National diabetes specialist nursing degree: An update

Together with the exploding predicted prevalence of diabetes nationwide (Yorkshire & Humber Public Health Observatory [YHPHO] and National Diabetes Support Team [NDST], 2006), there is evidence that the number of people with diabetes in the UK has doubled between 1994 and 2003 (Hippisley-Cox and Pringle, 2004). This increase relates, in part, to the effect of the ageing population and increased screening and diagnosis over the same time period. However, the incidence of new diabetes has also risen over this time period, from 1.8 to 3.3 per 1000 people (these figures are age standardised to take account of the ageing population; YHPHO and NDST, 2006). The estimated prevalence of diagnosed and undiagnosed diabetes in 2005 in England was 4.67 % of the population, or approximately 2 350 000 persons (YHPHO, 2005).

Diabetes networks are therefore facing a potential predicament in ensuring that their workforces have the necessary skills, support and educational opportunities available to provide effective and efficient care for people with diabetes at the point of contact. We feel that there is an insecure environment of reconfiguration and change within primary care trusts and an under-funded National Service Framework for diabetes; so despite having vision, the need to overcome constraints is paramount.

The vision
The National Education and Development Group for the national diabetes specialist nursing degree (Table 1) predicted this very problem and aimed to respond by developing practitioners with specialist and high-quality diabetes nursing skills at the point of contact for people with diabetes. This would also allow for succession planning – ensuring availability, support and provision of well-educated and developed DSNs.

From the national survey of diabetes nursing course provision of Crowley (2002) and from the work of Llahana et al (2003) about the potentially inadequate preparation of nurses for the multifaceted, advanced and complex role of diabetes specialist nursing, the degree evolved and metamorphosed into what is envisaged and intended to be a nationally available programme specifically to prepare nurses to be DSNs.

The first intake of students on the pilot programme, in October 2005, met these aims, as the students are practice nurses, district nurses, new-to-post DSNs working in diabetes centres and acute nurses from endocrinology wards in district general hospitals. This mixture of nurses has worked well, enabling sharing of each other’s roles and responsibilities within diabetes care delivery.

The structure of the pilot degree has followed the curriculum shown in Table 2; the third module has just been completed.

Degree ethos
The degree ethos is the vision of developing diabetes nursing in a structured, layer-by-layer approach to build on prior learning. Figure 1 demonstrates this vision. Through working with their clinical mentors (described later), all of whom are experienced and keen DSNs, the students develop their skills in diabetes management (Figure 2). The curriculum (shown in Table 2) tallies with the vision.

• First module (Theoretical and practical aspects of diabetes care). The growing experience of students in skill acquisition and knowledge is assessed over 12 months by portfolio. This corresponds to the ‘clinical problem’.
• Second module (Evidence-based practice in diabetes care). This corresponds to the left-hand circle: gaining an understanding of the evidence-based process and translating this into practice.
• Third module (Psychosocial issues in the care of a person with diabetes). This represents the right-hand circle. It includes developing an appreciation and understanding of patient preference, and developing consultation, communication, change management and psychological skills in diabetes nursing.
• Fourth module (Education and management strategies for people with diabetes). This uses evidence such as that from Loveman et al (2003) to cover the final layer of skill development in making a ‘clinical decision’ that is informed, evidence based and patient centred, and that can be translated into the educative process of informing and supporting people to learn and develop skills in their diabetes self-management (Kawamoto et al, 2005).

Clinical mentors
Essential components of this clinically focused degree are the clinical mentors for the students, all of whom are experienced and keen practising DSNs. As diabetes nursing is predominately a practice-based profession, the clinical environment for learning and exploration is essential to this process (Hutchings et al, 2005; Lambert and Glacken, 2005). Each of the clinical mentors has been pivotal in the student learning experience and regular communication between students, their clinical mentors and the teaching team has engendered a tripartite approach to the learning experience and student support (Webb et al, 2003).

The main problems encountered have been lack of time, and other commitments. However, this is not unique; in fact, in our experience, it is common in current health care. Nonetheless, having clinical mentors within this degree has facilitated knowledge translation within the current practice of diabetes specialist nursing, focusing on changing health outcomes using evidence-based clinical knowledge (Davis et al, 2003). The role the clinical mentors are playing is fundamental, we feel, for skills development and knowledge acquisition in diabetes specialist nursing for these students.

