From practice nurse to diabetes nurse educator: The transition

I have been in a diabetes nurse educator role (DNE) for almost two years and I would encourage any nurse with an interest in diabetes to follow a similar path. This article aims to reflect on my own personal experience as a DNE and to help new diabetes nurses prepare and adapt to their new role.

Prior to becoming a DNE, I was a practice nurse for 5 years. Taking on the role of a practice nurse was a huge challenge as it was my first job in a primary care setting. Before that I had enjoyed 10 years in Accident and Emergency, but a change in my personal circumstances required me to choose a pathway that fitted in with family life. This change enabled me to refocus on my career and has involved a great deal of learning. It certainly has been a challenge for many reasons. I quickly realised that my knowledge of diabetes needed further development.

Previously as a practice nurse, my role was initially to carry out annual reviews for people with type 2 diabetes. This naturally progressed to medication reviews with GP support, considering not only diabetes control but blood pressure and cholesterol control, and importantly, patient education. An MSc programme in diabetes gave me much greater insight into the complexities of managing people with diabetes. Around the same time there was a shift in the organisation of care for people with type 1 diabetes. Historically, they had been managed in secondary care but were now being discharged back to primary care. Generally, at the time, there was limited knowledge and skills around insulin management in primary care. The knowledge and skills I gained and the contacts made on the MSc course were invaluable in enabling me to improve the quality of care.

Having a background in practice nursing has been an excellent starting block for the new role and it felt like a natural progression to venture into a specialist area. I benefitted from a basic knowledge of the initiation and titration of oral anti-diabetes agents, as well as an understanding of screening programmes and the consequences of poor glycaemic control. Additional skills, such as experience of working in a community setting and good communication skills, are also of great importance.

Often practice nurses develop a special interest in certain areas and certainly for me it was a natural progression to go on to specialise in this area.

Diabetes nurse educator
My role as a DNE is quite diverse. I work in multidisciplinary team clinics alongside a consultant diabetologist and specialist diabetes dietitian. Our patients are usually initially seen at three visits 8 weeks apart and a management plan is set. They are followed up in between in the nurse-led intensive support clinics by myself and the dietitian, where they are given support, education, titration of medication and help with self management.

An important part of my role is to deliver our patient education programme ‘’Diabetes and You’’ for people newly diagnosed with type 2 diabetes, alongside our dietitian. The programme covers what diabetes is, diet, exercise, medications, complications, annual reviews and foot care.

I also carry out home visits to housebound individuals, working closely with the district nurses and community matrons. This can be particularly challenging as it often involves dealing with social issues, multiple chronic diseases, learning disabilities and mental health problems.

Being part of a new team, commissioned to deliver a new service has been hard work, exciting, personally rewarding and a challenging career change.

Preparation is key
When moving from practice nursing to a specialist post, preparation is key and I found the following very beneficial:

• Observation of established DSNs carrying out their clinical role.
• Working closely alongside the consultants, dietitians and my DSN colleagues.
• Training in the delivery of the education programme.
• Observation of different services delivering education programmes.
• Attending educational events in diabetes to expand my knowledge.
• Self motivation in developing skills by background reading in relevant subjects.
• Observation of the podiatry and retinal screening programmes to assist in understanding of the role.
• Undertaking study in the specialist area (MSc programme).

Settling in
My locally developed structured orientation programme, which was planned for my first month, helped me to start to build up the more specialist skills I required in my new role.

This involved working with the DSNs in the acute areas, hospital clinics and the newly established community clinics. This exposed me to the area in which I had the greatest learning need. My concern was getting to grips with type 1 diabetes and the complexities of insulin management, which initially I found overwhelming. Working within a team of experienced DSNs certainly exposes your knowledge gaps but also helps you to identify and fill them. By the end of the month I felt I had enough confidence to review people in a community-based multidisciplinary clinic, with minimal supervision. Over the next 6 months, established protocols and pathways helped me develop my own style and skills to deal with type 1 and type 2 diabetes. My preferred learning style is definitely experiential and actually doing the job increased my confidence and skills rapidly.

Reflection
Reflecting on my time as a DNE has been a useful exercise. I think that the first 6 months were about finding my feet and really getting to grips with insulin therapy, different regimens and titration. The following 6 months involved not only developing those skills further but also learning and understanding more about the service and its management. In the past year, I have become more confident in the management of type 1 diabetes, as well as the more complex multiple oral therapies in type 2 diabetes. I am comfortable working with practice nurses in joint practice-based clinics and running my own nurse-led clinics. I now feel confident to suggest changes in management, whether it is in insulin titration or changes in regimens, initiation of insulin and use of newer agents.

I try to use each clinic as a learning experience and reflect on the decisions I make afterwards to ensure that they are in each individual’s best interest. I feel it is important to ask peers for help with difficult cases. I think it is important to recognise your limitations and seek help when unsure. I am lucky that I feel well supported and always feel I can approach and ask colleagues for help. Each consultant (medical or nurse) I work with has taught me that, for most individuals, there are a variety of treatment options. Each person’s case is different and what may work for one does not always work for another.

A practice nurse background
I believe that having a practice nurse background has been useful for a variety of reasons. Working in a clinic setting and working to strict appointment times was a skill already in place. Experience in using the EMIS (Egton Medical Information Systems) computer system and having an understanding of developing templates has ensured that diabetes annual reviews are recorded comprehensively. Good background knowledge in all chronic diseases is extremely helpful in managing diabetes during exacerbations and also the knowledge to be able to signpost people to other available services that may help them to manage all aspects of their health. Having a good rapport with community services, knowing their availability and different roles is particularly beneficial when dealing with housebound individuals, especially if they have had no community support. Good communication skills and the ability to build up relationships with patients is definitely a skill needed in both roles.

The MSc course raised my awareness of the complications of diabetes and gave me the opportunity to observe the work of the podiatry service. I undertook competencies to carry out foot screening as part of my annual reviews, which provided me with the skills to educate my patients in good foot care.

Importantly, I made sure I attended as many diabetes education events as possible to ensure that my knowledge base was up to date. Although I  have learnt a great deal so far, I still feel that I have so much more to learn. I have developed confidence working with people with type 1 diabetes and this has been a gradual process that has developed with each working day.

Advice to others
Considering my experience so far, I would advise anyone thinking about a career in specialist nursing to:

• Spend some time shadowing a DSN, observing the different aspects of the role.
• Gain experience of working in a variety of different settings, for example, in primary, secondary and emergency care.
• Ensure that you have a background experience of diabetes. For example, experience in oral anti-diabetes agents is beneficial.

Working with specialists on the job has been invaluable for me. I have also drawn on my past nursing experience to help me develop clinically and I have enjoyed using my management background again, working within a team rather than on my own. I am fortunate to be surrounded by a very supportive team and, after a period of apprehension, I am now growing in confidence.

The prevalence of diabetes is continually increasing and I plan to stay in this specialist area. My priorities for the foreseeable future are to undertake the non-medical prescriber’s course and to finish my MSc. I have found my experience very enjoyable and I would not hesitate to recommend this career path to any aspiring specialist nurse.