An analysis of how DSNs can improve patient outcomes and deliver cost-effective care and be instrumental in preventive medicine in future

Diabetes Specialist Nurses (DSNs) are central to good patient care. Globally, the concept of DSNs has been around for 60 years. The role was developed and continues to evolve to specifically meet the needs of people with diabetes and their families and to provide experience and expertise as part of diabetes management. They are crucial in supporting independence and in helping patients manage their diabetes more confidently and prevent expensive complications. DSNs also support people with complex needs and provide primary care teams with specialist expertise that reduces emergency hospital appointments. More importantly, evidence reveals that DSNs are cost-effective, they improve clinical outcomes and reduce the length of stay in hospitals. On the occasion of World Diabetes Day, WHO, therefore, lays emphasis on the role of DSNs in ensuring better patient outcome in diabetes management.

Role of DSNs in diabetes care

Dr V Mohan, Chairman & Chief Diabetologist, Dr Mohan’s Diabetes Specialities Centre, Chennai, India says, “DSNs are a valuable addition to any diabetes clinic. Diabetes is a chronic lifelong condition in which the success of the treatment largely depends on the education that is given to the person with diabetes. Most often the diabetologist/endocrinologist is far too busy to spend sufficient time with their patients. This is where the role of the DSN comes in. DSNs are basically nurses, who have undergone specialised training in various aspects of diabetes. In clinics in the West, particularly in the UK, Europe and in the US, DSNs not only take on the role of diabetes education but in some of these countries, they are even licensed to practice and to prescribe medicines and to make adjustments to doses of insulin or antidiabetic drugs. In addition, they can help in taking the history of diabetes, teach people with diabetes about diet, exercise, self-monitoring of blood glucose, the correct way of taking insulin, continuous glucose monitoring, insulin pumps etc. They can also, if trained, help in the treatment of minor diabetic foot problems and also screen their feet so that, if any high-risk cases are identified, they can be referred to a podiatrist or to a diabetes foot specialist, diabetologist or surgeon. Thus, the DSN plays a vital role, both in the outpatient diabetes clinic and also in the in-patient diabetes services. In the latter situation, they can help in starting of intravenous fluids, form part of the team for the treatment of diabetic ketoacidosis, hypoglycemia or other diabetes emergencies like hyperosmolar and nonketotic coma. In some clinics, DSNs are also trained to screen other comorbid conditions like hypertension and depression. The role of DSN is therefore multifold and they form one of the most important team members in the diabetes clinics.”

According to Elizabeth Joseph, Chief of Nursing, Wockhardt Hospital, Mumbai the DSN is often the first point of contact for the patient and also a liaison between patient and other healthcare professionals. This multidisciplinary team includes physician and other specialists such as neurologists, nephrologists, diabetologists, ophthalmologists, foot surgeons, dietitian, physiotherapist and clinical pharmacists. 

Likewise, Dr Sweta Budyal, Consultant Endocrinologist & Diabetologist, Fortis Hospital, Mumbai shares a perspective on how the role differs between in-patient and out-patient services, For inpatients, the first and foremost is to implement the protocols set for screening all admitted patients for detecting high glucose and to monitor patients with Diabetes and non-diabetics found to have high Glucose for the first time. Then subsequently the focus is on executing the plan made by the treating team for the management of high Glucose, along with ongoing education and sensitisation of the patients about the importance of lifestyle modification, Insulin injection technique etc. The role and responsibility of the nurses on the other hand is completely different in outpatient setups. They help the clinicians in obtaining the basic information, creating proformas for good data-keeping and doing preliminary examinations like vitals and anthropometry data. The role of nurses with respect to patient education is of paramount importance when it comes to educating and empowering patients about various aspects of care, along with Nutritionists and Diabetes Educators. They complement the roles and responsibilities of each of the care team member.”

Need for training and empowerment of DSNs in India

UK’s Royal College of Nursing’s white-paper published in the year 2014 indicated a growing body of evidence to support the importance of DSNs in both improving patient care and reducing costs to the NHS. Their report mentions that specialist diabetes inpatient teams can reduce prescribing errors, improve patient outcomes, reduce the length of stay, increase day case rates and reduce the number of admissions. The savings from the introduction of such teams can substantially outweigh the cost of the team.  

