of the team approach as a whole should not be underestimated.

Adolescent girls and boys differed in how they incorporated diabetes into their identities and how they managed the illness

Williams C. Gender, adolescence and the management of diabetes. J Adv Nurs1999 Nov; 30 : 1160 –6 [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] QUESTION: In what ways do gender and adolescence interact to...

Driving and insulin--consensus, conflict or confusion?

All drivers requiring insulin treatment must be able to demonstrate satisfactory diabetic control and recognition of hypoglycaemic symptoms before being allowed to drive a motor vehicle. Clinicians have a duty to discuss fitness to drive with their patients. However, is the advice given consistent and in line with the regulations published by the Driver and Vehicle Licensing Authority (DVLA)? Six 'real-life' case scenarios were posted to clinicians (consultant diabetologists, specialist registrars and diabetes specialist nurses) within Wessex, UK. The identical cases were also sent to the DVLA for their comments. Sixty-six doctors (36 consultants) and 70 diabetes specialist nurses were contacted by postal questionnaire of which replies were received from 17 consultants (47%), 17 specialist registrars (57%) and 39 diabetes specialist nurses (56%). Although there was general agreement in cases of hypoglycaemia unawareness, there was disagreement where patients had or were at risk of unstable control albeit for a short time. Patients treated with insulin may receive conflicting information concerning their ability to drive.

Diabetes specialist nursing: looking to the future, learning from the past.

Diabetes specialist nursing, like many other aspects of nursing, is facing a challenging time in terms of limited resources, staff stress and increasing client caseloads (Naughton and Nolan, 1998). This trend seems set to continue and therefore reflection on and analysis of the role of the diabetes specialist nurse (DSN) is essential so that DSNs can understand their role and meet such challenges proactively. This learning experience (Jarvis, 1992) will also enable DSNs to communicate effectively their role within their teams and to their peers and managers. The author contends that many of the problems currently faced by DSNs can be identified in the initial reactive creation and development of the DSN role which, in some cases, was 20 years ago. Therefore, this article discusses how the past could be influencing the present and future for diabetes specialist nursing. It cannot attempt to provide an exhaustive discussion, but will focus on the following major aspects: DSN titles and commencement; role entry and subroles; and role set and role definition. The article concludes with a vision for the future, informed by this analysis of the past.