Within secondary care, diabetes specialist nurses (DSNs) often have responsibilities in both inpatient and outpatient settings, as part of a wider multidisciplinary team (MDT). With the diabetes prevalence increasing, along with the complexity in diabetes presentation, the role of DSNs is more crucial than ever.
Inpatient settings
Precise routines will vary, but DSNs will review referrals made by ward-based staff, and triage these, so that some will be reviewed by doctors and others by nurses. The types of referrals cover the spectrum of the inpatient journey, from admission to discharge. Referrals at the admission stage include patients presenting with a new diabetes diagnosis, with diabetic ketoacidosis (DKA), with hypoglycaemia, in hyperosmolar hyperglycaemic state (HHS) or with suboptimally controlled diabetes. During an admission, patients can be referred due to persistent hyper- or hypoglycaemia, for advice on insulin dose titration, more complex issues such as feed or steroid-related hyperglycaemia, including checkpoint-inhibitor related diabetes, and support for using an insulin pump. Referrals can be about pre-operative advice and end-of-life diabetes care and towards the end of the patient journey, they may require education prior to discharge.
Following distribution of the referrals, DSNs attend the wards to assess the patients and gather further information from patients and staff, which aid in the decision-making process. Communication and interpersonal skills are key elements of the DSN role, and we often have to play detective to get to the bottom of a particular referral. We rely greatly on ward staff, as they provide overall patient care, whereas we have a specific focus on diabetes. A key role is to provide advice and information to help them understand the care plans and the decisions that we make about their patients. This staff education role takes the form of ad-hoc, bite-size episodes while they work on the wards, or more formal ward or classroom-based sessions, including online learning. The education can be related to clinical incidents or medication errors related to diabetes, and these are fed into both informal and formal education as learning points. Although some trusts have developed a diabetes educator role specifically for healthcare practitioner education (Stewart, 2019), DSNs are educators as part of their daily interaction with staff.
DSNs also incorporate key calendar dates into their staff education strategy and where educators are available it is a joint effort. World Diabetes Day, for example, is universally commemorated on 14 November and diabetes teams hold a variety of activities to raise awareness about the condition. DSNs work with ward staff, particularly on diabetes wards, to participate in decorating wards, displaying information, and even setting games and competitions to raise funds for diabetes charities. Other dates include Hypo Awareness Week in October (highlighting hypoglycaemia) and Insulin Safety Week in May. Although these activities are informal, with fun and games, education remains the key element.
Patient education is a key DSN role, and, as with staff, this can be formal, such as teaching someone new to insulin the appropriate injection technique, as well as all the associated skills such as blood glucose monitoring and management of hypoglycaemia. Although ward staff talk to patients about various aspects of diabetes as part of their care, including observing their injection technique, the education provided by DSNs is specialist in nature, and therefore merits a referral. Formal patient education tends to involve those newly diagnosed, or those initiated on a new diabetes therapy. Patient education can also be informal and opportunistic – for example, while discussing the cause of a patient's DKA, a DSN would take the opportunity to inspect a patient's injection sites, revise site rotation and offer sick-day advice.
DSNs are at the forefront of improving diabetes practice, and so are involved in carrying out inpatient audits (Smyth, 2017) and creating and reviewing diabetes guidelines. The National Diabetes Inpatient Diabetes Audit (NaDIA) (NHS Digital, 2020) and the more recent NaDIA-Harms (NHS Digital, 2021), provide data on inpatient occurrences of hypoglycaemia, DKA and HHS. This information is used by DSNs and the wider diabetes team to provide focused education and service-improvement projects (Kempegowda et al, 2018).
As part of improving practice, DSNs play a pivotal role in admission prevention and preventing delayed discharge. Most DSNs are non-medical prescribers and so can respond to referrals requiring dose adjustments to existing diabetes medications, as well as prescribing and de-prescribing. These jobs would previously be left to generalists, who may not possess the expertise and experience of a specialist prescriber. When decisive prescribing decisions are made, there is a strong evidence base that a dedicated inpatient DSN team contributes to reducing length of stay and excess bed occupancy for people with diabetes (Akiboye et al, 2021). Many diabetes teams also offer a weekend service, in which DSNs can provide education and advice which can expedite patient discharge (Joint British Diabetes Societies for Inpatient Care, 2013; 2019).
