Improving Diabetes Patient Care Through Nursing

Diabetes care is complicated, expensive, and time consuming. The American Diabetes Association’s (ADA) Standards of Care call for educating patients about diet, exercise, medications and glucose testing. The medical doctor (MD) providing diabetes care should screen for and treat complications, and maintain patients’ glucose, blood pressure and lipids within their individualized target ranges. Patients with diabetes are often hospitalized and need specialized care in the hospital.

Clearly, medical doctors cannot provide all this care, especially at authorized payment rates. Diabetes care is more than prescribing medicines and doesn’t fit well in 10–15 minutes appointments. Fortunately, other health-care professionals, especially nurses, can help.

There are about 3,000,000 registered nurses (RNs) and 700,000 vocational nurses (LVNs or LPNs) in the U.S. (compared to about 1,000,000 MDs), who can provide care to people with diabetes in many levels of the health-care system.

Nurse care managers

Care managers are usually RNs who have been trained in monitoring, scheduling, database management, care coordination and educating patients.

A study at Johns Hopkins of 542 low-income African-Americans found that those who consulted with a nurse manager and received visits from community health workers (CHWs) had 47 percent fewer emergency department (ED) visits and 56 percent fewer hospitalizations than a usual care group.

Care managers addressed obstacles to management, such as depression, poverty and “household problems interfering with medication adherence.” According to the study, both CHWs’ and nurses’ visits focused on health education, nutrition, foot care, medication adherence and assistance accessing the health-care system.

“The study created an alternative way to get problems addressed,” said Martha Hill, dean of the Johns Hopkins University School of Nursing. “Patients could see the nurse the next day instead of waiting long periods for physician visits or going to the ED.”

Diabetes specialist nurses

Diabetes specialist nurses have received training and/or certification and hold an advanced practice registered nurse (APRN) license and assist in the medical management of diabetes. These nurses can be especially valuable in individualizing treatment, which is called for by the ADA Standards of Care. An English study reported that “Nurses are best placed to implement guidance on caring for frail, elderly diabetes patients.”

“We have now established guidance about which medications should and shouldn’t be given to different patients,” said Dr. David Strain, a lead author of the study. “Nurses may be better placed than doctors to make these decisions. They often get more time to talk to people with diabetes, so they have often been able to elicit potential complications of treatment that may get overlooked during shorter consultations with doctors.”

Diabetes specialist nurses can also treat patients in the hospital, where patients often need additional attention to manage blood glucose levels.

Preventing and managing hypoglycemic episodes in the hospital is also a responsibility for nurses. In some hospitals, after the patient has been assessed to be safe, patients using an insulin pump for diabetes management may continue to self-manage their diabetes control, which nurses can facilitate.

Primary-care nurse practitioners

Nurse practitioners (NPs) are registered nurses who have continued their education by obtaining either a Master of Nursing (MSN) or Doctor of Nursing Practice (DNP) from a nurse practitioner program, preparing them for the APRN role. They usually work in collaboration with an MD. They prescribe medications as well as order tests.

Researchers at Kaiser Permanente wrote, “There is evidence that nurse practitioners improve clinical outcomes for patients with Type 2 diabetes in primary-care practices through their capacity to initiate, change and adjust medications without physician authorization. Their willingness to embrace alternate methods of patient communication (via telephone, e-mail or e-visits) has been shown to increase the convenience and quality of care while reducing costs and improving glycemic control.”

An article in Diabetes Spectrum reported that “Studies have suggested that the quality of care provided by primary-care nurse practitioners is equal to that provided by physicians.” A paper in JAMA concluded care by NPs leads to the same outcomes as care provided by primary-care physicians.

Nurses in the office and community

Patients with diabetes need to have their feet examined and be screened for peripheral neuropathy. Office nurses can learn to do this. Patients with diabetes may have a variety of difficult problems such as sleep apnea or sexual dysfunction, and nurses who have formed relationships and trust with patients often learn important patient history that the individual may have not or been too embarrassed to share with their doctors.

In the community, nurses can screen large numbers of people for diabetes with blood tests. This early detection may enable people to change behavior or start medications before complications can develop.

Nurses in the clinic and community can be RNs, who have an Associate’s or Bachelor’s degree in nursing. A Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN), who usually has 12–18 monhts of training to prepare for the license exam, can also work in a clinic or community setting. Some programs employ nursing assistants or CHWs who do not hold a license.

Visiting nurses (usually RNs) can assess and treat patients who need skilled care at home. In the home, they can see and evaluate the problems patients are having managing various issues, such as diet and self-care.

Nurses who have a high rate of contact with patients who have diabetes can learn diabetes screening, teaching and coaching skills such as those used in motivational interviewing. There is training, education and/or certification available for all levels of nursing practice.

Diabetes educators and advance diabetes managers

Registered Nurses, including nurse practitioners, dietitians, pharmacists, physicians and many other health professionals who are qualified can be trained and certified as certified diabetes educators (CDEs). CDEs can teach patients to self-manage and can help them address problems and barriers that come up throughout their life with diabetes.

In 2001, the American Diabetes Association and the American Association of Diabetes Educators jointly created a Board Certified Advanced Diabetes Manager (BC-ADM) credential, which is available to certain health-care disciplines holding a Master’s degree or higher.

ADMs must demonstrate skills in clinical practice, assessment, diagnosis/problem identification, planning and intervention, clinical coordination and case management. They must also have a range of professional competencies such as collaborating, consulting and quality improvement.

With more than 30 million Americans having diabetes, nurses play a number of vital roles in providing the extensive care and education that the diabetes management requires.

Access additional resources and practical information to enhance the care and treatment of your diabetes patients.

About our experts: David Spero, BSN, RN, Registered Nurse; Pamela J. Rickerson, MSN, APRN, MLDE, ACNS-BC, BC-ADM, CDE