The role of an inpatient DSN

My role of inpatient diabetes nurse began in February 2003, and is currently a 1 year secondment. Before moving into diabetes care, I worked on the emergency admission unit and consequently found myself on a steep learning curve in diabetes care. However, my previous skills have enabled me to visit any adult ward in the hospital with an adept understanding of a patient’s general health needs, and provide diabetes care in light of their current illness.

It is well understood that diabetes is a chronic and progressive disease influencing every physical, psychological and social aspect of life. However, for many healthcare professionals the significance of living with diabetes is often underestimated.

In previous years, information from the Worthing and Southlands NHS Trust’s clinical incident reports demonstrated that people with diabetes felt that their views were often ignored, and that the diabetes team was involved too late, if at all. It also revealed that diabetes management did not always reflect best practice. Optimal management of inpatients with diabetes (through the introduction of an inpatient diabetes nurse, for example) can improve patient satisfaction and reduce length of stay and readmissions (Davies et al, 2001; Bhattacharyya et al, 2002).

Standard 8 of the NSF relates to patients admitted to hospital, and advocates that:

‘People with diabetes admitted to hospital, for whatever reason, will receive effective care of their diabetes. Wherever possible, they will continue to be involved in decisions concerning the management of their diabetes.’ (Department of Health, 2001)

The role of the nurse in delivering diabetes care is well documented (Da Costa, 2000), and has been specifically recommended in achieving standard 8 of the NSF:

‘The employment of an inpatient diabetes specialist nurse to oversee diabetes management can reduce length of stay and release bed space. Patients are more knowledgeable about, and satisfied with, care provided in this way.’ (Department of Health, 2001)

Within the hospital environment, the role of the DSN is to:

• Assess and review patients with specific issues.
• Ensure that an individual’s diabetes regimen is disrupted as little as possible.
• Advise and educate patients and staff.
• Refer patients to other specialist teams as required, thus enabling a smooth transfer back to primary care.

Prior to the inpatient DSN position within the trust, a DSN was only involved in patient care at the request of the ward staff. As a consequence, many patients who needed input received no specialist care at all. Furthermore, as a result of current resource demands on the diabetes centre to provide outpatient services, inpatients were frequently a second priority. With the additional resource of an inpatient DSN, the diabetes team aims to improve patient access to quality diabetes care and reduce the risks of inappropriate treatment and delayed discharges.

In order to evaluate the role, an audit was undertaken to establish current inpatient diabetes care on four randomly chosen elderly and medical wards. The four wards involved now receive a daily visit from the inpatient nurse with structured education sessions. A repeat audit will be undertaken at the end of 2003. The findings from these audits will be used to influence and prioritise areas of development within future inpatient care.

Staff education: reducing clinical risk
Six months into the role, my greatest surprise has been how little knowledge many nurses have with regard to diabetes and the issues of caring for a person with diabetes. While it is not expected that a general nurse will have a substantive insight into diabetes care, many nurses (independent of grade) have not even achieved a basic understanding. For example, some nurses have no understanding of the differences between type 1 and type 2 diabetes, the action of basic drugs, or how to deal with hypoglycaemia successfully.

Through the education and empowerment of nurses, the inpatient DSN can:

• Help to reduce the risk of patients receiving suboptimal care, e.g. incorrect prescriptions, prevention of acute complications (hypoglycaemia and diabetic ketoacidosis), inappropriate and/or inadequate diet etc.
• Prevent delayed discharge (and hence reduce length of stay).
• Enable patients to continue to self-care.
• Provide nurses with the opportunity to develop their own understanding of diabetes.

To date, the four wards that receive structured education have seen nurses begin to develop an enthusiasm for diabetes that was not previously evident.

Education of nurses alone is not the idealistic solution it sounds, particularly with the continuous turnover of nurses. It is impossible to provide education for every member of staff that needs it, and it would be an endless task at the expense of the time spent with individual patients. However, as long as the inpatient DSN position is in place, an ongoing approach is likely to be adopted, with the aim to provide such service to wards that have been identified as having a special need for input, or directorates where people with diabetes have a greater length of stay than people without diabetes.

Additionally, since the introduction of the position, students are increasingly requesting to spend a day with the diabetes nursing team. On occasions, ward managers are allowing trained nurses to attend as part of their personal development. The mere presence of an inpatient DSN appears to be raising the profile of diabetes within the ward environment.

Patient access and length of stay
One of the main findings from the preliminary audit was that a significant number of patients who needed input from a DSN were identified, who would otherwise have been missed. These patients were only found by going to the wards and identifying every patient with diabetes admitted to hospital, and reviewing each individual. It would not be possible on a trust-wide basis to assess every person with diabetes who is admitted to hospital. Educating nurses to refer patients appropriately, and targeting high-risk wards (such as admissions) appears to be the way forward. The overall aim is to identify and prevent clinical incidents before they arise.

Furthermore, the inpatient DSN has a unique opportunity to identify a percentage of the population who rarely, or never, access primary care services. Many patients I meet remain unaware of the aims of control or the importance of annual checks, for example. Being admitted to hospital can give patients the chance to learn about their diabetes, providing them with the opportunity to use their newfound knowledge to make changes to their daily life, and improve their control and long-term health outcomes. We cannot make an individual adhere to treatment, but if patients are not armed with knowledge and information then they are unable to make informed choices about their self-management.

Patient education
As a nurse whose focus has always been in acute care, I rarely had the luxury of spending time with patients as I do now as an inpatient DSN. Patients comment almost daily how grateful they are that someone has taken the time to explain their treatment to them. Sitting down with a patient in hospital and providing health education and information about treatment remains a rarity in the over-stretched health service in which we work.

During admission, patients have an opportunity for regular meetings with a DSN. Some patients may have the equivalent of two or three clinic appointments during one admission. If this time improves their ability to manage their diabetes more effectively, then it is time well spent.

Many patients are admitted to hospital for reasons unrelated to their diabetes. Much of the inpatient DSN role is managing an individual’s diabetes while they are too unwell to do so. However, while many patients find their diabetes care being taken out of their control, the inpatient DSN can facilitate independence and self-management if they are able or wish to do so.

Continuing care across primary and secondary services
It is fundamental that the transition of care between primary and secondary services runs smoothly, and that patients are followed up appropriately. It is important that a patient is safe on discharge, and that appropriate services (such as district nurses) are in place to help a person manage their diabetes successfully once discharged and prevent readmission. A letter to the GP informing them of issues or changes in regimen, for example, may be all that is needed to ensure the communication channels remain open.

Conclusion
The role of the inpatient DSN is specifically targeted at standard 8 of the NSF for Diabetes. However, in reality it encompasses many of the other standards in which empowerment and collaboration between patients and healthcare professionals is fundamental in improving health outcomes.

The position of the inpatient DSN is exciting and multifaceted. Though in its infancy, the role of inpatient DSN has the potential to improve quality of care and service provision for people with diabetes who are admitted to hospital.