Introduction
The recent headlines highlighting the shortage of nurses in the UK National Health Service has prompted me to reflect on my own nursing career, which has spanned almost 40 years. The majority of this time (30 years) has been spent in diabetes care, where there have been many changes in diabetes treatment and the delivery of care. The diabetes nursing service is frequently contacted by enthusiastic nurses, currently working on wards or in general practice, who are keen to pursue a career in diabetes care. This has encouraged me to share my experiences in this field.
The early days
My interest in diabetes first developed around 1985 whilst working as a ward sister on an acute medical ward. People with diabetes were admitted to hospital to start on insulin injections and stabilize their blood glucose levels. Nursing staff on the ward were involved in the education of these patients (where we even tried to induce hypoglycemia for educational purposes!) and there was regular contact with diabetes specialist nurses (DSNs). Diabetes nursing struck me as a rapidly advancing and challenging career move. However, at that time, in the area where I worked, DSN posts were community funded and a community qualification (health visiting or district nursing) was a prerequisite. The rationale for this was that diabetes was a manageable condition (rather than an illness) and the focus should be on health promotion and not attaching a label to an often otherwise healthy individual. The health visitor’s course (12 months full time), which focused on public health and health promotion, looked interesting and so I embarked on this at the University of Liverpool (UK). Several months after qualifying, I was successful in securing a local DSN post. In 1988, when I started my career in diabetes care, there were very few DSNs, and most of my training was acquired by working alongside consultant medical staff and shadowing the few locally available DSNs. In addition, I completed the English National Board for Nursing, Midwifery and Health Visiting diabetes course at the University of Manchester.
The management of glycemic control in type 2 diabetes was far less complex than it is today. Initial treatment was with sulfonylureas (then glibenclamide) for patients of a healthy weight and with metformin for those with a body mass index greater than 25 kg/m2. Insulin was reserved only for those with the poorest glycemic control, and many patients were warned that they may need to start on insulin if they did not improve their glycemic control. DSNs focused only on glycemic control, and much of my time in the early days was spent seeing patients in their own homes.
Career development
Over time, the DSN service expanded, as did the role. Patient education was popular and new skills were required. I therefore embarked on a further adult education teaching certificate before introducing a patient-centered education program into our service. An adapted version of this program currently runs in three local clinical commissioning groups. Evidence-based practice was encouraged, which helped to identify another learning need: Making sense of research publications and research skills. To develop these skills I was able to secure a research secondment to investigate the quality of life of adults with chronic conditions (diabetes and growth hormone deficiency), for which I was awarded a Master of Philosophy in 1995. Several publications in peer-reviewed journals also resulted from this work.
Service demands provoked a review of the DSN service in the late 1990s. To develop a career structure, the new role of diabetes nurse educator was introduced to work alongside the DSNs. The role is essentially that of a DSN-in-training, and involves a period of mentorship from a DSN. My role changed again to accommodate a leadership role.
In the early 2000s, the role of nurse consultant was introduced to encourage senior nurses to remain in a clinical role, rather than moving to teaching or management. In 2002, I was appointed as a nurse consultant in diabetes and continue to work in this role today. Initially, the role was focused on improving the quality of care for inpatients with diabetes, and so an inpatient DSN team was introduced. The team is now supported by a designated diabetologist. Service development and research has always been a major interest for me, and this has necessitated the development of additional skills, such as the management of cardiovascular risk factors and non-medical prescribing. This work has resulted in many publications and I was awarded a PhD in 2012. In recent years, we have been commissioned to deliver diabetes services in two clinical commissioning groups and my role has developed to incorporate this.
How has the DSN role changed?
In the early 1990s, one of the major controversies in diabetes nursing was where potential DSNs should be recruited from: Community nurses or hospital-based nurses. This debate is ongoing, although it has changed slightly. Currently, in many areas, the majority of diabetes care is delivered by practice nurses, many of whom have a special interest in diabetes. They are experienced not only in diabetes management, but also in the management of other diabetes-related risks, such as cardiovascular disease. However, since approximately 15% of all hospital beds are occupied by a person with diabetes [1], hospital-based nurses will have exposure to acutely ill people with diabetes on a day-to-day basis, although they may not be directly involved in the patient's education and altering their diabetes treatments. Both groups of nurses can bring valuable skills and experience to the DSN role.
Nowadays, the role of the DSN has expanded to cover areas such as the management of cardiovascular and renal disease, insulin pump therapy, and painful diabetic neuropathy. Many DSNs are now non-medical prescribers, enabling them to manage caseloads independently. Inpatient diabetes has emerged as specialty in itself. However, it’s always wise to return to the basics. A major role of the DSN is patient education and assessment, which may include home visits. Whilst there is no doubt that home visits are resource intensive, their value cannot be dismissed since much can be gained by seeing some patients in their own home.
There are now many diabetes-related courses and degree modules to help new DSNs to develop their skills and knowledge. In our own service, all new DSNs are appointed a mentor to work with for at least 12 months, and all are expected to achieve diabetes-related competencies. The prevalence of diabetes is increasing on an annual basis, and only a minority of people with diabetes are managed by specialist services. One major role of DSNs must be to educate and upskill other healthcare professionals on diabetes management.
The UK National Health Service is under intense pressure. Senior nurses are being encouraged to take on roles which have traditionally been medical roles. Whilst this is keeping nurses in the clinical arena, we need to ensure that nurses are adequately trained to fulfill these roles.
Here, I have described my personal journey from junior DSN to nurse consultant; others may have taken a different but equally challenging path. The role is dynamic and responsive to the needs of the individual service. I would encourage any aspiring nurses to take up the challenge and forge their own pathway.