Diabeta

Introduction

The role of the DSN can be very demanding, with increasing workloads and pressures to offer extra services and to teach. This can cause the DSN to feel stressed, despondent and helpless. In this article the author describes how changes in a practice can transform the workload of a DSN, while maintaining a high standard of patient care. Telephone contact, face-to-face appointments, diabetes clinics, nurse-led clinics and group education are provided. In fact, patient contacts have risen, while less routine follow up is made.

Three years ago I was struggling to cope with my steadily increasing workload, demands to offer and develop extra services, and increasing numbers of requests to teach. I was getting into work earlier and earlier, working through lunch, leaving later and later, and taking work home to do in the evenings and at weekends.

If I had a week's holiday it involved extra work during the week before and after, just to keep my head above water. I was feeling increasingly stressed, despondent and helpless -- as if on a carousel that was spinning faster and faster, and I was just managing to hold on by my fingertips, but they were being prised off one by one -- sound familiar?

Turning point

Having decided things had to change or I had to resign, I took time out to examine in depth what we did and why. I gained the agreement of my two colleagues to begin implementing changes; we piloted them for an agreed period of three months, and then discussed what worked and what did not.

Over a period of about 12 months we gradually refined our new system. The rest of our multidisciplinary team were supportive of the changes, and were kept informed of the process during our regular team meetings.

Outcome

Now, my life as a DSN has been transformed. I always take a lunch break, I rarely work even 15 minutes late, and I never take work home. All this has been achieved with no extra staff and an increasing number of new patients seen each year. I offer the details of how we have changed our working pattern in the hope that it may be helpful to others.

Implementing change Telephone

First, we have stopped being slaves to the telephone. Previously, we were interrupted all day long by telephone calls from patients and others, all demanding advice or information there and then. If we were in consultation with a patient at the time, we would tell them we would call them back. However, some people insisted we talk to them immediately. Either way, it disrupted the consultation, and patient confidentiality was compromised.

The team agreed a nurse would be available to take telephone calls for half an hour first thing in the morning, and half an hour at the end of the afternoon. At all other times, an answerphone takes messages, which are returned at our convenience during the day. We have a message book so we log calls and 'tick' off when they have been returned. Some patients do not like leaving messages on answerphones, but they have the option of ringing back at a time when the telephone is being manned. The new system has generally been well received.

We do a lot of follow up of patients by telephone, and we used to waste much time trying to ring them, only to find they were out. We now have a finite number of telephone appointment slots during the day. We have found it is more convenient for our patients to be in first thing in the morning, at lunchtime or at the end of the day, so the appointments are made at these times. Patients are happy to wait by the telephone if they know when we are going to phone, and we rarely miss a call now.

Face-to-face appointments

Additionally, we have a finite number of face-to-face appointments each day, and do not book in more patients than we have slots. There are two emergency slots with each nurse every day, so if someone needs to be seen urgently, or if we have a referral for a new patient with type I diabetes, they can always be accommodated. Our waiting list is never longer than 2 weeks, and we help each other out if someone's diary is full, sharing new referrals as we have space.

Lunch

We have a lunch break between 12.30 and 1 pm each day. We never encroach on this 'protected' time. Sometimes we go to the canteen, sometimes we eat sandwiches in our office, sometimes we take a walk around the hospital grounds. We try not to talk 'work', but catch up on each other's social news, or just relax!

Diabetes clinics

We used to provide DSN cover for all clinics. These had increased to every morning and every afternoon, and took up a huge slice of DSN time. The use of this time was variable: sometimes we could be asked to see nearly every patient, and felt extremely pressurised; other times we might see just one or two patients; and, occasionally, we saw no patients. We discussed this with our medical colleagues, and after much negotiation have agreed to provide two half-hour slots of DSN time per clinic. If more patients need to be seen, they are booked in for another day. If it is urgent, they can be accommodated in an emergency slot within 24 hours.

Nurse-led clinics

Every Friday morning we run an open access, nurse-led clinic for patients newly diagnosed with type 2 diabetes. The numbers referred have increased from an average of eight patients per week to 18 per week over the last 8 years.

