It is estimated that 4.9 million people are now living with diabetes in the UK. This is equivalent to one in 14 people, with diabetes registrations almost doubling in the last 15 years and an estimated 850 000 people in England living with undiagnosed type 2 diabetes (Diabetes UK, 2022). Every week, diabetes leads to more than 184 amputations, 1770 strokes, 590 heart attacks and 2300 cases of heart failure (Diabetes UK, 2023). The NHS spends at least £10 billion a year on diabetes, which represents approximately 10% of its entire budget; of this amount, almost 80% of costs are associated with treating complications, with over a quarter of beds being used by people with diabetes in some hospitals (Diabetes UK, 2022). As those with diabetes represent a significant portion of the patients cared for by clinics, hospitals and in the community, it is imperative that any means to attain effective management be explored, to empower patients, prevent diabetes-associated complications and lighten the burden on an already stretched healthcare system.
The role of the community nurse
Ideally, it is the role of any healthcare provider to empower and support patients to be confident in and capable of self-management of both types of diabetes; however, the reality is that self-management is often difficult in many instances, partly due to a rising number of patients with conditions impacting memory and cognition. For instance, it is estimated that 13–20% of older people with dementia in the UK also have coexisting diabetes (Mattishent et al, 2019), representing a significant population that may require assistance in diabetes management. Community nurses (CNs) are well-placed to participate in a preventative and holistic approach to management in collaboration with other multidisciplinary team (MDT) members, especially for those more vulnerable populations, due to their unique access and insight into patients’ living conditions, lifestyle and needs.
Where can the community nurse help?
Dietary management
CNs can play an important role in the treatment, management and prevention of diabetes through the promotion of dietary and lifestyle adaptations (O’Flynn, 2022). There is no specific recommended diet for people with diabetes, and an individualised, food-based approach is advised; however, older people with diabetes should be assessed for nutrition risk using a validated screening tool, with MDT collaboration in the form of dietician referrals, enabling an approach that aims to prevent hypoglycaemia and symptomatic hyperglycaemia, while maximising nutritional intake (McClinchy, 2018). Point-of-care testing (POCT), in the form of fingerstick testing, is a mainstay of diabetes management in the community, and can aid in the provision of targeted nutritional advice.
Diabetic foot management
CNs are increasingly being called upon to carry out annual foot reviews on housebound diabetic patients, with a diabetic foot inspection and assessment, including the identification of:
- Sensory neuropathy (loss of the ability to feel a monofilament, vibration or sharp touch) and/or the abnormal build-up of callus
- A reduction in the arterial supply to the foot (absent foot pulses, signs of tissue ischaemia or symptoms of intermittent claudication)
- Deformities of, or problems with, the foot (including bony deformities, dry skin or fungal infection), which may put it at risk
- Other factors that may put the foot at risk (including reduced capacity for self-care, impaired renal function, poor glycaemic control, cardiovascular and cerebrovascular disease, or previous amputation) (Turns, 2012).
Blood glucose awareness and insulin administration
It is acknowledged that many CNs must administer insulin to patients for a variety of reasons, typically due to a lack of patient capacity, placing strain on an already overburdened healthcare system. However, again, this is an area in which MDT collaboration can be beneficial. A modular training programme developed by specialist diabetes nurses at the Shropshire Community Health NHS Trust to upskill both CNs and non-registered practitioners in diabetes care and insulin administration in the community and residential care homes has proved effective in this regard, demonstrating a 41% improvement of knowledge following partial module completion, which has levelled inequalities and variation in care provision (Leading Change, Adding Value Team, 2019). Delegation of insulin meant that mealtimes and insulin administration could more easily be arranged to coincide, improving the control of blood sugar levels and reducing the risk of hypoglycaemia, while the ability of non-registered practitioners to administer diabetes care, including insulin, under the supervision of a CN has released CNs to support other patient groups while ensuring patient safety and quality of care (Leading Change, Adding Value Team, 2019). Under this system, diabetes care plans and the continued suitability of the insulin delegation are reviewed monthly by a CN (Leading Change, AddingValue Team, 2019). Similarly, case studies from a service evaluation undertaken by the Greater Glasgow and Clyde health board revealed that, in the case of insulin administration and diabetes management, CNs play a vital role in care optimisation through personalisation and MDT collaboration. In one cited case study, the close relationship between a district nurse (DN) and a non-concordant patient with comorbid type 2 diabetes and alcoholism enabled improved blood glucose monitoring and adjusted insulin administration, in partnership with a community diabetes nurse specialist (CDNS) and a GP; in another, the type and timing of a patient’s insulin injections were adjusted by her DN, in collaboration with a consultant and CDNS, to facilitate maintenance of her normal sleeping patterns and avoid unnecessary disturbance for insulin administration (McDowell and Boyd, 2018).
It is important to note that, in 2022, the National Institute for Health and Care Excellence (NICE) guidance on continuous glucose monitoring (CGM) made recommendations on the use of these systems and widened eligibility to include everyone with type 1 diabetes and, for the first time, some of those with type 2 diabetes with multiple daily insulin injections, including those with recurrent or severe hypoglycaemia, or a condition/disability that precludes self-monitoring (NICE, 2022a; 2022b). In early 2023, NICE released draft guidance on hybrid closed-loop systems (artificial pancreas technology), which indicated that these might be suitable for those with type 1 diabetes who are having difficulty managing their condition, with the final recommendations yet to be published (NICE, 2023). In consideration of this, the CN’s role in managing diabetes in the community may involve supporting patients in the use of these CGM and insulin delivery systems.
Conclusion
Offering health education, support and advocacy is part of the CN’s role, and nowhere is this truer in the case of diabetes, a chronic condition that continues to grow in prevalence. As always, the CN’s unique and intimate insight into the lives of patients will facilitate person-centred care and, in partnership with the wider MDT team, the CN will have the opportunity to implement a preventative, holistic and personalised approach to diabetes treatment and management.