Leading change

Nurse leaders at Hertfordshire Community NHS Trust have worked with Health Care Assistants (HCAs) to develop their role through additional training so they can lead on insulin administration in the Diabetes Service. The team’s initiative highlights their leadership in quality improvement to address unwarranted variations seen locally in insulin administration and has significantly improved patient and staff experience of the service amongst other positive outcomes.

Where to look

Across Hertfordshire Community NHS Trust, a service review revealed that 352 patients with diabetes required a home visit for insulin administration between once and three times a day. This resulted in Registered Nurses (RN) spending a high proportion of time administering insulin between the hours of 8am and 10am, and 4pm and 6pm, which was impacting on other aspects of the care they needed to provide leading for instance to delayed treatment in other areas. The service review identified unwarranted variation in the form of missed visits and decreased RN capacity in general as a result of this insulin administration demand. Recognising this unwarranted variation led the nurses and HCAs to develop and implement a new way of working and led on its implementation within the service.

What to change

 

The nurse leaders worked with HCAs to develop a solution to the pressures in the system and address the unwarranted variation in the Diabetes (insulin administration) Service. Several factors needed to be addressed, to make improvements in outcomes, experience and use of resources:

• The high proportion of RN time administering insulin;
• The pressure on RN’s due to increasing numbers of patients requiring insulin;
• An increasing number of patients unable to self-manage insulin administration;
• A task focused approach to achieve visits within a specified timeframe.

The team researched possible options available and identified that the administration of insulin by non-registered staff such as the HCAs had been implemented successfully in other areas. The evidence base they identified stemmed from the article called “Guide on delegating insulin management to HCA’s” (Diabetes UK website; Nursing Times, 2016).

HCAs were identified as key leaders in this piece of work as they had a valuable skill set which closely aligned with the needs of the new way of working. A multi-disciplinary team approach was undertaken and to manage resources within the team including this new delegated role with patient-centred care at the heart of their work. With support from the nurse leaders, the new delegated role was piloted within the team.

How to change

To support this change, a project group was established, consisting of a Clinical Quality Lead (Nursing) as Project Lead, Transformation Project Manager, and clinical staff (nurses and HCAs). Robust criteria were developed to train HCAs to administer insulin to specific patients with diabetes as a part of a bespoke training programme that was delivered. This included a competency workbook, a Standard Operating Procedure, identification of appropriate RN mentors for all HCA staff and the development of an insulin Workbook to guide the HCA once out in practice. The training programme consisted initially of one day at a local university to enhance diabetes knowledge, including practical sessions on how to give sub-cut / IM injections. This was partnered with the Trust e-learning modules including sharps awareness, Anaphylaxis, Six Steps to Safer Insulin, and all HCA’s prior to commencing the training needed to be up to date with all other mandatory training.

Adding value

• Better outcomes – Measurement of the project included; monitoring incidents, complaints, patient experience and productivity which are described below. As a result of the project, Hertfordshire Community NHS Trust now has their own in-house diabetes training programme, which is led by the Diabetes Specialist Service Nurses, supported by local clinical leads from the community teams – demonstrating integrated working across services for better patient outcomes.
• Better experience – A one year update session for HCA’s that have been administering insulin for a year has just been held and the evaluation from all 22 was extremely positive. Staff reported feeling valued, supported and more knowledgeable.  Clinical leaders involved with the project report better job satisfaction and an increased understanding of each other’s roles. Patient experience has been very positive, and audits have been carried out regularly in every locality to determine how likely they are to recommend the service to family and friends. One hundred percent of those asked reported they were extremely likely to recommend the HCA led service to friends and family.
• Better use of resources – Almost half of the patients requiring insulin administration are being seen by the Trust HCAs, which has released RN time to focus on more complex tasks and case and service management roles . HCA’s administering insulin has released 20 minutes of RN care hours per patient visit and has increased productivity of the community nursing teams in addition to travel time. A review of the project indicates that HCAs are providing a safe and effective service to patients including, but not limited to:
  • No insulin administration incidents or errors;
  • Patients receiving insulin at consistent times;
  • Improved control of patient blood glucose levels.

Challenges and lessons learnt for implementation

The underpinning principles of this project were patient centred care and releasing Registered nurse care time for increasingly complex patients. It was crucial from the outset to engage the Diabetes Specialist Nurses, District Nurses and HCA staff to explain the benefits of the change and why it was needed. It is imperative to spend time with all staff involved in a change to ascertain and allay any concerns. Full staff engagement facilitates joint ownership and motivation to succeed in quality improvement methodologies.

The project has been extremely positive for many reasons, including staff morale, HCA competency development, releasing RN capacity, patient experience, improved patient outcomes, and identification of ideas for future projects.

A marker for success has been interest and shared learning with other Trusts as to how the service developed, maintained and rolled out the project for the health care assistants.

For more information contact

Suzy Narroway
Professional Clinical Lead
Suzy.Narroway@hct.nhs.uk