The training programme giving all health teams the skills to manage diabetes

With diabetes on the rise, one nurse has created a practical, customisable ten-point approach

With diabetes on the rise, one nurse has created a practical, customisable ten-point approach

Ruth Miller developed the programme to raise awareness of diabetes among non-specialist
staff. Picture: Barney Newman

Diabetes: the statistics 

  • The prevalence of diabetes in England is increasing, with data from Diabetes UK showing that more than a million people with the condition were admitted to hospital across the country last year
  • One in six hospital beds are occupied by someone with diabetes, a figure predicted to rise to one in four by 2030
  • With 58,000 with the condition experiencing an episode of severe hypoglycaemia during their stay, questions have been raised about hospitals’ ability to deliver even the most basic diabetes care

Diabetes nurse consultant Ruth Miller knows only too well that people with diabetes are dying because of a lack of knowledge among healthcare professionals. 

She recalls the inquest of a young woman, who had presented at an emergency department disorientated and with unexplained injuries.

The woman had type 1 diabetes and schizophrenia. She was admitted under the care of the mental health team but was not referred to the diabetes team. After returning home, she was found dead, having had a hypoglycaemic episode.

‘She had been running her glucose low because of her anxiety about developing complications,’ says Ms Miller. ‘If the emergency department had let us know, we may have been able to help her.

‘Nocturnal hypoglycaemia was actually written in her notes. She had classic symptoms, but the diabetes team was not made aware.’

Ensuring mistakes are not repeated

This is not the only case Ms Miller is aware of where a person with diabetes has not received appropriate care, with tragic results.

Using her experience as the clinical lead for diabetes, she developed and piloted Diabetes 10 Point Training, a resource for healthcare professionals caring for people with diabetes, based on the most commonly seen errors.

‘The most complex inpatient diabetes care is delivered by non-specialists, despite staff often lacking access to diabetes training’

Ruth Miller, nurse consultant

‘The most complex inpatient diabetes care is delivered by non-specialists, despite staff often lacking access to diabetes training,’ Ms Miller says.

‘Having experience in leading transformation projects by standardising practice, I knew the importance of training to ensure staff possess core competencies,’ she adds.

‘The inquest was shocking and I noticed the same mistakes being repeated,’ says Ms Miller. ‘It was not highbrow medicine. The patient had told staff assessing her that she was experiencing nocturnal hypoglycaemia. Hence point one of the training – listen to the person.’

Ruth Miller (second left) delivers a training session. Picture: Barney Newman

About the training

The multidisciplinary training is brief, relevant and clear, with attendees receiving small aide-memoire cards of the main points. And it is flexible to the needs of clinical areas.

The programme has been such a success that it has been developed for and implemented in a range of clinical settings and is being rolled out across hospitals, mental health teams, community teams, haemodialysis centres, homeless teams and care homes in north west London.

    A community Diabetes 10 Point Training programme was developed and implemented in Camden in north London in 2014, and in Poole, Dorset, in 2016.

    Between January and June 2016, Ms Miller led the introduction of the training of more than 640 healthcare professionals at Poole Hospital.

    It was not all plain sailing, with a major challenge being to convince others of the need for change.

    ‘Ensuring diabetes was on the trust's agenda and raising awareness in the hospital was a priority, and I frequently presented to the trust board, medical directors and senior nursing staff,’ says Ms Miller.

    She notes that as the prevalence of diabetes is increasing, so are the numbers of patients coming through all services and settings. This, she says, presents a significant challenge for staff education across the patient pathway.

    Small checklist cards of the main points are given out in the training. Picture: Barney Newman

    Flexible collaboration

    Ms Miller, who was a finalist in the Innovations in your Specialty category at the 2018 RCNi Nurse Awards, says evaluation of the training programme showed it improved staff confidence and patient safety.

    Participants’ self-reported confidence in 11 domains was assessed immediately before training and three months after, with a significant improvement in confidence in every area after the training.

    ‘Basic diabetes knowledge is not always being achieved through training, which is concerning. We are talking about healthcare professionals not knowing the difference between type 1 and type 2 diabetes’

    Emily Watts, Diabetes UK

    The trust also moved from the highest quartile for insulin errors to the lowest quartile over the six-month period. Data from the National Diabetes Inpatient Audit, which covers hospital trusts in England and Wales, show insulin errors dropped from 24.5% to 13.3% and prescription errors from 38.8% to 15%.

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    The ten-point tool is endorsed by Diabetes UK as an example of good practice.

    ‘Diabetes is extremely complex and most people working in hospitals, care homes or on mental health wards are not specialists, but everyone needs to have basic knowledge,’ says Diabetes UK programme manager for inpatient care Emily Watts.

    She says that the programme gives staff the knowledge to ensure safety in wards or care homes.

    ‘Rather than putting on once-a-year training, Ruth grabs them by the bedside, gives them a card and goes through what they must know,’ Ms Watts adds.

    ‘Importantly, the training can be made specific to areas – surgical wards need to know different things to a maternity ward, for example.’

    Ms Miller goes through Diabetes 10 Point Training with two colleagues. Picture: Barney Newman

    Clarity and simplicity

    Picture: Barney Newman

    In her current role as nurse consultant at NHS North West London Collaboration of Clinical Commissioning Groups, Ms Miller has also developed diabetes training modules for care homes, mental health trusts and dialysis centres (to find out more, see box).

    Ms Miller says her work is timely because people with diabetes and mental illness have worse outcomes for the two conditions – 15% of people with serious mental illness have diabetes yet up to 70% are undiagnosed, with life expectancy reduced by up to 20 years as a result.

    ‘The tool has made a real difference to nursing practice and I have big ambitions to improve nursing care on a larger scale,’ she adds.

    ‘We are also working on developing an online module of the Diabetes 10 Point Training programmes to ensure training can be accessed by as many patient-facing staff as possible.’

    Anyone interested in adapting the training can contact Ms Miller through the Diabetes 10 Point Training website

    ‘We have more diabetes referrals than ever’

    Imperial College Healthcare NHS Trust in London has ten satellite haemodialysis units, many of which are some distance away from the main hospital site.

    This can make them quite isolated in terms of day-to-day engagement, and the high turnover of staff in the London area meant healthcare teams’ diabetes competencies needed reinforcing.

    This was proving a challenge until the trust implemented the Diabetes 10 Point Training programme. Diabetes clinical nurse specialist Jo Reed delivered the programme alongside Ms Miller, before going on to deliver it by herself.

    ‘Renal diabetes is complex and so the training had to be bespoke. It is fair to say we learned from each other and had fun along the way,’ says Ms Reed.

    ‘Training has been successful because it is flexible. It can be delivered to a group or on an individual basis and can be adapted for any healthcare professional'

    Jo Reed, diabetes clinical nurse specialist, Imperial College Healthcare NHS Trust

    The training has raised diabetes awareness and knowledge, adds Ms Reed, which is confirmed by pre and post self-assessment questionnaires.

    ‘It is not designed to make staff experts but to give them sound basic knowledge and the confidence to act on things they find,’ she says.

    Ms Reed says she now has more diabetes referrals than ever as staff recognise the need for interventions at an earlier stage, ultimately improving patient care.

    ‘Training has been successful because it is flexible,’ she says. ‘It can be delivered to a group or on an individual basis and can be adapted for any healthcare professional.’


    More information

    Diabetes 10 Point Training

    Elaine Cole is editor, RCNi projects


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