Improving review of housebound people with diabetes through competency-based training

This article describes a project carried out within a clinical commissioning group (CCG) in Kent in 2019, to review the diabetes population on a community nursing caseload, focusing on those requiring community nurses to administer insulin. The project was led by a nurse consultant (diabetes) with strategic support from the clinical lead of the multidisciplinary team (MDT).

A previous article published in the British Journal of Community Nursing described the aims and objectives of the project (Gregory, 2019). This second article provides more details of competency development for unregistered practitioners to improve the diabetes outcomes for those on a community nursing caseload, focusing on their training outcomes. The key focus was that of improving the nine key care processes (NHS Digital, 2019) (Figure 1) for those who may not achieve this because of being housebound or unable to access the usual annual review held in GP surgeries.

Figure 1. Nine key care processes in diabetes management

Training of unregistered practitioners (associate practitioners and health care assistants) was a secondary consideration in this project, but it underpinned future training within the community setting.

In the CCG in which the project was undertaken, most members of the team from Bands 2–7 carry out insulin administration, a task that is generally allocated 20–30 minutes on the community information systems. During the visit, blood glucose is monitored, insulin is administered and documentation is completed.

Because community nursing teams have heavy caseloads and the number of people being treated with insulin has increased over the years, the capacity is often stretched beyond capability, and insulin regimes may be changed (to suit the service), or the timing of insulin administration is not considered. Once-daily regimens with a long-acting basal insulin were common within the patient cohort, and hypoglycaemic episodes were often missed; further, basal insulin levels increased because of higher blood glucose levels during the day (Gregory, 2019). Thus, in this cohort of often frail, dependent patients, once-daily regimens of long-acting insulin are not always appropriate.

Because insulin administration and blood glucose monitoring are task orientated, a holistic approach is not always considered, and overall diabetes care can be patchy. For staff to view diabetes in a holistic way, there needed to be much more education and understanding around the tasks, and they had to make the best use of the time they had for visits. The training was not just to educate about diabetes, but also to expand the knowledge of staff administering insulin, including an understanding of the profiles and timing of insulin. Holistic diabetes management was key to the project being successful, including annual review and the nine key care processes. Until the project was carried out, community nursing teams did not carry out any part of the annual review, partly because it was not within their remit, and partly because they were not familiar with process or did not feel competent.

Annual review of patients on the caseload

Annual review (based on the nine key care processes) of housebound patients at the start of the project was variable, and was primarily carried out by the practice nurse or advanced nurse practitioner (ANP) within the surgery if time was allocated for home visits.

Foot assessment

Even though members of the community team visited daily, the foot assessment of this cohort of patients was generally low, at only 18% in one area and averaging 35% overall. This was partly because it foot assessment was not seen as part of the community nurse's role, and partly because they had not been trained; additionally, it could not be recorded as a task, so time was not allocated for it.

During the project, all the practitioners were taught and observed foot assessment, from the very basic ‘touch the toes’ (Diabetes UK, 2016) to Doppler testing for peripheral arterial disease. A full annual review was carried out for all patients by the nurse consultant, who then supervised the practitioners to complete the assessment. This was supported by education on theory through classroom-based learning, as well as attending clinics with the MDT. By the end of the project, an average of 90% of the patients on the caseloads had received a foot assessment. The only patients who did not receive an assessment were those who were under podiatry or the MDT because they required dressings.

Other key care processes

Similar improvements were demonstrated in the remainder of the key care processes, namely, blood pressure, HbA1c, kidney function, weight, smoking status and cholesterol assessment, shown in Figure 1. Figure 2 shows the improvements in the proportion of the 47 patients on the community nursing caseload in three hubs who underwent the nine key care processes after the project was implemented.

Figure 2. Proportion of clients in each group before and after the project (post=after the project; pre=before the project)

Retinal screening and urinanalysis were not possible for all 47 patients on the caseload, because many patients were unable to attend for retinal screening, and some were unable to provide a urine specimen for albumin to creatinine ratio (ACR) analysis.

The caseload review was carried out by the MDT lead and community nursing leads, and it identified a total of 63 visits per day to administer insulin, covering 47 patients across three hubs. All grades of staff (Bands 2–7) administered insulin to those patients, but the task was primarily delegated to the lower grades of staff. A large number of staff members had not received any formal training or competencies in diabetes or insulin administration, and, although they could perform insulin administration as a task, they had very limited knowledge of insulin profiles and timing.

