Tomorrow’s diabetes practitioners – where do we start?

The need for providing staff involved in the care of people with diabetes with relevant skills is one aspect of the National Service Framework for Diabetes delivery strategy (Department of Health, 2003). Diabetes UK provides a list of courses/programmes to meet the educational needs of registered nurses (Diabetes UK, 2003). However, it is not just registered nurses who deliver diabetes care. Indeed pre-registration nurses are often responsible for delivering care to people with diabetes, some of whom have very little insight into the development and progression of diabetes.

In 1996 a report from the British Diabetic Association (BDA) – now Diabetes UK) – advised that: ‘Pre-registration nurses should receive some training from a senior diabetes specialist nurse. Nurses’ training should include skills to enable them to work as part of a multidisciplinary team’ (BDA, 1996, pg5). In discussion with colleagues, ‘training’ does take place but contact time is variable.

This article discusses a diabetes module set up as an attempt to address the above BDA recommendation. An accredited option module for pre-registration student nurses undertaking a higher education diploma in nursing/registered nurse with BSc (Hons) top-up was developed.

Believed to be the first in the UK at the time of development, nursing students in the adult treatment branch of their educational programme at Kingston University in Surrey can choose from a menu of five different option modules, prior to qualifying as a registered nurse. The aim of the option module ‘Introduction to Diabetes Care’ is to ‘. . . enable students to increase the breadth and depth of their evidence-based knowledge and practice in order to meet the needs of adults with diabetes’.

Setting up the module
The module was originally the idea of the module leader in 2001 and was created in anticipation of recommendations of the National Service Framework for Diabetes strategies document (DoH, 2003) for workforce planning development. The module went through the normal university validation requirements in June 2002 (with both internal and external scrutiny). This demanded attention to the development of suitable level 2 and level 3 learning outcomes, and the inclusion of a variety of teaching and learning strategies which total 150 hours for a module of 15 credits.

Successful validation also required the inclusion of learning opportunities in practice and a suitable assessment that would give the students 15 credits at the level at which they are studying the module.

Most students access the module at level 2 (diploma) but there are some who have performed sufficiently well in the earlier part of their programme who access the module at level 3 (degree). These credits can then be used towards the achievement of a nursing degree after the completion of their original diploma.

A variety of teaching methods are used including straightforward lectures, discussion, demonstration for practical aspects, group work to facilitate learning and both self-directed and guided study so as to offer variety, provide interest and satisfy the different learning styles of different students (Stengelhofen, l996).

Course content
Classroom contact is a total of 20 hours usually delivered in 10 two-hour blocks over a period of eight weeks, although the whole module stretches over 18 weeks in order to include a week’s placement in a diabetes unit and one classroom revision and evaluation session. Students undertake these placements in about five diabetes clinics, located within South West London, which take one student a week for six consecutive weeks.

At the end of the module the students sit a two-hour unseen written examination in which they are required to obtain a pass. The maximum number of students who can undertake the at one time is 30, and recruitment to the module has been close to this ceiling.

At the beginning of the module the students are issued with an accompanying handbook, which sets out learning and practice outcomes, the lesson timetable, the assessment, reading list and contact numbers for the module leader. By the end of the module, students will be able to demonstrate achievement of learning outcomes against specific curriculum themes and against learning outcomes specified by the English National Board in 2000 for entry to the nursing register. The module is delivered by a number of university lecturers but, importantly, their input is supported by healthcare professionals who have a specific interest or work in diabetes care.

Clinical placements
The clinical placements with DSNs have proven interesting both to the students and the DSNs. During the week long placement, the DSNs arrange for the students to see different aspects of diabetes care, i.e. in general practice, with the podiatrist, dietitian, consultant, optometrist, etc.

From the educational perspective these placements bring classroom learning alive and they allow theory to be applied in the practical setting. Placements enable students to appreciate not just the pivotal role that people with diabetes have in the promotion of their own health (Kester, 2004), but also the very different role of the nurse as a facilitator in diabetes management in contrast to that of the hands-on carer (Lee and Winter, l998).

The placements have been fascinating for the DSNs: the majority of the students are clearly enthusiastic, driven and motivated. However, there are occasional cases where students have worn excess jewellery to work, should have slept at home and who appear to lack interest! A crucial learning experience for all!

Evaluation of the module
We are currently running the module for a third cohort. For this cohort we have responded to feedback from the first two saying that some material needs greater emphasis, and have included an additional six hours of classroom time in order to achieve this. From feedback we have also discovered that many of the students have relatives with diabetes and some have diabetes themselves. This may be partly due to the fact that our student population is largely from an Afro-Caribbean background where there is an increased risk of developing diabetes (Diabetes UK, 2001).

Past students have appreciated their learning being complemented by sessions from specialist nurses who could answer ‘hands-on’ questions. In addition, they enjoyed the quality of teaching and enthusiasm of lecturers, and felt the module had been well organised. One session, which has been of particular interest, is the talk from a person with diabetes who gives a frank insight into life with type 1 diabetes. Student comments included:

‘We will think about how we treat patients as a result of this session.’

‘Inviting someone to speak from a personal point of view was brilliant!’

Feedback from the practical sessions has been insightful.

We have support from the pharmaceutical companies that produce insulins, who come in and show how to use the various pen injection devices. The students recognise the appropriateness (or not) of the devices for certain client groups, and often relate this to patients they have met during their training.

The placements have been a great success. Students see people with diabetes who are not ‘ill’ but empowered. As most of the students recall seeing patients whom they visited with district nurses or have seen as inpatients, this has helped the students see diabetes care from a different perspective.

Discussion
We believe the creation and execution of this module at Kingston University has set the ‘gold standard’ for diabetes education in pre-registration students. Its inclusion within the curriculum recognises the nature and potential gravity of this lifelong condition. In addition there is a potentially positive impact for people with diabetes and for recruitment into the speciality. Indeed, to date a number of students have been so enthused that they have indicated that they would like to specialise in diabetes.

In-house interest has permitted two further strategic developments. Firstly, the module has been validated so that it may be accessed by students undertaking the BSc (Hons) in Adult Nursing. This is a programme leading directly to a degree in nursing – a very positive and welcome development in line with our own aspirations to develop the module for students from the child nursing branch in due course. Secondly, interest in skills acquisition has also lead to the inclusion of blood glucose monitoring quality control skills by objective structured clinical examinations (OSCEs) in the common foundation programme of the pre-registration nursing education programme. Bromley (2000) states that OSCEs provide a useful means to achieve objective assessments of clinical competence. Students are required to demonstrate safety and competence with this skill, as judged against a number of set criteria (this being just one of a number of other skills that are also objectively assessed). Their achievement contributes to student confidence in clinical placements and specifically reinforces the importance of accuracy in performing blood glucose monitoring from an early stage in student nurses’ educational programmes.

There is no doubt that the next generation of DSNs and nurses with a specific interest in diabetes need a grounding in the subject area, which will make an impact upon their motivation and career planning. If we earnestly wish to influence both the numbers of these groups and the quality of care that is delivered to people with diabetes, then what better place to start than with finishing pre-registration student nurses? For, after a period of initial consolidation, this group has their future nursing career before them – perhaps in diabetes care.