An evaluation of the role of diabetes nurse consultants in the UK

The role of a nurse consultant is structured around five core functions (see Box 1).

A preliminary evaluation of the role of the nurse consultant undertaken in 2001 was generic, rather than speciality based, and focused on the initial establishment of the role and included views on the impact of the role on patient experience (Guest et al, 2001). Although Dawson and McEwen (2005) evaluated the impact of nurse consultants in critical care, most of other evaluations have been generic and carried out through telephone interviews, questionnaires and tape-recorded interviews (Woodward et al, 2005; Coster et al, 2006). In a national survey of nurse consultants, Redfern (2006) suggests the role can benefit patient care and service provision; however, those who made the greatest impact were adequately resourced and were well supported by their peers and medical colleagues.

Objective
The authors’ objective was to undertake an evaluation of the diabetes nurse consultant role from a national perspective using a 360-degree feedback evaluation tool that would provide the nurse consultants with an individual report on their effectiveness in their role and local environment, along with a collective evaluation of the overall performance of nurse consultants in diabetes care in the UK. It would also enable the individual nurse consultants to be more focused on their professional development, receive confidential feedback from their colleagues and to provide encouragement and motivation for them to move forward in their career (Maddison Group, 2003).

Demographics
There are currently 25 diabetes nurse consultants in the UK. The first was appointed in 2001 and ten appointments were made in the last year. Their locations are shown in Figure 1.

Methods
In order to evaluate the role of the diabetes nurse consultants, the 360-degree feedback process was chosen. Some group members had already used this tool for professional development and our decision to use it was based on their positive experience. In an evaluation of nurse consultants in four trusts, Redwood et al (2007) also used this tool to obtain information about the roles of the nurses from users and colleagues.

The 360-degree feedback is a process whereby a selection of people who have an interest in an individual’s performance are asked how they perceive that performance against a set of indicators or competencies. Feedback is collected by use of a paper- or web-based questionnaire. The results are collated and a report is produced. Support is provided by trained managers or an external coach who review the report with the individual or group of individuals. The objective of the 360-degree process is to enable the individuals to be more focused on their professional development, receive confidential feedback from the people who have a stake in their performance, and provide encouragement and motivation to move forward in their career (Maddison Group, 2003). This also benefits the organisation as the individual(s) should be motivated and focused with a clear direction.

Nine diabetes consultant nurses who had been in post for over 2 years undertook a 360-degree feedback evaluation. This was believed to be important as it was felt the post would be well-established and the feedback would be a truer reflection of their performance. Coster et al (2006) also reported a higher impact on service in nurse consultants who had been in post 2 years or more.

Each consultant nurse nominated a representative cross section of 15 colleagues to participate in the feedback process (See Box 2). They did not purposefully choose colleagues who would rate them highly as this would have biased the results and would not benefit their professional development.

The web-based questionnaire was sent electronically and returned confidentially. It was centred on the five competency areas. Each competency was rated for its importance, from 1 to 5, and on the individual or group performance (Table 1). Each competency received a score for importance and performance from each group of colleagues nominated (except the manager who was scored individually).

Independent assessors collated the results of the questionnaire, and individual and group reports were produced. The report reflected how the individual and the group were seen by others. All of the scores were tallied to produce a top ten and bottom ten score for importance and performance for both the individual and the group. In total, there were 36 performance areas.

Results
A total of 105 people provided feedback on the nine diabetes nurse consultants who participated in the 360-degree feedback evaluation (Table 2).

Following this, eight of the nine nurse consultants attended an action learning set. Action learning is a process of reflection and learning through the support of a group or ‘set’. By reflecting on experiences and, in this case, the 360-degree feedback, learning takes place and then action can be taken to move forward and ‘get things done’ (McGill & Beaty, 1992). This is illustrated in Figure 2.

The action learning set was led by an independent consultant with specialist skills in this area. Each nurse consultant identified from their individual report an area of ‘weak performance’ in relation to their work environment. This was explored within the group and potential strategies for dealing with this were identified. Although Redwood et al (2007) used the 360-degree process, the information obtained in this did not progress to an action learning set.

Summary of competencies
The mean score for each of the competencies was excellent and results were comparable between importance and performance (Figure 3).

The mean overall scores for each of the five competencies were consistently high, ranging from 4.0 to 4.8 out of 5, but overall, importance tended to score higher than performance (mean scores of 4.6 and 4.1, respectively). Expert practice was identified as the key area of strength based on the views of the individual consultants and the feedback providers.

Top ten scores
The top highest performing areas indicate again that expert practice is an area of strength for diabetes nurse consultants, with 50% of the scores in the top ten relating to this competency (Figure 4).

Bottom ten scores
These results indicate lowest performing areas and, therefore, potential areas for professional and personal development. These indicate a varied picture although performance in all categories was greater than 3.8, with five results scoring 4.0. However, it is interesting to note that self-leadership features four times in the bottom scores, reflecting the demanding role of the nurse consultant. This is clearly recognised by the individual nurse consultant and colleagues (Figure 5).

Discussion
The top ten scores, as rated by colleagues, identified the expert practice aspect of the diabetes nurse consultant’s role as the highest scoring area. We feel our strength lies in education and development even though expert practice received the highest score overall. Both expert practice and education are used in clinical practice to support people with diabetes, carers and healthcare professionals, which underpin the role of the diabetes nurse consultant.

Results for the bottom ten scores reported by our colleagues and ourselves showed that self-leadership is the main weakness. Each core function produces its own workload and the nurse consultant often finds it difficult to manage this effectively. Initially, management responsibility was not included in the diabetes nurse consultant’s role. Woodward et al (2005) noted the role ‘should not include management responsibilities’ as it was considered to be far reaching enough. However, a number of nurse consultants have had to take on management responsibility and other areas of responsibility, which add to their workload. Redwood et al (2007) suggest that heavy workloads can be obstacles to establishing new specialist services and that effective leadership requires a supportive environment.

During the action learning set, areas for professional development were identified, and action points agreed. These are outlined below.

• Reflect on the increasing demands of the diabetes nurse consultant’s role and communicate with managers regarding support in order to achieve an improved work-life balance.
• Develop and participate in research projects and present findings.
• Develop a work plan to communicate effectively with all stakeholders in order to increase awareness of the extent of the diabetes nurse consultant’s role.

Throughout the 360-degree process, the nurse consultants rated themselves lower than the feedback providers did. It became evident from our discussions during the action learning set that the nurse consultants who participated possibly had higher expectations of themselves than the people they worked with. However there are great expectations of the role both locally and nationally, with nurse consultants frequently being asked how their role differs from a senior diabetes nurse. This may, in itself, lead to nurse consultants feeling they are underachieving in some areas of their role.

Conclusion 
The 360-degree feedback process laid bare not only the strengths, but also the weaknesses of the diabetes diabetes nurse consultant’s role. There are only 25 diabetes nurse consultants in the UK and this demonstrates that they are expert practitioners and educators. The results provided focus for personal and professional development. Although our weakness is self-leadership, this is probably endemic in many areas of healthcare. The action learning set enabled us to reflect on our performance with the support and feedback of our peers and, as a result, we were able to form action plans to enhance our development.