Diabetes is a well known condition which can result in significant morbidity and mortality. The World Health Organisation (WHO, 2016) recommends sharing the care of diabetes between primary and specialist teams, using referrals through primary to secondary to tertiary care. Research clearly highlights that an early diagnosis, along with effective management of care can determine the clinical course and outcome of diabetes. Health services worldwide are finding it challenging to provide systematic, ongoing and skilled care due to a growing prevalence of diabetes (Worswick, 2013). Diabetes UK (2019) report that diabetes continues to be a growing health concern, with 4.7 million people in the UK known to have this condition; this number signifies an exponential increase, having doubled over the last 20 years. Mortality rates remain high due to the macrovascular complications of the condition, with over 500 diabetics dying prematurely. It is also reported by Gillet et al (2013) that self-management is often difficult due to the rising number of older people developing diabetes who already have other conditions such as dementia and arthritis. This results in community care having to administer insulin, adding pressure to already constrained services (Leading Change, 2019). Leahy et al (2015) report from The Irish LongituDinal Study on Ageing (TILDA) that type 2 diabetes is the leading cause of death and disability in Ireland, and it is well known that diabetes increases risk of heart attacks, heart failure and kidney disease, resulting in a loss of independence and early mortality. They further note that diabetes accounts for 10% expenditure in the Health Service Executive (HSE), the Irish public healthcare system. The 2015 report also highlighted diabetes being more common in men than women and that those with diabetes are more likely to be obese with low levels of physical activity and suffering with other ailments such as high cholesterol and high blood pressure. The TILDA study provided, and continues to provide, the first Irish national prevalence in diagnosed, undiagnosed and pre–diabetes in older Irish adults, shaping the future for evidence based prevention programmes.
To increase prevention of diabetes and to decrease the burden to healthcare services in the long term, leading change across the community setting is a vital component of reducing mortality and morbidity with diabetes. Health and Social Care (HSC, 2017) states district/community nurses are well placed to support people living with diabetes in the community. As nurses are members of a multi-disciplinary team (MDT), they can be part of a provision of services with a management strategy of a preventative holistic approach in community nursing and primary care to effectively manage the care of diabetes. It is important that care is not solely focused on treatment and management; diabetes prevention and its integration across MDT in community settings also needs to be part of this change (Ali et al, 2021). So what does the research indicate regarding nursing and the community?
Nurses role – diabetes management and prevention
The crucial role of the diabetes specialist nurses (DSNs) in the provision of good patient care and promoting self-care management cannot be underestimated. They are often the first point of contact for people newly diagnosed with diabetes, and care can be employed in a variety of settings (Gosden et al, 2007). Their work in the provision of education, training and support helps achieve the MDT approach with promoting self-care in diabetes and through screening and prevention of type 2 diabetes (James, 2011).
All nursing staff have an important role in the treatment, management and prevention of diabetes through the promotion of dietary and lifestyle adaptations (Halfyard et al, 2010). The risk factors associated with diabetes are well-researched; these include lack of physical activity, a poor diet, high blood pressure, high cholesterol, smoking and excessive alcohol consumption. According to Murphy et al (2017), healthcare professionals can promote the adaptation of lifestyle and dietary changes, which can often lead to the reduction of incidence rates in type 2 diabetes. While type 1 diabetes cannot be prevented, advice on taking steps to prevent further health conditions can help reduce the need for further care by ensuring that treatment is provided as early as detection.
Diabetes UK (2013) highlight the vital role practice nurses have as they are often the people who carry out the annual diabetes and foot checks. Practice nurses also play a clinical role in screening, maintaining and supporting people with diabetes.
