The future role of the diabetes specialist nurse

As the new millennium approaches and the new National Health Service develops, the moment is opportune for diabetes specialist nurses (DSNs) to work fast and together, towards defining their role and responsibilities in appropriately meeting the future needs of people with diabetes.

In her article in this issue, Maggie Watkinson sets out her ‘Vision for the future’ (page 86) presenting the challenges ahead. The reality is that the predicted ‘epidemic’ of diabetes is already upon us. We are now accustomed to diminishing health care resources and local prioritising in health services. We know that by the year 2000, 25 per cent of the current nursing workforce in this country will be retired and that many nurses are leaving the profession to seek greener pastures. Although a national nurse recruitment campaign is now under way, it is, in my opinion too little, too late. Most direct nursing care in the future will be provided by trained but unqualified nursing assistants and by relatives in the home. This will reduce the overall costs of health care, necessary for the survival of the health services.

Fewer qualified nurses in all areas of health care will become supervisors and trainers, while providing a high level of nursing expertise in direct care provision. Qualified nurses will take on a higher level specialist and/or technical role, at the same time engaging in research, while managing, supervising and training others. In primary care groups, nurses will play an increasingly important part in assessing local health needs and in commissioning health services.

In a review of diabetes specialist nursing, now is a good time, individually and collectively, to review the past, learn from the present and plan for the future.

The past
Diabetes nurses have been around for the last 70 years, following the discovery of insulin. A painting in the entrance hall of the Joslin Centre in Boston depicts a nurse seated beside a child, demonstrating an insulin injection. This nurse was a Deaconess trained in the practice of nursing, using the art and philosophy disseminated by Florence Nightingale. The painting is entitled The Wandering Nurse and clearly shows an early understanding of diabetes nursing. In the UK, this nursing speciality has developed since the early 1980s when Janet Kinson, a nurse teacher and diabetes nurse, set up the first course for nurses with an interest in diabetes.

The present
The diabetes specialist nurse is so called, as she/he is employed whole time in adult and/or childhood diabetes care. Diabetes nurses enter the field by intention, by chance and, occasionally, because they or a family member have diabetes. Hitherto, there has been little career structure development and no nationally accredited training scheme to meet their professional needs.

Diabetes nurses are all registered nurses, many of them with long and varied experience in the hospital and/or community setting. Many now hold multiple qualifications, degrees and higher degrees. Some have received no training and minimal continuing education. Their grading (and salary) does not necessarily relate to the responsibilities of the post they hold. The way diabetes nurses work, the responsibilities they take and the work they do is variable within and between health districts. Inevitably, the diabetes nursing service received by people with diabetes differs from place to place.

Diabetes nurses are autonomous, yet work in a multidisciplinary team and with many other teams in hospital and community settings. They take considerable responsibility in the care of people with diabetes. Their nursing training gives them a holistic view of the person and family concerned, allowing a continuous and friendly relationship to develop. They may be ‘facilitators’ and some may ‘co-ordinate’ diabetes services in a health district. Mostly, they do not receive any special training, other than having ‘done’ the ENB928 course and any other courses deemed relevant to their post, where their continuing education has been locally approved and adequately supported. Diabetes nurses are not only concerned with diabetes education; they also have a vital clinical role in diabetes care and are a local resource for the diabetes population.

Above all, diabetes nurses learn about diabetes from the people for whom they care. It is through their contact with these individuals, allied with the experience they gain over time, that they gain the ‘something special’ that makes them a diabetes specialist nurse.

The future
As the number of people diagnosed with diabetes increases, diabetes nurses will provide resources and training to enable others to deliver ‘direct’ diabetes care. Their role, responsibilities and caseload will be locally agreed and defined to meet the needs of the local population, ensuring equality and accessibility to an agreed standard in every health district. The diabetes nurse in the future will be involved in ‘facilitating’ diabetes care across boundaries and in all health service settings. Diabetes nurses will be involved in research. Their clinical and educational practice will be ‘evidence based’ and monitored. At another level, specialist nurse consultants may emerge. The explosion of new information, technology, communications systems and changing social patterns will rapidly change the way we live and work in the future.

A national professional framework for DSNs, associated with accredited training, accessible at appropriate levels and encompassing the necessary knowledge, skills and expertise to ‘do the job’, is now urgently required.

Maggie Watkinson’s vision for the future is thoughtful and thought provoking, in particular her closing remarks regarding the need for vision and leadership in diabetes nursing. These qualities are certainly needed and the opportunities are all out there waiting. The real challenge is the commitment to change from the Old World to the New, turning the vision into reality and ‘making it happen’ before the dawn breaks on the year 2000.