Teaching methods

A total of six community/primary care practitioners took part in the programme: three were seconded from the community trust, and three seconded from primary care (GP surgeries). Therefore, each hub had a practitioner from primary care and the community, which enhanced the learning between the two.

Over the 9 months of the project (approximately 3 months in each hub), a total of 47 initial home visits were carried out with the nurse consultant and the practitioners, with the total number of reviews amounting to 114.

The practitioners had varying knowledge and experience of diabetes care, so it was important to use different teaching and learning methods (Gravell, 2013) to support their individual competencies and to achieve the learning outcomes.

These learning outcomes were detailed in a workbook for each participant and in supplementary self-directed resources. A total of 16 hours each week was allocated to the project, and half of this time was spent with the nurse consultant or observing clinical practice (such as MDT clinics and eye screening). The other half was divided into classroom-based teaching and self-directed learning, to achieve the nine competencies (Box 1).

Box 1.Competencies that the participants in the project needed to achieve

• Screening, prevention and early detection of diabetes
• Diet and nutrition
• Blood glucose and ketone monitoring
• Oral medication
• Hypoglycaemia
• Intercurrent illness
• Hyperglycaemia
• Complications
• Insulin administration

The learning schedule was developed by the nurse consultant, with all self-directed learning being marked and feedback given by the nurse consultant. Generally, there would be one day of visiting and reviewing patients (observing or being supervised), and the next day would involve classroom-based or self-directed learning of theory.

This blended learning approach offered a flexible way of learning, while including formal, structured teaching as well. It gave the practitioners an experience of a variety of learning methods, and therefore enhanced their learning experience, enabling them to put theory into practice. This method of learning allowed things to be explained in different ways (Gravell, 2013).

Asking the practitioners to write a reflective journal or notes from the beginning of the project became effective action, since they could identify gaps in knowledge and also when these gaps were filled. This demonstrated an improvement in practice and gave them insights into their learning journey.

Competency framework

The TREND framework-An integrated career and competency framework for adult diabetes nursing (TREND, 2015)-clearly outlines competencies within each Agenda for Change band of nursing staff, including unregistered practitioners (associate practitioners and healthcare assistants). Competencies in the present project were based on the TREND framework (TREND, 2015) for those working within diabetes, and were aligned to the competencies expected for unregistered practitioners. The framework was used to assess and help the practitioners achieve the competencies, and other resources from TREND were used to support their learning.

Classroom-based teaching

The theory was taught to the participants by the nurse consultant in a classroom-based environment at the local diabetes centre, usually over 4–6 hours on a single day. Teaching resources, such as PowerPoint presentations and videos, were used, in addition to other interactive resources, such as games, quizzes and case scenarios. Because of the small number of participants, it was easy to address questions and conduct discussions within the group.

Observation

Observing the nurse consultant on the practical ‘hows’ of carrying out an annual review and foot assessment was embedded into the individual review of each patient. Observation of an MDT foot clinic was a real learning curve for all of the practitioners, as they mentioned in their reflective journals, alongside their observation of a retinal screening clinic. This practice helped them change their practice and added to the information they have since shared with the people they support. After the observation sessions, the nurse consultant observed their practice. Again, because of the small number, there was time to discuss this at each assessment, with plenty of opportunity to involve the patient and take a full history.

Self-directed learning

Generally, 4–6 hours of self-directed learning supported and consolidated the classroom and observation learning. The content of the self-directed learning was developed by the nurse consultant, and included e-learning, extension of quizzes from the classroom-based teaching, reading journals and writing a summary and/or reflection of learning so far.

The websites of national organisations, such as Diabetes UK and National Institute of Health and Care Excellence (NICE), were searched for policies and guidelines around the management of both type 1 and type 2 diabetes. Meanwhile, learning sites such as Diabetes on the Net, Cambridge Diabetes Education Programme and the Abbot Libre Academy were used to obtain more in-depth knowledge regarding the disease and resource use.

It is important to include a way of measuring the extent of learning, and this was achieved through work set and marked by the nurse consultant using various methods, such as summaries, formal questions and case studies.

Results

Qualitative findings

The reflective and self-directed component of the learning allowed the participants to provide detailed feedback. All six participants reported an increase in knowledge, not only in theory but also in practice.

