The privileged nurse – making sure that the nurse’s voice is heard

Aim: To describe strategies taken to drives nursing-led models of care Introduction: Nurses are positioned well to advocate for their patient group. Helping them to make: informed decisions regarding their health, navigate a complex medical system and helping with ethical decisions. Simultaneously, nurses can advocate for the pivotal role of the nurse more broadly to healthcare. The abstract explores activities and strategies that have created a career in diabetes nursing. Methods: The following quote, “Ask not what your country can do for you – ask what you can do for your country” lays the foundation for change. ‘Country’ was substituted with organisation and community. ADEA was the organisation, the national peak body for diabetes educators; community was people living with diabetes. An accumulative identification of linkages and champions, setting sights on lifelong learning and mentoring, intuitive reflexivity, and embracing leadership roles. Results: A strong voice for diabetes nursing on multiple platforms including national steering committees, research and medical advisory committees; e.g., Cochrane, DVA, PBAC and NHPA. Several research projects that have supported improved health outcomes through models of nursing care; reductions in diverse adverse outcomes of between 15-40%. Inclusion of nurse practitioner role within all diabetes project material and consumer fact-sheets in Australia. Discussion: Nurses need to seat themselves at the table, they need to embrace the important information that they can bring and their nuanced understanding of health, to inform care. Conclusions: As a nurse, one sits in a position of privilege, which can create worthwhile and meaningful change

Capabilities versus competence – what’s the difference? The move to capabilities in diabetes care

Background: Many countries use competency frameworks to prepare health professionals. In Australia, they were a 1990 Training Reform Initiative to increase industry competitiveness and support economic recovery. The basis for curriculum development became enterprise-driven rather than individual trainers setting priorities. Competency frameworks are task-orientated tools standardising technical skills in stable clinical situations; however, healthcare environments are dynamic. Aim: To identify an improved way of educating the health professional workforce to meet diabetes consumer healthcare needs. Method: A systematic narrative literature. Findings: Literature suggests competency-based frameworks have little utility in an environment aimed at increasing scope of practice by creating a skilled, flexible, and innovative workforce. Limitations of competency-based training include its ties to specific workplace healthcare roles and discipline requirements and work as it currently exists. It is grounded on one-dimensional views that learning processes are identical to the skills to be learnt and a notion of the professional as the supervised worker. Competency frameworks do not recognise the benefits of autonomous practice, a key enabler of innovation. Capability-based training offers an alternative; it extends beyond technical skills to emphasise the components of adaptability to change, lifelong learning, and self-efficacy. Based on Sen’s capability approach, a moral framework describing how opportunities are made feasible and constrained by internal (personal) and external (social and environment) factors. Capability-based training focuses on aligning learning with human motivation and adults’ preferences for autonomy and learning. Conclusion: Existing competency frameworks designed to equip health professionals with the knowledge, skills, and attributes to provide diabetes care do not recognise the dynamic environment of healthcare. Australia’s geographical nuances require a flexible, adaptable diabetes workforce with skills to practice at extended levels to provide appropriate safe diabetes care. To expand the workforce’s capacity to address future diabetes healthcare needs, understanding the diabetes capabilities required by health professionals is essential

Diabetes Capabilities for the Healthcare Workforce Identified via a 3-Staged Modified Delphi Technique.

Consumers access health professionals with varying levels of diabetes-specific knowledge and training, often resulting in conflicting advice. Conflicting health messages lead to consumer disengagement. The study aimed to identify capabilities required by health professionals to deliver diabetes education and care to develop a national consensus capability-based framework to guide their training. A 3-staged modified Delphi technique was used to gain agreement from a purposefully recruited panel of Australian diabetes experts from various disciplines and work settings. The Delphi technique consisted of (Stage I) a semi-structured consultation group and pre-Delphi pilot, (Stage II) a 2-phased online Delphi survey, and (Stage III) a semi-structured focus group and appraisal by health professional regulatory and training organisations. Descriptive statistics and central tendency measures calculated determined quantitative data characteristics and consensus. Content analysis using emergent coding was used for qualitative content. Eighty-four diabetes experts were recruited from nursing and midwifery (n = 60 [71%]), allied health (n = 17 [20%]), and pharmacy (n = 7 [9%]) disciplines. Participant responses identified 7 health professional practice levels requiring differences in diabetes training, 9 capability areas to support care, and 2 to 16 statements attained consensus for each capability-259 in total. Additionally, workforce solutions were identified to expand capacity for diabetes care. The rigorous consultation process led to the design and validation of a Capability Framework for Diabetes Care that addresses workforce enablers identified by the Australian National Diabetes Strategy. It recognises diversity, creating shared understandings of diabetes across health professional disciplines. The findings will inform diabetes policy, practice, education, and research

Exploring Diabetes Competencies: Engaging with Colleagues using the Delphi Method