Teaching team
The degree is being predominately taught by DSNs and specialist clinicians within diabetes care, such as consultant diabetologists. Bev Bookless and Anne Greenley from the National Diabetes Support Team have also taught the current students. The University of York teaching team comprises a former DSN, the programmes lead in diabetes education and two lecturer–practitioners in diabetes nursing, both of whom practise half-time as DSNs. This combination is delivering vibrancy, currency, dynamism, enthusiasm and well-informed support for the students, as diabetes specialist nursing is at the forefront of all session delivery.

Student views
Each module so far has had excellent feedback; although the students recognise that it is hard work, they seem to think it is worth it. In May 2006, we also sent out an anonymised survey to the students (n=12) asking three questions about the degree (Table 3).

All of the respondents would recommend the course to new-to-post DSNs, practice nurses, community or district nurses, and DSNs wanting to further their learning. Ninety per cent of the respondents would also recommend the degree to acute nurses. None of the respondents would recommend it to occupational health nurses.

Part of the present learning is assessed by portfolio and will therefore be tailored to individual learning outcomes. During the degree we promote the idea of life-long learning (DoH, 2001). Some students are already considering progression to an MSc programme, and, of these, most are considering an MSc in Diabetes Care. Another student is thinking about a post-graduate teaching qualification. Because of differences in students’ prior learning and experience, we cannot predict where everyone will go next, but one nurse has already secured a DSN post during the course, and we will continue to check on progress.

We have monitored the students’ feedback closely in this programme, to enable us to pass on details to the National Education and Development Group, and also to the UK Association for Diabetes Specialist Nurses, who fund the degree.

Students have responded in terms of appreciating the clinical focus of the degree and valuing the teaching team and the clinical mentors throughout the degree. One student commented, in module feedback, that:

‘I am more confident now that I have gained more knowledge about diabetes specialist nursing. I feel that with this knowledge, I can start to play my part in specialist nursing, though I need more practice, and thus I really value having a clinical mentor to guide me with this skill acquisition.’

Students have commented positively on their learning being appreciated and their needs being supported and met throughout the first three modules of this programme. In particular, the students have evaluated the programme as being diabetes specialist nursing focused and have made comments such as ‘[the degree is] refreshing’, ‘[the degree is] completely applicable to my practice’, ‘I have learnt loads’, ‘I am completely enthused’, ‘I love my learning’ and ‘I am really enjoying this degree’.

This is clearly what the National Education Development Group and also the teaching team for the pilot degree at the University of York site had hoped for.

Reflective practice
A theme that runs throughout this degree and is reflected in the teaching styles is reflective practice. As Davis et al (2003) recognised, the case for knowledge translation into clinical practice development is important and encouragement both to reflect on practice and to practise what we know and have learnt is to be supported and encouraged. Applying reflective practice within this degree has been a means of facilitating an approach that is student centred, allowing each individual to progress, develop their skills and grow within their sphere of practice and according to their learning needs.

Reflective practice, while often confused with reflection, is neither a solitary nor a relaxed meditative process. Reflective practice, in our experience, is a challenging, demanding and often trying process that is successful if both supported and seen as a collaborative effort.

Osterman and Kottkamp (2003) suggest that reflective practice is interpreted and understood in different ways. Within the degree we both teach and support reflective practice to be a means for the students to develop a greater level of self-awareness about the nature of their performance and their learning needs. This reflective awareness creates opportunities for the students’ professional growth within diabetes specialist nursing and the development of skills. This reflective process is assessed by portfolio (Gordon, 2003), as well as by assignment.

Degree place funding
Given the current national funding difficulties for study leave, particularly the embargoes in place across many acute and primary care organisation, we are fortunate to have Workforce Development Confederation (WDC) funding for the degree in place at the University of York and also at King’s College London, the next site where the degree will be available. As the degree is on a national level, students from outside the WDC funding area have accessed a reciprocal arrangement for funding of programmes across WDC areas. No students have had to self-fund the programme at this time.

National availability
The National Education and Development Group designed and structured the degree as a national qualification which it is hoped will be adopted to be available across the UK, to try to ensure clarity and similarity of educational preparation for new-to-post DSNs and also for nurses wishing to develop their diabetes specialist nursing skills. The degree staff at King’s College London, the next site, will include: Angus Forbes, a Lecturer; Jakki Berry, a Lecturer–Practitioner; and Eileen Turner, a Nurse Consultant.

Future developments
We will continue to give feedback to you regarding this programme via the Link section in the journal. We hope that this degree can indeed be available nationally as was always intended by the UK Association for Diabetes Specialist Nurses and the Royal College of Nursing Diabetes Forum. Finally, we encourage readers to discuss the degree, and the potential for its provision locally, with their higher education colleagues and providers, to keep diabetes specialist nursing at the forefront of diabetes education and development.