‘I have changed my ways … how I administer insulin, and I am more aware of the importance of timing. I feel I have learnt the importance of diabetes and ensuring that all our housebound patients receive appropriate care and have care plans in place.’

(healthcare assistant, community trust)

‘Since working on the project, I have found I am asking a lot more questions. I spend more time going over the person's documentation, what medication they are on, their eating patterns and hypo[glycaemia] symptoms. I also check when they last had their review and blood test, if they have been ill and risk of steroids.’

(associate practitioner, GP surgery)

All participants have reported a greater understanding of the nine key care processes and annual review, and they no longer view home visits for review of patients with diabetes as a task; rather, they view them as an opportunity to improve the care and service they already provide:

‘This will help me to work closer with my team at the surgery, to ensure all of our housebound patients have an annual review.’

(healthcare assistant, GP practice)

‘I have had my eyes opened to a whole new perspective on the causes, symptoms and treatment that people receive from the MDT, and the knowledge I have gained is amazing; I am fascinated by and interested in the subject.’

(associate practitioner, GP surgery)

Initially, the participants scored themselves high in the self-assessment. When challenged, their explanations highlighted deficits in perceived and actual knowledge:

‘I thought I knew a lot about diabetes, but I have learned so much … I have new knowledge in abundance.’

(associate practitioner, community trust)

‘It has been a brilliant learning curve, and I already feel I have so much more to offer in knowledge to assist and protect vulnerable patients.’

(healthcare assistant, community trust)

Knowledge and competency self-assessment

Putting knowledge into practice was the key aim of training unregistered practitioners in this project. The intention was not only to change their practice if needed, but also to challenge their team to improve diabetes care.

At the beginning and end of the project, each of the participants self-assessed their perceived knowledge and performance in some key areas of diabetes management, areas that can potentially reduce errors and hospital admissions, specifically, hypoglycaemia, insulin administration and complications. These answers were scored from 1 to 10 (1=no knowledge, 10=fully knowledgeable), with the maximum score being 30 (each area included three sub-areas). The results of these self-assessments are summarised in Table 2.

Because all the participants had already been supporting people with diabetes in their roles prior to the training, some of the initial scores were higher, and there were discussions throughout the project around perceived and actual knowledge/competence. Because insulin administration was a ‘task,’ they were competent to perform this task but were not necessarily knowledgeable on the wider implications of insulin therapy.

Through the project, as the participants received more education and insight, they became aware of the gaps in their knowledge (as was also demonstrated in their comments above). Despite this, the self-assessment scores at the end of the project were significantly higher than the pre-project scores, which, along with the increased proportion of patients receiving each care process (shown in Figure 2), supports the case for training of unregistered practitioners.

Conclusion

Although this project involved only a small number (n=6) of unregistered practitioners as participants, the training and mentorship provided to them led to both qualitative and quantitative improvements in their knowledge and skills base within diabetes care.

All practitioners who participated expressed a desire to learn more about diabetes and implied that the impact of the training had been positive.

The blended learning proved to be an effective way of learning for all six participants, and they reported that observation and a hands-on approach to learning were reported as being the most beneficial, as they brought to mind the individuals for whom they cared.

It is hoped that improving the practitioners' knowledge and giving them appropriate resources will improve the outcomes for the cohort of patients receiving care from the participants, which will be the subject of subsequent investigation. The results of this service development project require further testing on a larger scale, and changes within the community teams and the way they work should be examined in depth.

It is clear that, in this small-scale project, the practitioners' knowledge and understanding of diabetes has improved. The principles and model could be applied to any community nursing team, but further development would be needed to claim external validity or generalisability.

KEY POINTS

• People with diabetes who are homebound often fall between services
• Although unregistered practitioners perform insulin administration in the community, they are rarely formally trained for the holistic care of homebound people with diabetes
• Through a community nurse caseload review, unregistered practitioners at one clinical commissioning group were provided training and achieved competencies in conduction annual reviews of those with diabetes
• The aim was to improve their knowledge and understanding of diabetes and consequently the quality of care received by those under their care

CPD REFLECTIVE QUESTIONS

• What is your experience of the nine key care processes in diabetes management?
• Reflect on the similarities and differences in your caseload and that of the group mentioned in this article.
• What are the key areas to focus on when delivering basic diabetes training?