Outpatient settings
As with inpatient settings, routines will vary, but the focus of outpatient diabetes clinics is on patient review and education. DSNs participate in a range of clinics that include the wider MDT, with the aim of supporting people living with diabetes in self-managing their condition. One of the aims of diabetes care is to provide continuity of care for patients who were reviewed as inpatients. One such area of continuity is when patients' surgery is delayed due to suboptimal glycaemic control and they are referred for pre-operative optimisation to ensure safe conditions for surgery. Where appropriate, patient who are reviewed as inpatients are followed up in clinic and by DSNs to reinforce any education, provide support and advice to promote self-management. People with diabetes spend on average 3 hours a year with a health professional, and for the remaining 8757 hours they manage their diabetes themselves, making the role of the diabetes MDT, including DSNs, a pivotal one (Diabetes UK, 2015)
DSNs are at the centre of outpatient services, where they run nurse-led clinics and support consultant and dietitian-led ones. People with diabetes being looked after in secondary care attend an annual clinic, where they have an overall review, including blood pressure, HbA1c (glycated haemoglobin, a measure of average blood glucose levels over 2-3 months), medication, injection sites, foot check and retinopathy screening, and this review involves members of the MDT. Newly diagnosed patients are referred from primary care and DSN input involves educating the patients about the type of diabetes and management options. Depending on the type of diabetes and presentation, some will require oral or injectable medication and home blood glucose monitoring, whereas others may need to introduce lifestyle changes. DSNs work in partnership with dietitians in delivering the education, following National Institute for Health and Care Excellence (NICE) guidelines for type 1 and type 2 diabetes (NICE, 2022a; 2022b). They help patients to understand what diabetes is and how the various activities, lifestyle changes and medication work to manage their condition and this is carried out on an individual or group basis.
When people require insulin therapy for managing their diabetes, education involves the different types of insulin, and their profiles, including onset of action, peak and duration. They also learn insulin administration technique, including site rotation, storage, and sharps disposal. For patients who need to carbohydrate count, they are taught how to match their mealtime insulin to carbohydrates, and this is done in conjunction with dietitians. Other patients are referred by GPs with sub-optimal diabetes control and may need to start taking medication such as SGLT2 inhibitors (sodium-glucose co-transporter-2 inhibitors, also known as ‘gliflozins’) and GLP-1 agonists (glucagon-like peptide-1 receptor agonists). For SGLT2 inhibitors, DSNs are instrumental in teaching patients how the medication works, potential side effects to look out for and, crucially, what action to take in response to these. For injectable GLP-1 agonists, patients are taught the mode of action, the injection technique, timing of administration, potential side effects, and action to take in response to these. Once initiated, the patient will be followed up regularly to assess tolerance and efficacy of the medication.
For people requiring blood glucose monitoring, the DSNs will teach them the importance of blood glucose monitoring, how to use the meter, agree individual blood glucose targets and what to do if their readings are out of target. In recent years, certain groups of patients have become eligible for flash and continuous glucose monitoring, and DSNs are involved in their education, supported by other members of the MDT. The sessions are held as either individual or group format and, where appropriate, virtually, and following the initial session, patients are followed up by DSNs and other MDT members, to support them in making the most of the technology to improve their glycaemic control.
Technology also includes patients who qualify for pump therapy, and DSNs are involved in assessing eligibility and running pump clinics, alongside consultants and dietitians (NICE, 2008). The pump programmes are intensive, and so take up a large amount of individual DSNs' workload, therefore some teams have specific DSNs who specialise in pump therapy. Follow-up takes the form of either face-to-face or virtual appointments, providing support and trouble-shooting advice for self-management. In recent years, some clinics have been involved in trialling the hybrid closed loop systems pump (artificial pancreas), and DSNs have been central to this work.
As previously mentioned, the overarching aim of diabetes care is to empower self-management and provide support and prevent hospitalisation, where possible. To this end, one of the services offered by outpatient DSNs is a telephone support clinic during the week and where 7-day working is in place, over weekends and bank holidays. In addition to regular review clinics, patients can telephone and receive advice on dose titration from non-medical prescribers. Other telephone advice includes sick days management, travel advice, hypoglycaemia, and any diabetes-related queries. This service has become an essential lifeline, more so during the height of the COVID-19 pandemic, particularly for those who were isolated and reluctant to attend hospital. Even outside of COVID situations, DSNs are there to listen in a compassionate and non-judgemental way.