Communication and collaboration: link nurses in diabetes care

For non-specialist nurses, finding the time, funding or motivation to undertake traditional courses in diabetes may be difficult in areas where it is not seen as a priority.

A link nurse may perhaps be described as an identified practising nurse with an expressed interest in a specialty and a formal link to specialist team members.

There have been several articles on this subject over the past decade, but little published work on diabetes link nurses. The perceived need for link nurses appears to have increased simultaneously with the diversification of nursing roles, which has resulted in increasing specialisation (James, 1983).

Link nurse schemes have been established in many areas, including continence (Gibson, 1989), nutrition (Charalambous, 1993), research and development (Collins and Robinson, 1996), wound care (Briggs and Banks, 1996), and especially infection control (Horton, 1988; Ching, 1990; Thompson and Smyth, 1996; Teare and Peacock, 1996). There are some diabetes link nurse schemes in operation in the UK, notably in Norfolk and York, but they are not yet in widespread practice.

Origination
The reasons given for setting up a scheme are to improve collaboration and communication with, and education of, nursing staff, thereby improving patient care. The origination of such schemes is shown in Table 1.

Most schemes have involved regular meetings and subsequent report to other nurses in the workplace, with both aspects being considered important. 

The continuing support of managers is vital at all levels, particularly during initiation of the scheme (looking for volunteers) and to allow it to continue (Charalambous, 1995; Collins and Robinson, 1996).

Personnel issues
The qualities required by the leader of a link nurse group appear to be largely those of any effective communicator and educator, with a similar commitment to change. The correct title for the leader would perhaps be ‘facilitator’, but this term has the potential to cause confusion in diabetes circles; in practice, the leader of a diabetes link nurse group is usually a specialist nurse.

The qualities of a good link nurse include willingness to attend meetings, an interest in the subject and some background knowledge, the ability to identify gaps in his/her own knowledge (or areas of poorer practice), and a desire to improve care. 

Link nurses should also have the skill and influence to be able to pass this knowledge on to others, hence the requirement for a qualified nurse (Charalambous, 1995). Most diabetes nurses can name those on their local wards who are especially ‘keen’ on diabetes; being a link nurse rewards their interest and keep them involved.

Evaluation
How well does a link nurse scheme work in practice? Research is scarce, but the benefits reported include an increase in:

• Collaboration (Charalambous, 1993; Briggs and Banks, 1996; Teare and Peacock, 1996; Thompson and Smyth, 1996)
• Communication (Gibson, 1989; Charalambous, 1995; Collins and Robinson, 1996)
• Motivation (Horton, 1988; Ching, 1990; Charalambous, 1995).

Ching (1990) reports significant improvements in practice on link nurse wards, compared with non-link nurse wards, when implementing a new policy (although she calls them liaison nurses):

‘[They] have the potential to reach all the nurses on the wards, will remain in the ward after the educational programme, and can also continue to be a resource for education and to motivate other nurses.’

Link nurse meetings
Collins and Robinson (1996) described link nurse meetings as: 

‘…a time away from clinical commitments to discuss problems or areas that need to be addressed.’

Such meetings provide an opportunity to reflect on practice in a supportive, knowledgeable atmosphere, and facilitate access to the specialist nurse by regular contact.

Are regular meetings useful? It certainly seems appropriate to use the time for a brief update on any current issues relevant to nursing practice, with the bonus of receiving immediate reaction (Horton, 1988). As the issue is ‘news’, it appears to make the subject of diabetes more real and less theoretical, which is important in enabling nurses to improve care. Reviewing the topics discussed at meetings and evaluating the scheme raises further issues (Briggs and Banks, 1996).

Meetings also remove the need for memoranda, reports and reminders. Where there are concerns about practice, these may be successfully eliminated by ‘reframing’ (Peterson et al, 1995), i.e. changing the focus from the person to the practice, rather than reacting negatively.

British Diabetic Association report
How did the independent group reviewing and recommending the provision of training, following the St Vincent Declaration, view non-specialist nurse education in diabetes? The BDA (1996) report of this group, Training and Professional Development in Diabetes Care, states that it:

‘…should be seen as a continuing process for all health professionals since people involved in diabetes care will never be “completely trained” nor will they cease to have responsibilities for the training of other colleagues.’

