Becoming a diabetes nurse educator: The journey from wards to a specialist post

Nurses who are embarking on a career specialising in diabetes care may be interested in pursuing a diabetes nurse educator (DNE) role. This is a journey that I have made personally, and the purpose of this article is to share my experience and offer some words of advice and encouragement. As well as giving practical advice, this article aims to share my perception of the role and the initial concerns and challenges I faced.

The role of a DNE differs from that of a DSN by way of the advanced skill and expertise that is possessed by a DSN. As a DNE I can identify a problem and suggest a solution, for example a change in treatment, but this needs to be approved by either a diabetes consultant or a DSN. Then I am free to then implement the change.

DSNs will often review very complex cases, such as those in critical care, those with newly diagnosed type 1 diabetes or those with an unclear diagnosis. There are times when a DNE will be required to also review these individuals. When this situation arises, I make sure I run my management plan by somebody more senior. DSNs also offer advanced clinic sessions, such as insulin pump clinics and antenatal clinics. As a DNE I absorb as much knowledge as I can from the DSNs to help develop my own skills.

I have been in the DNE role for 14 months, and I continue to really enjoy it and find it very challenging. To specialise in diabetes has been an ambition of mine since the beginning of my nursing career and with a great deal of hard work, dedication and self-belief, I am delighted to say that I have achieved my goal. Preparation was key and, from very early on, I made sure I was involved in every opportunity to learn about diabetes. For example, I was the ward diabetes link nurse and, prior to applying for my role as a DNE, I observed numerous diabetes clinics with specialist nurses and consultants in order to enhance my knowledge further and become familiar with the clinic setting.

Previous role as a staff nurse
I started my nursing career in 2008 on a general medical ward that specialised in diabetes and endocrinology. I became fascinated by diabetes and its various comorbidities, and the many other factors to consider, such as the different types of diabetes, environmental factors, lifestyle factors and behavioural issues, all of which affect glycaemic control and make diabetes a particularly individualised condition.

Thanks to a very supportive ward manager, I was able to learn the basics about diabetes through a large number of opportunities that were presented to me, such as blood glucose monitoring and interpreting blood glucose levels, an understanding of a small variety of treatments and their actions, insulin administration and experience of diabetes emergencies, such as hypoglycaemic episodes and diabetic ketoacidosis.

Diabetes nurse educator: My experience
In January 2014, I started a secondment in the diabetes centre as a DNE. Despite my preparation, soon after starting in my new role, working alongside experienced specialist nurses made me realise that there were so many things I had to learn.

I had a four-week induction, which consisted of shadowing experienced members of the team and learning as much as I could before I was expected to work semi-independently. I was allocated a mentor, who was an extremely knowledgeable and experienced specialist nurse. This gave me time to settle in and learn new things before I started consultations by myself. I met with my mentor on a regular basis for feedback and to enable me to identify learning needs and plan how to meet these needs. Having my mentor at hand to support me if I needed any assistance was very reassuring.

The first four weeks of working independently presented a steep learning curve. I quickly became familiar with the electronic case note system, which helped me shape my consultations. I also utilised a work diary to help with my time management.

One thing I really enjoyed during my first few weeks was building up relationships with patients. I enjoyed the fact that they would often ring me with updates and queries. This was something that I had not experienced in the ward environment. This continuity of care was very rewarding and it was great to see people with diabetes achieving good results with the advice and support of the diabetes team.

After six months my knowledge of type 1 and type 2 diabetes had grown significantly. Furthermore my confidence has also developed. I was beginning to review a variety of patients, for example, pre-colonoscopy patients and people who were on insulin therapy and due to go on holiday. With the support of my mentor I provided flight plans for two individuals (one going to Australia and one to Thailand). I also began to see more people with type 1 diabetes in clinic and became more confident with its management. With the support of my colleagues I was able to advise on more complex issues.

After twelve months I felt I had gained a great amount of knowledge and experience, but there is still a great deal to learn. I have recently attended the ABRACADABRA nursing conference and completed a local “Train the trainers” course, which helped develop my teaching skills for the future.

A focus on education
The DNE role is primarily focused on the education of both people with diabetes and healthcare professionals. This education is delivered in a number of settings, including acute areas within Aintree Hospital, local health centres and GP practices. Education can involve hypoglycaemia management and prevention, sick day rules, blood glucose monitoring, insulin administration and lifestyle advice. A DNE must perform a comprehensive assessment of an individual’s nursing needs and plan and implement care delivery appropriately. A DNE is expected to establish and maintain effective communication with people with diabetes and their families, and work collaboratively with other health professionals to ensure their needs are met.

