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There are a few (but growing) centers that will proactively see patients with diabetes in high-risk areas when admitted to the hospital, however, by far the most common practice is for patients to only be seen by a specialist team, including for diabetes, on receipt of a referral. In diabetes, referrals are often triggered by glycemic-related events, such as hypo/hyperglycemia and ketosis or for patient education.
We know that patients with diabetes stay in the hospital on average 1-3 days longer than their peers without diabetes who are admitted for the same reason.
We also know that glycemic events are associated with potentially worse outcomes, such as increased length of stay. Therefore, specialist teams receiving the referral after the event has already occurred seems counterintuitive, because the harm and potential impact on outcomes have already happened.
This led me to explore the possibilities of taking a proactive approach to diabetes support in hospitals for all patients with diabetes on admission. Offering an assessment undertaken by a diabetes specialist nurse, identifying risk factors, and through a process of collaboration with the patient, agreeing on steps to mitigate those risks. I named the intervention the proactive diabetes review model (PDRM).
I undertook a service evaluation exploring this in 2018 (Poster 134), which showed potential for reduced length of stay and hypoglycemia rates, however, the cost was a 30% increase in workload. Throughout my career, it has struck me that the assessments and procedures we undertake as nurses and the medicines and therapies we deliver are all evidence-based, but the way we deliver our services often are not.
New evidence-based interventions or learning take years to reach patients (care which is often delivered by nurses) and despite research being a pillar of practice, there seems a clear divide between research nurses (and staff) and the delivery of clinical care. With this in mind, and having also worked in research for several years, I wanted to explore the PDRM intervention more robustly to gain a greater understanding of how the intervention works. Especially given the possible associated cost and complex nature of the intervention.
Integrating research into clinical care is increasing, especially among specialist services. Though this is not often nurse-led research activity, and such integration often leads to complex funding streams. This results in nurses being all or in part on short-term, dual contracts, which is not appealing. I wanted to take my idea through the research process myself, but I did not have the scope or academic skills to do this, despite working in a dual clinical nurse specialist and research nurse role for 10 years. With the fantastic support of my manager and trust I have been successfully awarded both pre-doctoral and doctoral fellowships through the HEE-NIHR Integrated Clinical and Practitioner Academic Programme. This has been a game changer for me and my career, but as a nurse, I am among a minority.
In 2018-2020, nurses were not successful at all in receiving a doctoral fellowship. However, nurses did have some success in gaining integrated clinical academic fellowships, and this award subsequently changed to the Doctoral Clinical practitioners and Academic Fellowship (DCAF) in 2022. In the most recent application rounds, there was a notable drop of applications from nurses by 13%, leaving nurses accounting for only 16% of all applications, despite nurses and health visitors making up 50% of the professionally qualified NHS full-time equivalent workforce. Nurses were also far less likely to be successful. Allied Health Professions had a 38% success rate compared to nursing which had a 25% success rate. Notably, most nursing applications (75%) did not make it past shortlisting.
Trends of lower nursing success for such competitive awards are not new, but it is changing. The pre-doctoral clinical and practitioner academic fellowships and bridging awards have seen improved application and success rates from nurses and support a more optimistic future for nurses in these programmes.
In late 2022, I completed my study ‘A feasibility study of the effect of proactive diabetes specialist nurse reviews of patients with diabetes in hospital and process evaluation’. I successfully recruited 280 participants and it was the largest diabetes recruiting study in the East of England that year. I will be analysing and publishing the results in the coming year. My learning, however, has gone far beyond what I expected and far surpassed that of the outcomes of my study. The experience of this process has highlighted a new passion for understanding the role of the nurse and nurse-led services in the complex hospital setting, the need for and barriers to nurse-led research, barriers to efficient research delivery in the healthcare setting (and possible solutions) and much much more. I hope to share and help address these as my clinical academic career progresses.