However, in India, the concept of DSNs is less understood and sometimes even undervalued. But there are some healthcare providers who are increasingly focusing on reiterating the significance of DSN teams. A March 2020 study published in the International Journal of Diabetes in Developing Countries based on diabetes education and basic insulin-related knowledge assessment among nursing staff in a tertiary care hospital in India revealed some shocking facts.

The study showed a significant deficit in basic insulin-related knowledge among nursing staff. According to the study, a total of 101 nursing staff accepted to participate in the study. The facts include that almost 80 per cent of participants denied as trained for diabetes management in hospitalised patients in their nursing curriculum. 87 participants were comfortable giving insulin. However, only two participants could identify basal and bolus insulin as the type of insulin needed to manage hyperglycemia. 25 participants could identify the strengths of insulin vials available in India and only 8 could correctly mention the colour code of the corresponding insulin syringe. Moreover,15 participants could correctly identify the commonly used routes of inulin administration. 30 participants could identify all the correct subcutaneous injection sites, however, at least one wrong site was chosen by 78 participants. A similar deficit in knowledge was seen in hypoglycemia management, glucose monitoring, insulin storage, expiry of inulin and injection techniques.

This indicates that there is a need for continuous clinical education of nursing staff in order to keep them abreast with diabetes management. 

Moreover Dr Wasim Ghori, Group Medical Director, Physician & Diabetologist – AMSYS Heart & Diabetes Clinics, Mumbai shares a different perspective on this subject and highlights the need to empower DSNs so that earn the respect and public trust. “The general public sees nursing as combining knowledge, skill and professionalism with caring. Even though nurses have become healthcare professionals who possess a great deal of knowledge the public does not always value the skills and competencies nurses have acquired through education and innovation”, he maintains.

He further points out the following concerns:

  • The public perception of nurses: The public perceive a nurse as just someone who assists the doctor during and after treatment of the illness assisting the patient in keeping up his personal hygiene, giving the medications as prescribed by the doctor, dressing the wounds when there is a need ensuring the welfare of the patient.
  • Factors influencing the public’s perception of nursing – An analysis of factors that influence the self‐concept of nurses such as work environment, work values, education and traditional social and cultural values is important. In addition, a discussion of the relationship between public image and nurses’ self‐concept, professional identity and work performance is imperative too.
  • Improved knowledge is an essential tool for prevention of errors and providing higher quality care – Education helps nurses help people; providing nurses with the skills and knowledge they need to positively impact the lives of people in their communities.
  • Value on education, non-professional activities, physician-oriented atmosphere, conflict and lack of coherence in education, inappropriate communication skills, ignorance of patient’s right in education, lack of motivation and rewarding system in the organisation, and poor supervision.

Here are some ways by which healthcare can empower DSNs to improve patient outcomes:

Education and training: “I think the most effective approach would be to take them through a structured Diabetes Education Programme along with ongoing training about various aspects of Diabetes care like nutrition, exercise, basics of Insulin and oral diabetes medications, management of Hypoglycaemias, daycare of Diabetic patients, foot care, and screening for associated Cardiovascular Diseases (CVD)”, say Dr Sweta. Similarly, Elizabeth explains that a diabetic specialist nurse plays a crucial role in various teaching and training activities related to diabetic programmes. They undergo specialised diabetes training programmes in diabetic management. The certified Diabetes Nurse educator is a health professional who possesses comprehensive knowledge and experience in pre-diabetes, diabetes prevention and management in consultation with the physician. The eligibility criterion for admission to this programme is a graduate degree in nursing. The duration of this course is for three months. Diabetic educators are empowered to manage their diabetic patients by teaching, coaching and guiding them to understand the disease and the effects on personal, professional and behavioural aspects of an individual and how to improve their health. On the other hand, they facilitate in training other nursing staffs to be professionally skilled in handling diabetic patients.