We used to see each patient individually at the end of the group session to test blood sugar with a meter, assess him/her and initiate medication, if needed, according to a protocol. We would then see them all again 2 weeks later to check on their progress. We were responsible for all their follow up for the first 3 months after diagnosis. This was putting a huge burden on DSN time, and we felt the majority of the follow up could be done in primary care.

After gaining the agreement of our primary care colleagues, we now assess all patients -- blood sugar by a meter and a brief check of symptoms as they arrive. We screen out all patients with blood sugars>l4mmol/l, with or without ketonuria, and only see these individually at the end to initiate medication, if appropriate. All patients are then followed up in primary care, and we only review those we are specifically concerned about, e.g. those with weight loss or ketonuria.

Group education

We looked at all areas where we were giving individual patient education and asked "Could this be given as a group session?" This has resulted in several new sessions being implemented, notably one for patients new to insulin medication, so all the general advice about driving, exercise, injection sites, and so on, is given to all the patients new to insulin that month at the same time in an interactive session. This has again freed DSN time that used to be spent in following up these patients and trying to ensure we had covered all the relevant points.

The patients have also found it helpful to meet with others in their situation and exchange experiences. Apart from the initial session to give their first injection, most follow up of these patients is now done by telephone, unless we feel we need to see them face to face again.

Computerised system

Our department changed to the computerised diabetes management system Diabeta 3 in January 1999. This has had an impact on our workload and greatly improved communication between team members. Previously, if someone rang in for advice or dropped in, we had no time to access their medical records and so had to give 'blind' advice, which was only recorded in our nursing records. This is similar to the situation NHS Direct now experiences, and relies on in-depth questioning to ascertain all the relevant facts, before giving appropriate, limited advice. We were often not able to have the medical records for face-to-face appointments either, and writing letters to the relevant medical staff depended on secretarial time being available, or otherwise writing them ourselves.

Diabeta 3 enables all team members to access all patients' records as they see or speak to them, and generates letters to the appropriate individual at the touch of a button. We now run a paperless office, and all of our computer skills have been greatly enhanced. The system also enables easy audit of information recorded.

Conclusion

Because of the changes we have implemented, I can now truthfully say that I look forward to coming into work each day. I feel 'in control' of my workload. Additionally, as the statistics in Figure I show, our new patient contacts have risen during this period, while we are doing less routine follow up.

I offer my experience as an example of how you can improve your working life. You can stay sane and still have a lunch break!

[FIGURE 1 OMITTED]

RELATED ARTICLE: ARTICLE POINTS

1. DSNs are often faced with steadily increasing workloads, demands to offer and develop extra services, and increasing numbers of requests to teach.

2. Implementing changes to a practice can transform the workload of a DSN, without compromising patient care.

3. Manning the telephone for set times, and replying to answerphone messages at a convenient time, prevents the DSN from being a slave to the telephone.

4. DSN time is allocated to face-to-face appointments and slots during diabetes clinics. Emergency slots are available.

5. Nurse-led clinics and group education provides patients with in-depth information and frees up DSN time in individual follow up.

KEY WORDS

* DSN

* Implementing change

* Improved workload

PAGE POINTS

1 Patients are happy to wait y the telephone if they know when we are going to phone, and we rarely miss a call now.

2 We have a finite 2 number of face-to-face appointments each day, and do not book in more patients than we have slots.

3 We provide two half-hour slots of DSN time per clinic. If more patients need to be seen, they are booked in for another day.

4 Every Friday morning we run an open access, nurse-led clinic for patients newly diagnosed with type 2 diabetes.

5 We have implemented several new group sessions, notably one for patients new to insulin medication, so all the general advice is given to all the patients new to insulin that month at the same time in an interactive session.

Pat Miles is a Diabetes Specialist Nurse at Bournemouth Diabetes and Endocrine Centre, Royal Bournemouth Hospital.

COPYRIGHT 2002 S.B. Communications
COPYRIGHT 2003 Gale Group