Key skills
There are a number of essential key skills required for the DNE role. These include:

• Effective communication. It is essential to communicate effectively with people with diabetes and their relatives in order to obtain the correct information and to involve them in the planning and delivery of care. Furthermore, it is important to communicate daily with colleagues in your team in order to develop services and care quality. Good communication skills are also important when working with ward staff to improve an individual’s glycaemic control and when providing ward education.
• Background knowledge. Having some diabetes knowledge early on will help your progression in to the specialist role, and in my experience will help new information to be absorbed much more efficiently.
• Time management. This is fundamental in ensuring your work remains of the highest standard when working in a number of settings, and reviewing a large patient population.
• Team work. The diabetes team consists of a number of healthcare professionals, including specialist nurses, podiatrists, dietitians and consultants, so working as a team is fundamental in providing the best possible service.
• Flexibility/adaptability. The role requires working in a variety of settings, so being flexible is a very important skill. For example, as a team we cover a variety of settings, including an inpatient service, outpatient clinics in hospital and community settings, as well as weekly home visits to people who are unable to make it to hospital. This is done on a set rotation, although there are times when things can change and you are required to help out in a different setting.
• Initiative. The ability to think on one’s feet is a skill that is required on a daily basis in the role of DNE. Sometimes upon reviewing an individual, you can find their social circumstances do not coincide with the treatment choices that have been made by the medical team. An recent example of this was when I reviewed an older lady with type 2 diabetes who had been started on a treatment by ward doctors due to having persistent hyperglycaemia. However, while chatting with the lady I discovered that she had a variable appetite and lived alone. I felt the treatment that she was commenced on would put the lady at risk of hypoglycaemia and falls. In this instance, I opted to stop this and trialled another treatment option.
• Self-confidence. This is important when providing education; it is best not to come across as uncertain. You should be confident in your clinical judgement and decisions. However, it is imperative to know your limitations. Never be afraid to ask for advice or a second opinion, either on your decision, or that of somebody else.

The challenges
Complex cases
I found managing complex cases of type 1 diabetes very challenging. For example, people with erratic blood glucose levels or with poor compliance. It was type 1 diabetes that was my biggest challenge and was an area where I needed most support to make sure my management plans were thorough. I find I still have to do a great deal of reading around type 1 diabetes and its management and I continue to learn something every day from my more experienced colleagues.

Unfamiliar drug treatments
One of my challenges was becoming accustomed to treatments that were fairly new to me, such as glucagon-like peptide-1 (GLP-1) receptor agonists and sodium–glucose co-transporter-2 (SGLT-2) inhibitors. These drugs were not common on the ward I worked on previously. They presented a challenge for me because there was a wide variety available and there are a number of guidelines to be adhered to as they are not suitable for all. It is an ongoing challenge for me to remain up to date with the various drug classes.

Insulin pen devices

Learning about unfamiliar insulin pen devices was yet another challenge. I was most familiar with pre-filled and disposable pen devices from my ward experience, but was less familiar with pens that require cartridges to be inserted. I was able to become accustomed fairly quickly with each of the devices by spending any free time playing with them. I would also discuss pen devices with my patients, which was a great way of understanding the benefits or disadvantages of certain pens.

Blood glucose meters
As with the insulin pens, I did not have a detailed knowledge of blood glucose meters prior to starting as a DNE. I soon found that there were so many options and different meters available, and had to learn which meters would be best for which individuals. For example, there are more basic meters that suit individuals who are tablet controlled and do not need to monitor as frequently as somebody who is on insulin, there are the more “high-tech” meters that are able to assist individuals who count their carbohydrates, and meters that are also able to check blood ketone levels. As with insulin pens, spending time getting used to the devices was beneficial, and patient feedback was invaluable.

Being new to the service
One of my biggest challenges was being new to the service. I was often worried that people with diabetes would not confide in me and trust my advice as I was a new member of the team and still relatively young. I did experience this initially and found it difficult as I was still trying to adapt to the role. Although the patients were new to me, they were well known to the service and were used to seeing my colleagues and trusted in their knowledge. Patients would often like to see the same nurse each time, which was very understandable for continuity reasons, but unfortunately this is not always possible. However, in time, I became a familiar face in the diabetes centre and was able to build up good relationships with the patients, some of whom started to request to see me for their next appointment.

As their confidence in me grew, my confidence was also lifted, and I soon found myself adapting to seeing a variety of individuals who were on a variety of different treatment combinations. In spite of the wealth of information to take in, this was something I really enjoyed. It was challenging but refreshing having something new to learn every day.

Other challenges
Other challenges included becoming familiar with new pathways, new referrals and an electronic case note system. I also had to quickly learn about blood tests that I was not aware of, as well as the limitations of a restricted clinic time.

I found these challenges were overcome by gaining knowledge from my colleagues and reading as much as possible from journals and other relevant literature.

Practical advice
When providing education to people with diabetes, it is important to assess their current knowledge on the particular topic. They may have no understanding or they may have been told incorrect information, which may leave them with certain reservations. Alternatively, they may be very knowledgeable and recognising their knowledge will help you choose the most effective approach in providing education in a way that suits that particular person.

I would advise anybody wanting to pursue a career as a DNE to do plenty of reading, especially diabetes journals, and to keep up to date with the latest treatment options. I would definitely recommend completing a post-graduate diabetes module to enhance your knowledge and strengthen your CV. A recognised diabetes course is a prerequisite for most diabetes specialist posts. The course that I attended was very interesting. It involved a number of presentations from a variety of speakers. It greatly enhanced my knowledge base and I developed an understanding of the health promotion requirements for this patient group and an understanding of the practical aspects of diabetes in both normal and emergency situations. The course also explored the physiological, psychological and social processes that affect diabetes control. It gave me a much greater insight into the specialist nurse role.

Specialising in diabetes comes with a lot of responsibility, as it is such a complex condition. It is very challenging and no two days are the same. There is always something new to learn as each person’s diabetes is individual. Having a background of diabetes experience is a great advantage. I would suggest contacting the DSNs in your area to arrange to spend some time with the team. In this way, you can find out what the role consists of and if it is definitely the path you want to pursue.