Background: A 20% increase in adult diabetes is anticipated by 2030 when 58% of the CDE workforce will have reached retirement age. Fundamental to increasing equity in safe diabetes healthcare access across the health spectrum is a competent, flexible and adaptive workforce. Higher demand for healthcare professionals with both diabetes and non-medical prescribing competencies warrants a more efficient means of developing the workforce. Aim: To develop a Capability Framework by accessing the opinion of a diverse range of diabetes expert healthcare professionals and academics, of different disciplines and work settings. Method: The qualitative research used an online Delphi method informed by consultation and focus groups to gain consensus. A Consultation Group was engaged to inform the Delphi survey development phase. A pilot Delphi survey was administered via Qualtrics, an online platform, to six diabetes experts to test Qualtrics features and confirm questions captured the intended information. An expert panel from across Australia commenced the final Delphi survey. Analysed data obtained from the Delphi survey formed a list of competencies under nine capabilities. An Expert Advisory Group was engaged to review the positioning of competencies, wording and omissions. Further, ‘member checking’ will ensure the trustworthiness of results. The Delphi expert panel ranks the importance of the identified competencies for each of the capability areas until consensus achieved. Results: Fifty-seven diabetes experts from nursing, dietetics, podiatry, pharmacy, exercise physiology and academic backgrounds were recruited to the project and administered the Delphi survey. The Delphi method captured demographic data and comprehensive lists of skills, knowledge and attributes required by health professionals working at basic to expert levels in diabetes care. Discussion: Using Delphi as a method enables ease of access and reach to the breadth of diabetes healthcare professionals across the nation. Also, it allows for re-examining the understanding of valuable information

Capability Framework for Diabetes Care: A health workforce investment

Background: Diabetes has become more prevalent, and technologies and medicines used to manage it more complex. Over a quarter of consumers accessing health services daily have diabetes and access health professionals with varying levels of diabetes-specific knowledge and training. Consequently, they receive conflicting advice, which leads to consumer disengagement. Aim: To develop a national consensus framework to guide their training by identifying capabilities required by health professionals to deliver diabetes care. Method: A 3-staged modified-Delphi technique gained agreement from a purposefully recruited panel of Australian diabetes experts from various disciplines and work settings. The Delphi technique consisted of (Stage-I) a consultation period, including a semi-structured consultation group and pre-Delphi pilot, (Stage-II) a 2-phased online Delphi survey, and (Stage-III) an external appraisal period, including a semi-structured focus group and health professional regulatory and training organisations survey. Descriptive statistics and measures of central tendency were calculated to determine participant and quantitative data characteristics and consensus. Content analysis using emergent coding was used for qualitative content. Results: Eighty-four diabetes experts were recruited from nursing and midwifery (n=60[71%]), allied health (n=17[20%]), and pharmacy (n=7[9%]) disciplines. Participant responses identified 7 health professional practice levels requiring differences in diabetes training, 9 capability areas to support care (assessment, diabetes self-management education, therapeutic relationships, communication, counselling, quality use of medicines and diabetes technologies, research/quality), and 2 to 16 statements attained consensus for each capability, 259 in total. Three sets of attributes underpinned the capabilities: support excellent communication, collaboration and advocacy; strive for excellence and promote health professionals’ health and wellbeing to foster their adaptability in dynamic environments. Conclusion: The rigorous consensus methodology led to the design and validation of a Capability Framework for Diabetes Care, which addresses workforce enablers identified by the Australian National Diabetes Strategy. It recognises diversity, creating shared understandings of diabetes across health professional disciplines

Cost Analysis of the Credentialled Diabetes Educator Diabetes in Pregnancy Care Model versus Conventional Care

INTRODUCTION: Diabetes in pregnancy (DIP) increases the risk of short and long-term adverse health outcomes in mothers and infants, with consequential resource implications. Reliance on conventional care including care initiation by an endocrinologist in rural/remote areas with resource and/or workforce constraints may compromise timely diagnosis and/or management. Innovative strategies such as the Credentialled Diabetes Educator (CDE) DIP Care Model, an evidence-based integrated interdisciplinary, screening and management protocol, may facilitate appropriate and timely care. AIM: Assess the economic credentials of the CDE DIP Care Model in a rural region of Australia. METHODS: Simple modelled economic analysis of Credentialled Diabetes Educator Diabetes in Pregnancy (DIP) care model compared with standard antenatal diabetes care, over a one-year period, from a health care system perspective. Assumed 1250 pregnancies, approximately the annual number in North West Tasmania. Source Data: Two, three-year uncontrolled clinical audits (07/2003-06/2006-retrospective; 01/2010-12/2012-prospective) of pregnancies identified as complicated by diabetes pre-and post-full implementation of the DIP Model in 2009. Model inputs: Rates of screening, identification, and outcomes assessed relative to all births in the region over each three year period. Adverse neonatal outcomes assessed as i) infants with congenital abnormalities (CA); and ii) infants with a severe metabolic impact (SMI), defined as infants born with macrosomia and hypoglycaemia +/-birth injuries. Resource use-derived from protocol (number and length of visits) and spectrum of use (tests, scripts) ascertained during clinical audits (2010-2012 post-audit). Neonates experiencing an adverse outcome were assigned an AR-DRG, P06A-B or P67A-C. Unit costs were based on salary costs for AHPs and published standards otherwise (2012 AUD). Average annual costs were assessed. RESULTS: Total costs increased by $33,447 under the CDE model including universal screening. Average expenditure for diabetes care reduced by$219 per patient managed given workforce changes (↓ physician and ↑ allied HPs visits). Five fewer babies were born without congenital abnormalities, and another five without severe metabolic impacts generating annual care savings estimated at over $150,000. CONCLUSIONS: Universal screening (CDE Model) more than doubled identification of women with GDM. The CDE DIP Care Model post-pregnancy follow-up facilitates pre-conception/early care. The Model is efficient and sustainable within a severely resource constrained rural context

