A helping hand for diabetes care

Specialist nurse Sandra Singleton and her team won Nursing Standard’s diabetes nursing award for an initiative to help school staff manage the healthcare needs of children and young people with diabetes. The individualised healthcare plan has been welcomed by leading groups in diabetes care and research, and has proved so successful that it is now being used nationwide.

A regional diabetes network team has developed a healthcare plan for children that has been introduced across the country.

The group from the Children and Young People’s North West Diabetes Network developed the initiative to ensure children with diabetes are well cared for at school.

Sandra Singleton (above) helped develop an individualised health care plan

Sandra Singleton, who led the team, says pupils with diabetes have a wide range of complex healthcare needs that put increasing demands on staff. These requirements include the monitoring of their glucose levels, injections, the management of changing insulin regimes, carbohydrate counting, treating emergencies and the monitoring of physical activities and sport.

‘This puts huge pressure on teaching staff in schools,’ says Ms Singleton, a nurse specialist. ‘We knew shared working between health care and education was essential to ensure the best outcomes for children and young people with diabetes.’

Ms Singleton says diabetes can affect a child’s concentration and perception skills and has a social effect on the child as they grow and develop. Yet until now there has been little to support school staff in caring for these pupils. Her team also found that people in schools were using different tools that were not easy to read in an emergency situation.

‘There was no standard care plan specific to caring for the child or young person with diabetes in the education setting,’ explains Ms Singleton, who works for Blackpool Teaching Hospitals NHS Foundation Trust.

‘Our goal was to develop one to enable consistent care for children with diabetes and also fit in with new legislation – and all before the implementation of statutory guidance on supporting pupils with medical conditions.’

Ms Singleton was asked by the diabetes network to lead a sub-group including other paediatric nurses, school nurses and parents, to develop an online, step-by-step guide.

The resulting care plan can be tailored to each child’s individual needs. It supports and manages care for any age and any insulin regimen in nurseries, schools or colleges. It covers all elements of day-to-day care and what to do in emergency situations.

‘The aim was to meet all national guidelines and provide a clear and concise, evidence-based, but individualised, care plan that can follow the child or young person through their education,’ explains Ms Singleton.

Easy to use

Under the initiative, the paediatric diabetes nurse completes the care plan with the child or young person and their carer, before sending it to school nurses or anyone else involved in caring for the child. It can be updated as needed, but this is done at least once a year.

‘The plan is easy to use and records all contact details,’ says Ms Singleton. ‘It also includes a training log. Teaching staff and parents like the plan’s flow charts which can be individualised, including what that child’s particular hypo treatment is, or if they are on insulin regimen or insulin pump therapy.’

The Individualised Health Care Plan for a Child or Young Person who has Diabetes (IHCP) can be printed as an A5 booklet, so that staff have it for easy reference; in an emergency they can refer quickly to its coloured flow charts for guidance.

The children are involved in setting goals for themselves and have a copy of the care plan too.

‘It ensures a better care experience for the child,’ says Ms Singleton. ‘The knowledge and confidence of the teaching and non-teaching staff in the education settings have been enhanced as well.’

Standardised, but child-specific, care planning is helpful to education staff like school nurse Jill Cullen

The care plan was initially tested in three different trusts and audited. It was presented to the national network in December 2013 for peer review by lead clinicians before being amended to meet national and international guidelines. The tool was then introduced regionally and nationally through the various diabetes networks.

‘There has been continual assessment and evaluation by the sub-group and from professional clinicians in the teams that have been using it,’ explains Ms Singleton. ‘It has been evaluated at regional and national level.’

The team also received positive feedback from the Families with Diabetes National Network. The Juvenile Diabetes Research Foundation has used the IHCP on its website, and Diabetes UK is using an adapted version as an online resource.

Evaluation results

Results of the individualised healthcare plan surveys sent to children and young people with diabetes and their parents, specialist nurses and teachers:

100% of parents whose children were newly diagnosed found the plan easy or very easy to follow.

90% of parents of children not recently diagnosed found it easy or very easy in comparison with previous care plans.

96% of parents felt the care plan was clear enough to feel confident that school staffhad enough information to manage their child’s needs during the school day.

100% of parents felt the flow charts detailed on the care plan are easy to follow.

