Leading change

Specialist diabetes nurses at Shropshire Community Health NHS Trust led on the development and implementation of a modular training programme for both community nurses and non-registered practitioners in diabetes care. This has improved the management of individuals’ diabetes, patient experience and use of resources locally.

Where to look

Diabetes UK (2016) discussed how as the population ages, the number of older people with diabetes is rising rapidly, many of whom have other conditions that make self-management complex, such as dementia, arthritis and tremors. As a result, an increasing number of people with diabetes rely on community care providers to administer their insulin injections. This report advocated the use of insulin delegation programmes to ensure people with diabetes are given their prescribed insulin injections at the right time, in the right amount and in the right way.

The diabetes specialist nurses identified unwarranted variation in diabetes care in the community and residential care homes, with increased demand for district nurses to administer insulin in these settings. This was identified through data including increased referrals, incident reports and the experience of nurses visiting care homes. The specialist nurses saw an opportunity to implement delegated administration, to support improvements in outcomes, experiences and use of resources.

The Nursing and Midwifery Council code of conduct (2019) highlights that to be accountable for the decision to delegate, the registered nurse must:

• Only delegate tasks and duties that are within the other person’s scope of competence, making sure that they fully understand instructions;
• Make sure that everyone they delegate tasks to is adequately supported to provide safe and compassionate care; and,
• Confirm that the outcome of any task they have delegated to someone else meets the required standard.

The non-registered practitioner is responsible for their own decisions and actions. For the non-registered practitioner to be accountable for their decisions and actions, they must:

• Have the knowledge and skills to perform the activity or intervention;
• Accept responsibility for the activity; and,
• Have the authority to perform the activity within their role, through delegation and the policies and protocols of the organisation.

What to change

Insulin delegation is the process by which a registered nurse allocates the task of insulin administration to a named, competent, non-registered practitioner, such as a healthcare assistant. An insulin delegation programme involves:

• Developing an insulin delegation policy, and updating other relevant policies and procedures;
• Assessing the diabetes knowledge and skills of everyone involved in diabetes care, including registered nursing staff;
• Theoretical and practical training for all staff who require it, and additional training for staff administering insulin; and,
• Competency assessment, mentoring and support for those administering insulin.

Specialist diabetes nurses carried out a detailed audit to establish the level of diabetes knowledge amongst community nurses and identify areas where delegation could be considered. The audit was carried out with 76 band 5 registered community nurses and highlighted opportunities for upskilling colleagues regarding insulin therapy, illness management, nutritional management, and footcare. These improvements could tackle the unwarranted variation in diabetes care.

How to change

Diabetes specialist nurses, community nurses, non-registered practitioners from the independent sector and a not-for-profit organisation from the third sector worked in partnership to deliver change. A modular training programme was developed to upskill both community nurses and non-registered practitioners in diabetes care. Each module’s learning objectives are supported by the Department of Health’s Knowledge and Skills Framework dimensions and by the Diabetes National Workforce Competence Framework. The programme consists of three modules, as follows:

• Module 1 – Diabetes awareness;
• Module 2 – Expansion of diabetes knowledge;
• Module 3 – Insulin administration for non-registered practitioners.

In addition to classroom teaching, there are written and oral competency assessments for blood glucose monitoring, hypoglycaemia management and insulin administration. These have been developed and supported by NHS Trust policy. Each community nursing team nominated staff to become diabetes mentors for the programme, who undertook the same training programme as the non-registered practitioners to ensure that their own knowledge and skills were up to date. A robust policy for the delegation of insulin administration to non-registered practitioners was developed and a core set of diabetes competencies written to support this.

The programme initially took place over 2.5 days but this was modified to be 1.5 days in total and a workbook was also developed to support staff. Competences are revalidated annually, or if a period of three months has elapsed since a non-registered practitioner has administered insulin. Diabetes care plans and the continued suitability of the insulin delegation are reviewed monthly by a community nurse.

The programme and supporting guidance are written into Trust policy for the administration of insulin by non-registered practitioners. In addition, a register and recall system was set up with Shropshire Partners in Care, a third-party not-for-profit organisation, to administer the annual recall and review of delegation and competency assessment and to manage the administration of the programme. Diabetes UK have published guidance based on this work to help community staff, such as community and district nurses and diabetes specialist nurses (DSNs), to improve their diabetes caseload management and develop an insulin delegation programme.

Adding value

Better outcomes – There has been improved knowledge levels of diabetes care and management. Within 12 months there was a 41% improvement in knowledge following completion of modules 1 and 2 which has proactively impacted the care being provided.  It is also anticipated that the programme could reduce and support people with diabetes to maximise their health, leading to less disease related complications. Care is often provided to people in the community by many different staff from different organisations and teams. Delegation of insulin has meant that meal times and insulin administration can more easily be arranged to coincide. In doing so they have been able to improve the control of blood sugar levels and reduce the risk of hypoglycaemia.

Better experience – There is routine evaluation of the delivery of each module and feedback from attendees. The survey encompasses a review of personal expectations, satisfaction with the training delivered and the application of learning in the workplace. Feedback is reviewed and modifications are made to the programme based on this continual feedback mechanism to ensure that the learning outcomes are achieved. Module feedback has been positive. Better control and less intervention by nurses and care staff has resulted in more time for people with diabetes to undertake other activities, improving their quality of life. This approach to personalising care has reduced the risk of complications of diabetes for these individuals, as well as improving the health of this population.

Better use of resources – The insulin delegation programme offers a way of supporting complex care by providing skill and competency development, supported by robust governance infrastructure. Non-registered practitioners can administer diabetes care, including insulin, while still under the supervision of a community nurse, ensuring patient safety and quality of care. Community nurses can be released to support other patient groups. There is now improved diabetes care planning with the use of non-registered practitioners to support their own clients in residential care home settings, reducing the need for, and frequency and number of, district nurse visits, especially in rural locations.

Challenges and lessons learnt for implementation

Although originally designed for non-registered practitioners, the programme has also been used by registered nurses who want to update their diabetes knowledge.

Find out more

For more information contact:

• Angela Cook, Head of Nursing and Quality, Shropshire Community Health NHS Trust, angela.cook@nhs.net
• Fiona Smith, Diabetes Specialist Nursing Team Leader, Shropshire Community Health NHS Trust, fiona.smith28@nhs.net