Generally, the delivery of effective diabetes care involves a multidisciplinary team approach, however, a diabetes specialist nurse (DSN) occupies a central position in caring for and supporting patients and their families over the course of the disease. In the day-to-day delivery of diabetes care, the DSN provides patient-centred care that meets the patient’s physical, social, and spiritual needs and they form the interface between the patient and other healthcare professionals. Due to the complexities of modern diabetic care, the roles and responsibilities of DSNs continue to evolve, however, this is accompanied by some challenges.
The role of diabetes specialist nurses
Diabetes is an international medical problem and people with diabetes often have multiple healthcare needs requiring assessment and various holistic interventions. Historically, the role of the DSN has been present for over half a century ago and they work in both primary and secondary care settings. For a long time, a DSN has been recognised as a highly skilled healthcare practitioner in diabetes care whose multi-faceted roles require certain professional qualities (see Box 1). This view is still supported by recent authors who state that DSNs’ roles include health education, clinical expertise, management and liaison with other multidisciplinary diabetes teams such as doctors, podiatrists, dieticians and clinical psychologists.
The National Service Framework (NSF) for diabetes consists of 12 standards that emphasise the provision of high-quality care and the DSN helps to implement the NSF effectively in order to improve the patient’s health outcomes (see Box 2). Thus, they help to identify people with diabetes, empower them and help to possibly prevent the onset of type 2 diabetes, and assist in managing complications that may result from all types of diabetes. They also help in caring for all age groups of people affected by diabetes, and this includes emergencies, during admission and pregnancy. With the general focus of shifting care of people with complex long-term condition to the community, a key function of DSN’s role is to support the patients through the long-term trajectory of diabetes in order to minimise the impact of the disease on the affected individuals.
Diabetes is a long-term condition that requires day-to-day self-care by the patient. Therefore, enhancing the self-care management of diabetes is paramount. The DSN helps the patient and their family to understand how to manage diabetes by teaching them about the disease, for example, importance of nutrition, weight management, monitoring, concordance with the regimen and how to recognise signs of complications. Furthermore, DSNs are involved in assessment and reviewing service provisions with the intention to provide personalised care that meets the healthcare requirements of people with complex and multiple needs. Regardless of these benefits, a Cochrane review of literature concluded that the DSN/nurse case manager only improves diabetes control for a short period of time.
Role development and its implications
The role of the DSN is diverse and continues to evolve in response to the healthcare environment and the needs of the patients and their families. However, there are challenges associated with restructuring roles and the impact of resources in regards to developing any role is often inevitable (see Box 3).
Although DSNs are highly skilled in diabetes management and a substantial amount have specialist qualifications in diabetes, DSNs are faced with the challenges of developing new skills in the current healthcare commissioning climate. These skills include planning, costing and developing services, writing bidding proposals and further embedding digital heath into the care of patients to enhance accessibility and convenience.
The use of modern technology is vital to the management of diabetes for patients, particularly in the community. Telehealth, such as giving health advice through the phone or other remote interventions, including a text-based blood sugar report is essential to support self-care management in this era of advance technology. Role changes place a demand on the nurses, which requires provision of educational support to enhance the transition from the traditional role to the new role. Thus, the DSNs need to continuously develop their clinical and interpersonal skills, therefore higher institutions need to respond to the requirements of these new roles. However, the current financial climate and pressure on the NHS due to factors ranging from the ageing population and prevalence of diabetes, to the increased cost of managing diabetes and its complications may have a negative effect on continuing development in future.
A survey conducted as far back as 1996 identified the need for more hospital DSNs and the demand continues to grow with an intermittent upsurge and decline in the recruitment of DSNs. The current situation suggested a reduction in the DSN workforce due to retirement, unfilled vacant post possibly as a cost saving measure, re-branding at lower levels and employing DSNs on short-term contracts. Nevertheless, the recent changes in the NHS commissioning of services placed more emphasis on DSNs to be able to offer quality and cost-effective services to the patient. The DSNs are expected to get more involved in designing, shaping, planning and delivering diabetes care. Arguably, there is evidence suggesting a lack of long-term effects of the DSNs’ role in diabetes control. DSNs often form a therapeutic relationship with their patients over time and this continuous ongoing interaction may help to sustain the effects of care given to the patients. Therefore, with the increasing number of new diagnosis, the declining workforce needs to be addressed by the government, NHS and healthcare education providers. Otherwise, this lack of recruitment and retention of DSNs may result in long waiting times for specialist support, avoidable complications and poorer healthcare outcomes, which is contrary to the NHS framework aimed to improve quality of care and aid positive healthcare outcomes.
Diabetes is a major public health issue due to its increasing prevalence, economic burden and associated short and long-term complications. The DSN plays a key role in caring for and supporting people with diabetes through long-term trajectory of the disease. The DSN helps to detect, prevent and manage the disease condition to reduce the unnecessary use of hospital facilities and enhance patients’ quality of life. However, the expansion of their role has also led to some challenges. Therefore, it is important for the commissioners of healthcare services to consider the current level of recruitment, retention and development of diabetes specialist nurses as they play a key role within the multidisciplinary team in improving diabetes services.
National service framework: www.diabetes.org.uk/Documents/Reports/Five_years_on_-_are_we_half_way_there2008.pdf
Diabetes UK (Diabetes Specialist nursing survey 2010):
Loveman E, Royle P, Waugh N. Specialist nurses in diabetes mellitus (Review). The Cochrane Collaboration (www.thecochranelibrary.com).
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