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Self-management of diabetes in the hospital setting

It is now well established that the key to good diabetes care is education. In diabetes care, education is complex and should include healthcare professionals and people with diabetes, along with their relatives and carers. Healthcare professionals delivering diabetes care should be fit for purpose, and possess the skills and knowledge to deliver not only clinical care but also emotional and psychological care and education. It is impossible for us all to be experts in each of these areas; however, we need to be able to recognise when a patient needs, for example, ongoing psychological support and who we need to refer to.

In terms of education, every contact with a person with diabetes is an educational opportunity – this is often informal but may lead to the recognition of an educational need. This is a two-way process and I was reminded of this only recently when a patient asked me about a new drug for the treatment of diabetes-related macular oedema. My knowledge was not good, an educational gap was identified and I sought to fill this gap. People with diabetes are encouraged to manage their condition on a day-to-day basis yet when they are admitted to hospital this is often not the case.

NHS Diabetes (2012) has published guidelines for diabetes self-management in the hospital, outlining a number of recommendations for acute trusts to consider:

  • The responsible nurse and patient should agree, on admission, the circumstances in which a patient should self-manage, and sign an agreement form.
  • The patient’s ability to self-manage should be re-assessed on a regular basis.
  • If there is disagreement about self-management, the diabetes team should be involved.
  • Self-administered insulin doses should be recorded on a prescription chart.

Once again, an educational need is identified. If the self-management of diabetes is to be successfully implemented, then ward-based staff need to develop the skills and knowledge required to support this. In our own trust, we have recently piloted a “self-administration of insulin” project on two of the acute wards. The project involved training the ward staff on the use of insulin pens and insulin injection technique to enable them to assess the competency of patients to safely administer their own insulin. In addition, forms for competency assessment and patient agreement were developed. In one ward area (diabetes and endocrinology), following training, the staff felt competent and confident to take on the role of assessing each patient’s ability to administer insulin. However, on the other ward (cardiology), staff reported that they did not see many patients who were using insulin pens and thus did not feel confident in the use of the pens. Consequently, they did not feel equipped to assess patient ability to administer their own insulin.

Following this pilot, and owing to a number of incidents involving insulin pens, we are now implementing a cascade-training project aimed at training ward staff how to use insulin pens. This “back to basics” approach will also include other aspects of insulin treatment such as injection technique. There is a learning point here. It has often been said that we teach patients to give their own insulin injections using insulin pens so we should surely expect that ward staff can do this. The difference is that people with diabetes inject insulin every day of their lives and therefore become confident and competent in doing so. However, some nurses will do this only occasionally so it is hardly surprising that they do not feel able to assess the competency of patients.

In this featured section, beginning on page 66, Sinead Dawes et al (from my own trust) describe their experience of setting up and implementing a local carbohydrate counting programme. The programme was evaluated by participants and, although HbA1c did not improve significantly at 3 months after completion of the programme (previous cohorts have demonstrated an improvement in glycaemic control), in this particular cohort, there was a significant improvement in quality of life. In a long-term condition such as diabetes, quality of life issues should not be overlooked.

It is now well established that the key to good diabetes care is education. In diabetes care, education is complex and should include healthcare professionals and people with diabetes, along with their relatives and carers. Healthcare professionals delivering diabetes care should be fit for purpose, and possess the skills and knowledge to deliver not only clinical care but also emotional and psychological care and education. It is impossible for us all to be experts in each of these areas; however, we need to be able to recognise when a patient needs, for example, ongoing psychological support and who we need to refer to.

In terms of education, every contact with a person with diabetes is an educational opportunity – this is often informal but may lead to the recognition of an educational need. This is a two-way process and I was reminded of this only recently when a patient asked me about a new drug for the treatment of diabetes-related macular oedema. My knowledge was not good, an educational gap was identified and I sought to fill this gap. People with diabetes are encouraged to manage their condition on a day-to-day basis yet when they are admitted to hospital this is often not the case.

NHS Diabetes (2012) has published guidelines for diabetes self-management in the hospital, outlining a number of recommendations for acute trusts to consider:

  • The responsible nurse and patient should agree, on admission, the circumstances in which a patient should self-manage, and sign an agreement form.
  • The patient’s ability to self-manage should be re-assessed on a regular basis.
  • If there is disagreement about self-management, the diabetes team should be involved.
  • Self-administered insulin doses should be recorded on a prescription chart.

Once again, an educational need is identified. If the self-management of diabetes is to be successfully implemented, then ward-based staff need to develop the skills and knowledge required to support this. In our own trust, we have recently piloted a “self-administration of insulin” project on two of the acute wards. The project involved training the ward staff on the use of insulin pens and insulin injection technique to enable them to assess the competency of patients to safely administer their own insulin. In addition, forms for competency assessment and patient agreement were developed. In one ward area (diabetes and endocrinology), following training, the staff felt competent and confident to take on the role of assessing each patient’s ability to administer insulin. However, on the other ward (cardiology), staff reported that they did not see many patients who were using insulin pens and thus did not feel confident in the use of the pens. Consequently, they did not feel equipped to assess patient ability to administer their own insulin.

Following this pilot, and owing to a number of incidents involving insulin pens, we are now implementing a cascade-training project aimed at training ward staff how to use insulin pens. This “back to basics” approach will also include other aspects of insulin treatment such as injection technique. There is a learning point here. It has often been said that we teach patients to give their own insulin injections using insulin pens so we should surely expect that ward staff can do this. The difference is that people with diabetes inject insulin every day of their lives and therefore become confident and competent in doing so. However, some nurses will do this only occasionally so it is hardly surprising that they do not feel able to assess the competency of patients.

In this featured section, beginning on page 66, Sinead Dawes et al (from my own trust) describe their experience of setting up and implementing a local carbohydrate counting programme. The programme was evaluated by participants and, although HbA1c did not improve significantly at 3 months after completion of the programme (previous cohorts have demonstrated an improvement in glycaemic control), in this particular cohort, there was a significant improvement in quality of life. In a long-term condition such as diabetes, quality of life issues should not be overlooked.

NHS Diabetes (2012) Self-management of diabetes in the hospital. NHS Diabetes, Newcastle Upon Tyne. Available at: http://bit.ly/ORPx2B (accessed 01.02.13)

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