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Nursing collaboration in diabetes care

Sara Da Costa
MBA BSc(Hons) DipN(Lond) FETC RGN
Nurse Consultant in Diabetes
Worthing & Southlands Hospitals NHS Trust

This article aims to explore some of the ways in which collaboration between practice and specialist nurses can improve patient care in diabetes.  Given the impact of the GMS contract, and the greater emphasis on care delivery in primary care, working together may appear more relevant at this time. However, my belief is that it has always been important because patients journey across both primary and secondary care and need to have consistent information and support to navigate such a complex system, which they may not even acknowledge, let alone understand. The role of nurses in providing such information, and enabling such shared care, will be explored by the following themes: education, networking and new ways of working.

Education and networking
Even before the dawn of standards, strategies and contracts, diabetes care involved patients from childhood to older age, in their own or residential homes, in practices and in hospitals. This has necessarily involved a wide range of clinicians, mainly doctors and nurses, of which there has always been insufficient skilled numbers. This has meant that working together and sharing the care has been essential from the outset, and one of the prerequisites for this is education.
When I became a diabetes liaison sister in 1988, I realised that I could not do all the diabetes nursing care in the district, and I looked outside of my hospital base to identify other nurses involved in diabetes care. By the early 1990s, education sessions for local practice nurses were set up to update their knowledge and skills and to establish a learning network. These nurses suggested the content and format themselves, which ensured high attendance. This early collaboration became easier because learning together built trust and made it much simpler to ask for advice when necessary. This is turn revealed a need for me to be accessible by phone, so a direct line for use by practice nurses and other clinical colleagues, as well as patients, was established.
Nursing education during this decade began to favour accredited rather than attendance-only courses, which meant collaboration with local universities. Practice, district and ward nurses in our district were surveyed via questionnaire and asked what their learning needs were, how and where such a course would be delivered, and whether they all wanted accreditation (which required full course attendance and submission of an assignment) or updating by attending specific days rather than the whole course. The majority favoured accreditation, but a significant number wanted attendance of core subjects only. The outcome was an 8-day diploma level course accredited via the University of Brighton, with the option of attending up to 3 standalone days within the course. The majority of attendees were practice nurses, and while this course continues, an additional accredited degree module now runs in the second semester. This was required as many nurses were achieving diplomas and required the next level for their clinical modules.
These educational initiatives have not only increased diabetes knowledge with the potential to improve patient care, but also created nursing networks that have proved the foundation for subsequent initiatives, in particular collaborative projects and new ways of working.

New ways of working
As our nursing and medical team expanded in secondary care and we moved into our diabetes centre, we gained the capacity to increase our nurse-led clinics and to develop group education and insulin transfer programmes. This also provided the opportunity to invite practice nurses to sit in on such clinics and sessions, and to further develop their educational skills and knowledge. Above all, it ensured a consistency of message and, for both DSNs and practice nurses, a greater understanding of the problems encountered.
Since Shifting the balance of power, there has been a greater emphasis on primary care doing more routine work, and patients receiving care closer to home.(1) There is a risk that secondary care could be marginalised by geography alone (because it is sited further away from many patients than their GP practice) and therefore patient access to such specialist service could be either reduced or denied. This risk is further increased by the GMS contract, which came into operation in April 2004, where elements of patient care are rewarded by points that translate into revenue for the practice concerned.(2)
In association with the Diabetes NSF Standards and Delivery Strategy, this has prompted an overall review of diabetes services and discussions regarding workforce models, care pathways and referral and discharge criteria.(3,4) It is therefore appropriate, as most diabetes care in both primary and secondary care is nurse-led, that we should collaborate in diabetes service redesign.
With no ring-fenced monies for diabetes service expansion, we as clinicians needed to consider what worked well for our patients, and what better care could look like, acknowledging all of the political and contractual influences previously stated. Practice nurses wanted closer links with the DSNs, in terms of named DSNs responsible for, and working in, each of our three localities. Patients wanted access to specialist care, but preferably closer to home. DSNs wanted to ensure appropriate patients did have this access, and wanted to make their service more integrated with that of practice nurses. Consequently, we have started to develop a pilot project to test the feasibility of this in a practice, with specific inclusions and exclusions, reflecting the referral criteria to DSNs.
DSNs are an expensive and a scarce resource, and they are there to perform a specialist function, not to take the place of practice nurses. These specialist clinics will run with the practice nurse (who will already have prior diabetes education as previously discussed) to further develop their skills and leave a legacy within the practice.
This project also has the potential to reduce waiting times for specialist care and to move more care from the hospital setting (albeit an outpatient diabetes centre) into primary care. This idea is supported by our PCT colleagues.
Another project that succeeded because of such nursing collaboration was our health community review of prescribing for blood glucose monitoring. In common with other areas, this prescribing is very costly and of debatable value - especially if patients are testing but not using the results. Working with our lead prescribing teams, a project group consisting of practice and specialist nurses had developed a protocol for prescribing that reflects frequency of testing in different situations, such as illness and pregnancy, and emphasises using the results to improve control. This is currently circulating as a final draft and will then form the basis of prescribing across our health community, and provide primary care with better guidelines in terms of who should test, and how often. This is in harmony with the GMS contract, which has specific targets aimed at improving diabetic control (eg, reduction in HbA(1c)).(2)

Conclusion
When reviewing patient care and services, one has to take into account the context in which such care is delivered. This includes not only the patients and the clinicians, but also the site(s) of delivery of care and the political and organisational targets and priorities. Consequently, collaboration appears to be essential, and invariably it is nurses who are most prepared to work together.
Despite the risks to secondary care, I believe that the GMS contract provides future nursing opportunities, which include independent contracting, practice partnerships and enhanced nursing services.(2) Specialist nurses should appreciate such opportunities and find ways to work together with their primary care colleagues. I believe that many of our local advances and initiatives  are the result of nursing collaboration and, as such, provide both a legacy of ongoing development and the potential for improvements in patient care.

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References

  1. Department of Health. Shifting the balance of power. London: HMSO; 2001.
  2. Chamberlain-Webber J. What does the GMS Contract mean? Prof Nurse 2004;19:14-7.
  3. Department of Health. National Service Framework for diabetes: ­standards. London: HMSO; 2001.
  4. Department of Health. National Service Framework for diabetes: delivery strategy. London: HMSO; 2003.