75% of the diabetes specialist nurses using the individual healthcare plan thought it was good or very good in comparison to previous documents they had used. Some felt it could be improved by making it mandatory for schools to use – some schools have opted to use their own local authority documentation.

88% of teachers using a care plan for a pupil with diabetes for the first time found it easy or very easy to use.

100% of teachers who had used a care plan before found it easy or very easy in comparison with previous plans.

100% of teachers felt the plan and additional training pack held sufficient information to ensure they felt confident in managing the pupil with diabetes in school.

95% of teachers who had used the flow charts in a situation found them easy or very easy to follow.

Surprise success

Diabetes UK’s clinical adviser Libby Dowling says: ‘Every child with diabetes should have an individualised healthcare plan, but we know some schools still have concerns around how best to compile one, and this is why this sample IHCP, created by Sandra and her team, is such a valuable resource.

‘We did not expect it to go as big as it did,’ admits Ms Singleton, whose team won the Excellence in Diabetes Specialist Nursing category, sponsored by Sanofi Diabetes, at the Nursing Standard Nurse Awards earlier this year. ‘We never envisaged we would end up with a national document that was supported by the two main voluntary organisations in the field of children’s diabetes.

‘The national roll-out is important for the child or young person so that if they relocate to a different area in the country, the educational setting would recognise it and their continued health and wellbeing would not be affected in any way.

‘I am exceptionally proud of what we have produced and achieved.’

Improvement work

Ms Singleton says that following the success of the care plan, more work to improve and develop it continues. It will be reassessed annually to keep up to date with changes in national and international guidelines.

Eloise Tidswell and daughter meet with school secretary Ann Gilfoyle (left) and school nurse Jill Cullen (right) to discuss the individual healthcare plan at St Joseph’s Wesham Catholic Primary School in Lancashire

It is also being developed for other age groups to meet newly identified needs. Around the world there is a recent higher incidence of very young children being diagnosed with diabetes, linked to the rise in obesity levels. These children are often not attending pre-school.

Devising a care plan for six-year-old daisy

Helen Nurse’s six-year-old daughter Daisy was diagnosed with Type 1 diabetes when she was a baby.

‘School care plans for children with diabetes are absolutely critical – I cannot see how they can be safe at school without one,’ says Ms Nurse, a vice-chair of the Families with Diabetes National Network.

‘The nature of the condition means there are so many variables – every day can be a different experience for the child and whoever is looking after them. You can’t always say “this child needs X, Y, Z” and it will be the same every day. It depends on what the child is eating, how much they are growing and how much exercise they are doing.

‘If the school cannot get hold of the child’s parent, they need to be able to refer to a good and reliable source of information.’

‘The nature of the condition means there are so many variables’

Ms Nurse says that learning how to manage diabetes comes with experience.

‘Parents are with their child nearly all the time so experience most things, but teachers often do not get a chance to gain that knowledge. They may not have seen a situation for a year, so it is important they have a document – something comprehensive and accurate that healthcare professionals approve – that they can refer to.’

Daisy has had a care plan since she was at pre-school.

‘At that stage, there wasn’t a standard care plan so I had to use internet forums to try to find a parent with a similar-age child that already had one,’ explains Ms Nurse. ‘Luckily I found one.’

Although the care plan created by Sandra Singleton’s team is standardised, it is also child-specific, which is important for different symptoms and treatments.

‘It is so important that all parents have easy access to the standardised care plan,’ says Ms Nurse, who made the care plan specific to Daisy. ‘Other parents might not be sure about creating their own, or modifying someone else’s. With the standardised plan, the parent can know it is a good document that will keep their child safe.’

Daisy’s teachers always have her care plan to hand.

‘She has a teaching assistant with her most of the time now who is getting very experienced at managing Daisy’s diabetes, but the plan is invaluable for when the teaching assistant is not at school, and helps the assistant deal with more unusual situations,’ says Ms Nurse.

‘Children with diabetes cannot be safe at school in the short term without it, but the condition has so many long-term implications if you do not get the management right.

‘Children are at school for one third of their week and so poor glucose control, which will occur if they are not looked after properly, can have serious long-term complications.’

Ms Singleton is also busy supporting the development of an online training resource at basic and advanced levels for teaching staff, which she hopes will be implemented later this year.

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