This brings into discussion another very important aspect of diabetes management and risk reduction. Using equipments such as point of care testing (POCT) can play an extremely important role in diabetes prevention and management. Practice nurses and community nurses are well placed to provide this type of non-invasive fingertip testing. These tests provide instant results, meaning dietary and lifestyle advice can be offered on the spot, tailored to the individual's health needs. POCT is defined as a laboratory service using small analytical devices conducted in a patient consultation setting rather than in a traditional central laboratory, thus providing results in real time with faster decision making. This makes it a convenient test with rapidly available results, providing immediate impact for the patients, with a potential change to their care and the appropriate advice provided at the appointment consult. Laima et al (2019) state that POCT facilitates efficient clinical management, reducing patient morbidity and mortality in primary care. POCT also contributes to cost savings in an overburdened healthcare system, enhances patients' quality of life and increases patient satisfaction. The increased utilisation of POCTs in primary health care is likely to play a significant role in the future (Laima et al, 2019). When used appropriately, POCT can lead to more efficient, effective medical treatments and improved quality of medical care. The author of this article, a nurse and nutritional practitioner, utilises POCT in their healthcare service where health promotion and prevention are the main goals. POCT is expected to continue to expand, changing the way healthcare is delivered, meaning more patient-driven and focused care (Laima et al, 2019).
Leading Change (2019) reports another area which proved successful in diabetes management in the community. They reported a previous audit by specialist diabetes nurses resulting in a modular training programme being developed to upskill both community nurses and non-registered practitioners in diabetes care. The programme was supported by the Department of Health's Knowledge and Skills Framework (2016) and by the Diabetes National Workforce Competence Framework (2015). It provided classroom teaching with written and oral competency assessments consisting of three modules: 1) diabetes awareness 2) expansion of diabetes knowledge and 3) insulin administration for a non-registered practitioner.
Another area explored through research and which needs further evidence of the outcomes, is a population health approach (Kindig and Stoddart, 2003). A population health approach has the potential to improve the quality of care of individuals by introducing solutions targeting groups and sub-groups at risk of developing complications from diabetes (Golden et al, 2017). Golden et al (2017) state this approach is a whole system effort which can systematically identify, reach and improve care for all individual patients from groups which are identified as being at risk of poor outcomes. Golden et al (2017) highlight that the steps in the process involve measuring health status of a defined group of people and the distribution of health outcomes within each group. Identifying determinants of health then occurs, with designing and implementing of interventions occurring after and lastly, measuring their effectiveness.
Research recognises that good diabetes care pathways address the needs of the local service and is underpinned by a multidisciplinary team. Koslowska et al's (2020) pilot of virtual clinics in diabetes care highlighted that MDT virtual clinics in the community are one of the options for joint collaboration with primary care staff being supported by the specialist team. They argue that virtual clinics are associated with improved outcomes and show a positive impact on care processes following the success of their pilot study on a population health approach in diabetes care. The pilot enabled the service to discuss the outcomes of audit, taking into consideration the characteristics of the population and plan for improvement, proactively identify groups of patients at risk of complications from diabetes, and then plan their care together. They also reported that unnecessary referrals were avoided by the encouragement of shared responsibility and decision making for changes in treatment.
Other areas where resources for diabetes help to shape diabetes care within the community are resources provided by Diabetes UK such as DAFNE (2020)-a working collaborative of 75 diabetes services across the UK and Ireland, which is an intensive insulin therapy for type 1 diabetes. Another example of care pathways is DESMOND (2020) – a group of self-management education models and toolkits for the management of type 2 diabetes.
Conclusion
Diabetes UK (2013) state how planning and organising for the future has never been more important. With an ageing population compounded by people having increasingly complex health and social needs, the NHS and the Health Service Executive (HSE - the Irish public healthcare service) face financial and workforce challenges. Considering the current restraints in healthcare environments, Kozlowska's (2020) recommendations on care management-requiring a coordinated MDT approach, with a focus on effective early care in primary and community settings to reduce pressure on acute services (and reduce the onset of diabetes complications) is more important than ever. Price et al (2014) report that collaborative working is fundamental to the delivery of diabetes care in primary care networks and a multidisciplinary approach is essential to ensuring all core elements of care are met. Primary care has historically struggled with insufficient staffing and capacity to meet rising patient demands and complexity. Utilising POCT for prevention of diabetes, education programmes for HCP's and a population health approach are all areas reporting the success of diabetes management and prevention and are areas which need to be further developed and implemented.