The BDA (1996) report makes the following recommendations (among others) for nurse training:

• Provide training locally as it is practical, cost-effective and encourages ownership
• Training should be integrated where possible to include hospital, community and primary care teams
• It should relate directly to the local provision of care and to the respective roles of all those in the diabetes team
• Training programmes need to give professionals greater practical knowledge so that they can deal with patients more expertly.
• The link nurse role should be explored.

Link nursing in practice
The current structure of the Northallerton Health Services diabetes link nurse scheme is shown in Table 2 and the aims and objectives in Table 3. These form part of an agreement given to prospective link nurses and their managers, which must be validated by their signatures. This arrangement was set up to encourage understanding of the scheme and commitment to it, in an attempt to prevent enthusiasm waning.

Written communications
The Sweet Nothings newsletter is produced before the meeting for distribution there, or is sent, along with minutes, to any link nurse who is unable to attend. Minutes of the meeting are in the standard format, but Sweet Nothings has a different format. 

It is collated by the diabetes administrator and is a deliberately informal collection of news and views, contributed by various members of the team. It includes references to relevant articles we have discovered; information regarding local issues such as supply of diabetes equipment, and a recipe, usually seasonal, that is suitable for healthy eaters. 

A survey of link nurses in the Northallerton scheme found that they read most issues, most displayed it at their workplace and it was generally well received, possibly because of the ‘local flavour’. Newsletters have been evaluated by Pettengill et al (1994) and Lindsay et al (1995). A copy is also circulated to all local GP practices, addressed to the practice nurse; however, this is currently their only involvement in the scheme.

Content of link nurse meetings
Speakers at meetings are often members of the multidisciplinary team, and recent topics have included diabetes and surgery, foot care, blood glucose testing, diet and older people, insulin pens, neuropathy (including impotence) and the British Diabetic Association. The talks are usually short, around 20 minutes, so that discussion may ensue; nurses almost always relate the subject in discussion to someone they have nursed, clarifying their understanding.

Evaluation
Workshop-style meetings are productive also: link nurses enabled the successful implementation of a new blood glucose meter throughout the trust. About three years ago it was decided to rationalise the meters used, working in collaboration with the biochemistry department. A medley of meters were in use, with little quality control; problems were regularly reported, even with the ‘official’ hospital meter. Effective training was difficult and time-consuming, and the newer meters appeared to have advantages. 

The link nurses wholly agreed with us and set to work evaluating the most accurate (for drop-size) meters after evaluation by the biochemistry department. The most user-friendly meter at the time has now been adopted across the Trust, with the minimum of problems. It continues to perform well.

Drawbacks
Time: A fair amount of administrative time is taken up by organisation of the meetings, although little of this needs to be performed by the specialist nurses. Those attending appear to consider it a good use of their time: the attendance rate is usually 70–80% of the total, but managers need to be aware of the commitment away from the workplace.

Discussion with the diabetes nurses involved in a surprisingly similar scheme in Norfolk (unpublished but presented at posters during BDA section conferences in 1996 and 1997) mirrors our experience, i.e. that nurses will attend in their own time, although we do not encourage this.  

Evaluation: This is difficult as a randomised trial would be unlikely to be able to take into account all of the variables.

Role erosion: Charalambous (1995) warns of potential problems for specialist nurses. Before reading about the Northampton experience (Anfield, 1998,) I would have thought this unlikely, but there is a potential risk that link nurses will indeed become a ‘faded replica’ of the specialist.

Link nurse suitability: There is a risk that nurses will be ‘sent’ from a ward where they will not be missed or will volunteer in order to get a break from the ward. This is rather a harsh judgment of our colleagues, and may theoretically be avoided by the link nurse agreement (Table 3). The requirement for professional profiling could mean that more is invested in membership of the scheme anyway.

Purpose: The purpose of the meetings, i.e. to improve and maintain standards of care for people with diabetes, must not be forgotten. Many published articles discuss the implementation of standards, and Charalambous (1995) correctly warns that the patient may be ‘in danger of becoming smothered by protocols and red tape’.

Conclusion
Nurses in every setting care for people who have diabetes, and to achieve uniform, quality care requires involvement from all concerned. There is some evidence that link nurses schemes work in practice, and our experience justifies continuation of the scheme. As yet, however, there is no evidence that link nurse schemes work better in diabetes care than other methods of communication, education and collaboration. I would suggest that the more intensive, accredited courses will always be vital as a demonstrable qualification and to expand knowledge and improve care directly, but that a link nurse scheme is unique in reaching a wider audience.