When asked to write a guest editorial with this challenging title, the first question I asked myself was ‘why do we need to consider the future of diabetes nursing’? Of course I then realised that if we did not consider the future then we may get frustrated when it changes into something that we do not like, and we feel we have no control over the changes.
Assuming that there will be a future for diabetes nursing (i.e. that there is no immediate cure for type 1 or type 2 diabetes) then it makes sense to consider it. Why? Because the future is made by the present – what we do now will influence the future. Having a sense of what the future potentially holds can act as a guide to decisions that we make today.
‘The best way to predict the future is to invent it…’ This quote (from a management guru whose name I forget) has been in my thoughts for many years. It has become a fundamental part of my philosophical approach to life and work, driving me to work confidently to change things that I see, and believe, need changing. My more recent reflections assert that the best way to predict the future is to consider what is driving change at the moment and see how you can influence the changes. So perhaps we should be considering what diabetes nursing needs to do now to influence the future. That will, of course, require diabetes nurses to have a vision (shared or otherwise) of how they see the future – something that, perhaps, we have not spent many hours thinking about. Living and working in the present is often hard enough!
The changing role of diabetes nursing
Diabetes nursing has changed dramatically since I began specialising in the early 1980s. When we consider the question: What is diabetes nursing now? the answer requires a reflection on community/practice/hospital roles, specialised diabetes nursing roles in acute care, pregnancy, footcare, renal care, psychology, education, research, and many more. The answer would also consider the career pathway of nurses in diabetes as educators, specialists/practitioners, consultants and practice nurses. So what may be the desired future of one group may not necessarily be the same for another group.
There are many factors that will/are influencing the roles currently and therefore need considering as we shape the future.
In the future there will not be enough registered nurses to deliver healthcare in its current form. There will be a smaller pool of nurses to attract specialist nurses from. How can we develop others to take on some of our traditional roles? We will be working in different ‘teams’ to those that exist now. They may consist of volunteer patients (as lay educators, e.g. Isle of Wight and Portsmouth), education support workers (Portsmouth), diabetes technicians (Peterborough)… and more.
The aging population means that more people will require healthcare, but the workforce may not be there! Increased numbers of patients and diabetes (along with other long-term chronic diseases) being on the increase mean there will be a greater number of people requiring care. As people live longer they will not necessarily be healthier.
Service delivery
Where will diabetes nursing be delivered? Where will diabetes nurse specialists/ consultant nurses be working? Despite the developing role of primary care it is still difficult to see how well GPs and practice nurses will respond to the potential opportunities of the GP contract. It is possible for GPs to develop entrepreneurial approaches to the commissioning and provision of health care but whether many will be able/willing to do so will be interesting to watch. Already some larger practices are directly employing DSNs to lead their diabetes service. Primary care trusts will be encouraging this as it may be that their role in the future will be focused on commissioning services rather than providing them.
This may also see the opportunity for the development of innovative independent community-based services. The developing role of primary/community care will naturally influence the role of hospital-based services. Many are now considering how their very specialised work can integrate with the improving specialist services in the community. This, of course, is not new for some areas. However, those working in hospital-based services also have opportunities to influence what is happening in primary/community care.
The influence of prescribing
Some diabetes nurses are already prescribing, albeit in limited ways, but the list of independent prescribing items is likely to increase and specialist nurses will be prescribing in all areas of relevance in diabetes care. This will put even more of them in the front line of diabetes care in all settings … should they all take up the challenge. The challenge of this process is the easy move towards the medical ‘model’ of delivering diabetes care. Already nurses are undertaking the annual review, now they will start prescribing, taking over more and more of the traditional medical role. Whilst this may be appropriate and desirable, there is another challenge here. We now realise that the simplistic model of annual review care is not sufficient to provide effective diabetes care. Increasing evidence suggests that this needs to be combined with structured education and ongoing support. These are currently delivered separately in most instances.
The prescribing developments provide an opportunity for nurses (and others) to combine effective, structured, ongoing educational care with evidenced-based clinical care. This approach will enable increased self-management by people with diabetes and improve health outcomes.
The current focus on Expert Patient Programmes as a means of enabling increased personal responsibility for health also provides an opportunity for nurses to link such programmes with disease-specific self-management programmes. Whilst there may be critics of the policy behind the Expert Patient Programme, it provides a window of opportunity to get structured self-management programmes further onto the map of healthcare.
The bigger picture: chronic disease management
Chronic disease management is now a priority within the NHS. The current focus on the small number of people with complex needs who are regularly admitted to acute hospitals (Evercare and Rincorn models) is driving a change for community nursing and social care. Those diabetes nurses who believe that self-management education is as important as working with the challenging end of complex clinical needs care now have an opportunity to ensure that message is not lost.
The focus on those people with complex conditions may require specialist nurses in diabetes to become increasingly skilled in care of people with heart failure, chronic obstructive pulmonary disease, etc (and vice versa). Many of our patients will experience all these conditions and as a result can be frustrated about getting different aspects of care from different groups of people who rarely communicate. The opportunity for integrated patient-centred care for this group is clear! These are just some of the challenges and opportunities that face diabetes nursing. There are many more, as there are plenty of examples of how others are changing the shape of diabetes nursing.
Responsibility for the future
To ensure that diabetes nursing influences healthcare and the profession – and ultimately people with diabetes – at this time of great change, there are critical factors that will drive its success. These factors are strong leadership (of the transformational kind) both locally and nationally, and a clear, shared vision for the future. Do we have these in place?
The future of diabetes nursing is being shaped by all of those who lead it and deliver it at the moment. The future is in our hands.
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