Adding to this, Dr Wasim Ghori, Group Medical Director, Physician & Diabetologist – AMSYS Heart & Diabetes Clinics, Mumbai, shares, “Nurses have valuable insights and unique abilities to contribute as partners with other healthcare professionals in improving the quality and safety of care. Furthermore, nurses are responsible for the wellbeing and safety of their patients even more so during the COVID-19 Pandemic. Their roles, responsibilities have changed significantly to meet the increased demand for care. Nurses should be fully engaged with other health professionals and assume leadership roles in redesigning care not only in India but in other countries too. To master the skills and knowledge they will need for this level of responsibility, it is imperative that they commit themselves to a rigorous educational program leading to an associate’s degree that will likely involve the study of nutrition, microbiology, anatomy and physiology, acute care, pharmacology, medical/surgical nursing and possibly maternal and newborn nursing.”

Empowering DSN using technology:

We are all aware that technology has not only empowered healthcare providers but have raised the quality of patient care in every aspect of healthcare delivery. Hence, the effective use of technology is extremely crucial to diabetes caregivers. “Increasing the accessibility and convenience of care is important and Telemedicine is now viewed as a way to provide guidance to patients about next steps or when to seek advice from a health professional. Telemedicine involves specialist assessment and active listening to meet patients’ information needs and educate them on symptom control and is particularly well-received for people with long-term conditions. Furthermore, diabetes care should be patient-centred and tailored to the individual to promote confidence in self-management. Telemedicine is a cost-effective way for nurses to deliver care. As well as enabling follow-up for some recently discharged patients without them needing to visit a clinic or make an appointment, it purportedly reduces the number of acute hospital admissions. Nurses can run telephone helplines, as well as hold telephone appointments or ‘check-ins’, to support rather than substitute direct contact care”, explains Dr Ghori.

Likewise, Dr Shweta adds, “Online diabetes courses and modular about diabetes training can be an important resource. Sharing of experience with other nurses and nursing societies across the globe to learn about the best practices in the field, would make a huge difference.”

DSNs and their role in times of COVID

Experts mentioned in the article inform that DSNs have played a pivotal role in the current COVID19 pandemic, right from screening and segregating of patients at the entry point, implementation of safety protocols set by the institutional Infectious Disease Department, smooth running of the diabetes clinics, boosting the morale of patients in difficult times, along with their regular roles and responsibilities related to diabetes care.

“During these unprecedented times, nurses have been on their toes to provide round-the-clock care and support to patients with diabetes. The sole motto was to make sure that the patients receive timely care and intervention. Routine care of diabetes was significantly disrupted during the current COVID-19 pandemic. Stress levels and disruptions to diet and physical activity also contribute to worsening outcomes during the pandemic. Hence, with the help of an online platforms DSNs and the patients can easily connect and modify the necessary treatment regimens and ensure better diabetes management”, says Elizabeth.

In the same light, nurses today are playing new roles in coordinating care from multiple providers, managing caseloads of patients with intense care needs, and helping patients transition out of hospitals and into the home or other settings. Today they do not just care providers, but work as ‘health coaches’ and in future, they will play a significant role in preventive medicine. It is time that this diabetes day, the industry, patient communities and decision-makers of healthcare policies in India stand up for the remarkable efforts taken by the nursing community to curb and manage the diabetes epidemic in our country. 

Diabetes Fact file

In 2020, according to the International Diabetes Federation (IDF), 463 million people have diabetes in the world and 88 million people in the Southeast Asia region. Of this 88 million people, 77 million belong to India. The prevalence of diabetes in the population is 8.9%, according to the IDF.
Measures for professional recognition and public respect for DSNs in India:
1. Create Diabetes Nurse Practitioners who are better trained to deliver various diabetes-related care aspects
2. Incorporate separate nurse visits to check on patient’s health along with doctor’s visits
3. Provide a written plan to the patient about the role of the team member, including the nurses in the care team
4. Set up phone helplines for navigation through routine simple problems faced by the patients, which are exclusively managed by the nurses
5. Ensure better communication between patient and care providers
6. Appointment of well-trained nurses as the leader of the Diabetes Care Team as in many of the Diabetes Clinics and Centre of Excellence in western countries

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