Is it time for a review of the skill mix within the diabetes inpatient specialist nurse team?

The year-on-year increase in the prevalence of diabetes is well recognised. Over the last decade, a 72% rise in the number of people diagnosed with diabetes in the UK has been reported (Hicks, 2017). Although the diabetes specialist nursing workforce survey (Diabetes UK, 2016) illustrated a need for more DSNs to support this increase in patients, the number of experienced DSNs is actually diminishing, with almost 60% eligible to retire over the next 10 years.

In England, the NHS has previously been shown to spend more than £2.3 billion per year on inpatient care for people with diabetes, approximately 11% of total NHS expenditure on inpatient care (Kerr, 2011). The 2015 National Diabetes Inpatient Audit (NHS Digital, 2016) demonstrated that 15% of inpatients in England and Wales had diabetes. However, for our Trust, the proportion is greater than the national average, at around 20%. This is due to the over-representation of people requiring treatment within our renal dialysis unit, inpatient renal ward, and vascular and stroke services. Furthermore, locally, there has been a general issue with recruitment and retention of staff, which reflects the plight of the NHS nationally. Despite being an award-winning diabetes service, East and North Hertfordshire Trust has had issues with recruiting to vacancies within the diabetes inpatient team.

The Diabetes Clinical Assistant post
In light of the struggling financial climate of the NHS, the skill mix within our inpatient nursing team was reviewed, and a decision was made to change the current model of recruiting only to band 6 and band 7 DSN posts. A Diabetes Clinical Assistant (DCA) post had been previously established in a neighbouring Trust. Although this had a predominantly outpatient focus, we adopted the role and adapted it to focus solely on the requirements of the inpatient Diabetes Outreach Team service.

Initially, it was estimated that the DCA would free up 2.5 hours per day of Diabetes Inpatient Specialist Nurse (DISN) time, enabling them to concentrate on Specialist Nurse duties. However, in reality, the role has evolved and the whole 7.5 hours in which the DCA is on duty are used to their full potential, allowing tasks that were traditionally carried out by the DISNs to be performed by the DCA.

When first in post, the DCA worked under direct supervision and was set aims and objectives in line with the Integrated Career and Competency Framework for Diabetes Nursing (TREND-UK, 2015). These competencies were utilised as the assessment tool to measure individual levels of ability and competency, as well as signposting to further training required and a timeframe over which objectives and goals were expected to be met. Structured timelines were developed and the individual was assessed incrementally.

Once deemed competent in all required areas, the DCA was able to work more autonomously, although always under indirect supervision. The expectation of the DCA was to work individually within the team setting and to always have access to a DISN or consultant. It was required that the individual held or attained a foundation degree in health and social care. The post was graded at Agenda for Change band 3 until this was achieved, then it became band 4.

The role of the DCA is varied and includes the education of both patients and staff groups. It is outlined in Box 1; however, this list is not exhaustive.

Feedback
Anecdotal and formal feedback, both from healthcare professionals and from patients and their families, has always been very positive. It is felt by all that the DCA can focus on the stipulated areas and deliver in-depth education for patients and their families in a flexible, time-appropriate way, thereby ensuring a positive learning experience for all concerned. Samples of the comments are:

“I felt very scared when the doctor told me I had diabetes and would have to inject insulin, but after Karen saw me I didn’t feel so bad. I think I’ll be ok.” Patient BV

“The lady who taught me how to prick my finger was lovely. She took her time and could see I was frightened.” Patient AD

“I really enjoyed the talk about diabetes. I can understand a bit more now.” Clinical support worker

“We love it when Janice comes to see our patients. We know they’re going to get a good education.” Ward nurse

In October 2016, the role of the DCA was presented and discussed at the DISN UK Group conference, and some of the audience expressed concerns that it may deskill DISNs and encourage Trusts to reduce the number of DISNs within their services. Such fears have so far proven to be unfounded within our Trust; the value the role provides is fully acknowledged but, despite the financial climate, it has not stopped DISN vacancies from being authorised. It could be argued that introducing the band 4 DCA role to the skill mix of the Diabetes Outreach Team has been an innovative move and that, with the dawn of the new Nursing Associate role (Nursing in Practice, 2017) – which this Trust is fully embracing – the DCA role even has the potential to develop and expand further.

Areas of controversy

• Is this a step too far?
• What are the implications for the future of the DISN teams and services? 

The answers to these questions are not in this article, and this is clearly a matter for further debate.

Let us know your thoughts
Is the Diabetes Clinical Assistant role an effective solution to the workforce crisis?
Do you have any experience with a similar initiative, or do you have any alternative suggestions?
Email us your thoughts at:
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