Career framework for the diabetes specialist nurse

Diabetes, which affects approximately 3% of the population of the United Kingdom, is a chronic condition with many long-term complications. Working exclusively in the field of diabetes care, DSNs have clinical, teaching and counselling skills, and are essential providers of continuing care. They have a unique role in the individualised assessment and delivery of appropriate evidence-based nursing, education and well-being. Through face- to-face contacts and telephone support, the DSN promotes and encourages independence, often making hospital admission unnecessary.

Working together with other members of the multidisciplinary team, the DSN crosses organisational boundaries to follow the patients from hospital to home, to work or to school.

Through both formal and informal methods of education, the DSN is able to increase awareness about diabetes for both professional and non-professional carers.

This document outlines a framework for career progression within diabetes specialist nursing, and defines the qualifications, skills and experience required for four different levels of practice in this specialty. The work required to produce this document was carried out by the specific working party whose remit it was to develop a career framework for diabetes specialist nursing which has never been available until now.

The members of the career framework working party are listed at the end of the article. Representatives on the working party were taken from the four professional groups involved in the Joint Education Working Party — UK Association of Diabetes Specialist Nurses, Education and Care Section or the British Diabetic Association, RCN Diabetes Nursing Forum and the Paediatric Diabetes Specialist Interest Group.

It is important to make it explicit that there is no timescale to progress through the suggested levels. Indeed, it may not be appropriate or necessary to progress to the next level. There will always be nurses who wish to practise at a level that they feel comfortable, although evidence of professional updating and development will always be expected of nurses working within a specialist area of practice.

Nurses should be proactive in creating/seizing opportunities for their personal development. However, it is recognised that development is not at a constant rate and will be affected by many factors including personal circumstances, staffing difficulties and financial constraints. Expert clinical practice is paramount in diabetes care. Nurses should not be made to feel that there is pressure to progress to a management position.

Movement between the four levels suggested is not necessarily upwards. For example, a DSN may decide to move back to a more clinical role rather than continue in a managerial role.

It is recognised that there are currently many capable, knowledgeable and experienced DSNs who do not possess an academic qualification. However, it is anticipated that in the future, with the increasing emphasis upon academic, as well as clinical, credibility, DSNs practising at level H(I) should hold a first degree, and those at level H(II) a master’s degree.

Proposed career framework for the diabetes specialist nurse (adult)*
The minimum requirements for entry to a diabetes nursing post are shown in Table 1. Information on the proposed four different levels of DSN are presented below. The members of the working party met on two occasions, but regularly communicated by telephone and fax over a period of eighteen months to develop the career framework. Each member of the Working Party had an equal opportunity to input ideas. It was the facilitator’s role to co-ordinate the group and produce the written document for discussion and approval by the Working Party. Once the final document was agreed by all the members of the Working Party it was submitted to the committee of the Joint Education Working Party where the document was ratified and agreed for publication.

*DSNs working with children should refer to the document Role and qualifications of the nurse specialising in paediatric diabetes (RCN, 1998)

Proposed four levels of DSN career framework
Diabetes Nurse
This would be a probationary year which would incorporate a structured induction period including specific objectives with time frames and learning outcomes. Mentorship support would be provided, either locally by a designated mentor from within the specialist nursing team or arranged with a neighbouring specialist nursing team.

This level would be funded as a G grade post but paid as an F grade post to allow funding for external training. The postholder would not initially be expected to take responsibility for a total caseload. However, as confidence and competence increase, the postholder would take on a small caseload under supervision.

Expected characteristics of this level

• Proven self-management skills (time, caseload, etc)
• Proven teaching/counselling skills, e.g. having a recognised course
• Increasing portfolio of diabetes study relating to current practice (first degree, intermediate or final level equivalent)
• Increasing knowledge of diabetes-related, evidence-based practice.

Diabetes Specialist Nurse
This level would apply to those nurses who have direct responsibility for a caseload, spending the majority of their working week providing direct patient care and participating in education in formal or informal settings for both patients and other healthcare professionals. The suggested grade for this level is G.

Expected characteristics of this level

• Proven self-management skills
• Proven teaching/counselling skills
• Demonstrable use of evidence-based nursing to change/develop practice
• Demonstrable use of reflective practice to evaluate clinical effectiveness
• Development of a specialist area of practice, e.g. paediatrics/adolescence, renal, pregnancy, etc (depending on the needs of the local service)
• Effective liaison between primary (primary care groups) and secondary care providers.

Diabetes Specialist Nurse H(I)
This level would apply to those nurses who are either leading a team of DSNs or working on their own. This nurse would spend part of the working week participating in direct patient care but would also be involved in planning educational programmes in collaboration with local colleges/ universities and other institutions. This nurse would also be a representative on such bodies as the Local Diabetes Advisory Committee, and act as a consultant/expert on local issues such as safe disposal of sharps and be involved in the development of diabetes care pathways or diabetes-related policies, working across professional and organisational boundaries. It is envisaged that this post will be a grade H. A nurse at this stage would be a dependent prescriber.

Expected characteristics of this level

• Three years experience in diabetes specialist nursing
• Proven leadership skills
• Proven teaching/counselling skills
• Demonstrable use of evidence-based nursing to change practice
• Demonstrable use of reflective practice to evaluate clinical effectiveness
• First degree
• Multidisciplinary team-building skills
• Ability to develop local standards for effective diabetes care
• Ability to provide or facilitate clinical supervision
• Participation in clinical research/critical evaluation of research
• Effective liaison between primary and secondary care providers.

Diabetes Specialist Nurse H(II)
This level would encompass all the roles of the previous stages. The postholder would maintain clinical expertise through participation in direct patient care. The postholder would view diabetes services nationally as a means of comparing and contrasting current local practice, being aware of political issues, and will play a crucial part in developing local services for people with diabetes. It is envisaged that this post will be grade I, but would require review when the UKCC issues its guidance on the establishment of nurse consultant posts.

Expected characteristics of this level

• Over three years experience of diabetes specialist nursing
• Effective co-ordination of a multidisciplinary team
• Effective team-building skills
• Effective resource-management skills
• At least first degree or working towards a master’s degree or post-graduate diploma
• Demonstrable use of evidence-based nursing to change practice
• Demonstrable use of reflective practice to evaluate clinical effectiveness
• Proven teaching/counselling skills
• Effective development of local care pathways
• Effective liaison between primary and secondary care providers
• Skills in critical evaluation of research
• Involvement in research activities.

What next?
Now that this document has now been published, there will be the opportunity for DSNs to discuss its usefulness at the forthcoming Journal of Diabetes Nursing conference to be held in London on 4 February 2000 (see page 134 for further details). I must reiterate that this is a framework document and not exhaustive. It is there to assist and support DSNs, not to restrict them.

It has been agreed that the document will be reviewed on an annual basis taking all changes in nursing policy and strategies, such as nurse consultant posts and Higher Level of Practice registration, into consideration.

Members of the Working Party Group – Career Framework for Diabetes Nurses

• Debbie Hicks (Facilitator) – UK Association of Diabetes Specialist Nurses
• Marilyn Gallichan – BDA, Education and Care Section
• Margaret Tipson – RCN Diabetes Nursing Forum
• Jan Mitchell – UK Association of DiabetesSpecialist Nurses
• Jane Houghton – Paediatric Diabetes Special Interest Group