Benefits of GLP-1 Analogue and Insulin Combination in a Nurse Practitioner Supported Service

Benefits of GLP-1 Analogue and Insulin Combinations in a Nurse Practitioner Supported Service (#117) Giuliana Murfet , Michelle Woods , Jenna Hills 1. Diabetes Centre, Tasmanian Health Organisation-North West, Burnie, TAS, Australia 2. Royal Hobart Hospital Diabetes Centre, Tasmanian Health Organisation - South, Hobart, Tasmania, Australia 3. School of Health Sciences, University of Tasmania, Hobart, Tasmania, Australia Aim: To describe outcomes of a GLP-1 analogue and insulin combination service supported by nurse practitioners/credentialled diabetes educators Background: NICE guidelines place use of GLP-1 analogues as third-line addition to oral therapy in obese patients where weight loss would benefit comorbidities. In 2012 the TGA approved their use as an adjunct to insulin Glargine; but this is not reimbursed by PBS. Ceasing GLP-1 analogues to commence insulin therapy can have a major impact on people with type 2 diabetes in terms of excess weight gain that may impact other co-morbidities. Methodology: Tasmanian has State-wide Drug and Therapeutics Committee approval to support 100 patients on combination GLP-1 analogue and insulin. Patients not able to reach target HbA1c on OHAs and GLP-1 analogue alone are listed onto the SDTC list for supported insulin combination treatment. The NP/CDE supports the success of this combination by coordination, initiating GLP-1 analogue, decreasing insulin titration and cessation of OHA’s, reviewing how the person is coping and his perspective into interpretation/ narrative of living with a chronic condition. NP/CDE assessment includes information about the client’s perceptions/reactions to health and illness, their knowledge, self help activities and alternative treatment modalities. Results: Approximately 70% of patients had a sustained reduction of HbA1c over 12 months greater than 1% (28% ≥2%). Weight loss was seen in 70% of cases (ranging 1.3 - 14kg); weight maintenance or up to 1.5kg gain in others. Pre-intervention mean HbA1c was 9.7% (range 7.7-12.9%), post mean 7.7% (range 6.5 – 9.2%). Review of data shows that additional benefits realised by patients are the reduction of hypoglycaemic risk and events. Further, other benefits seen were contextual and reflective to complexity of each case. Notably patients living with multiple morbidities had a diminished progression in other morbidities; such as; resolved chronic bilateral cellulitis. Conclusion: Use of GLP-1s in combination with insulin therapy may have a place in supporting metabolic profiles. This approach can be supported by NPs/CDEs

Assessment and Management of Obesity and Self-maintenance (AMOS): Outcomes of a multidisciplinary clinic for people living with type 2 diabetes and obesity

Background: Obesity is a prevalent and complex condition with genetic, environmental and behavioural determinants associated with comorbidities such as cancer, obstructive sleep apnoea, infertility, and cardiovascular disease. The Mean (M) BMI of adults attending Diabetes Clinics in regional Tasmania was 44.5 kg/m2. Interdisciplinary support leads to sustained weight loss and improved metabolic markers. However, reduced access to health services, nutritious dietary and physical activity options in rural and remote areas can challenge bariatric and diabetes management. Aim: To describe the effects of an interdisciplinary clinic focused on tailored bariatric management for people living with type 2 diabetes. Method: Single-centre randomised control trial in rural-regional Tasmania between 2015 and 2019. Participants randomly assigned to routine care (usual diabetes centre appointment) or intervention (tailored person-centred interdisciplinary bariatric management focused on self-maintenance). Intervention was provided by a nurse practitioner and dietitian (baseline, 6- and 12-weeks, then 3-monthly intervals to 24 months), a physiotherapist (baseline, 1-, 6- and 12-months), a credentialled diabetes educator at weeks 2, 4, 8, 10 (delivering support phone-calls), and psychologist when required. Glucose-lowering medicines altered to weight-neutral/lowering medicines. Metabolic surgery offered to suitable participants after 12-months. Results: 224 participants (113 intervention, 111 control). Mean age 60-years (24-73), 76.3% on disability/unemployment benefits and Indigenous Australians represented 7%. 16 had metabolic surgery (12 intervention, 4 control). Intervention participants showed greater weight loss (M=-4.2kg[MK1] (95% CI: -5.7, -2.6)) at 6-months; difference of -9.3kg (95%CI: -12.5, -6.2) at 24-month. HbA1c at 6-months showed greater reduction for intervention group (M=-0.37% (95%CI: -0.67%, -.06%)) and 24-months (-0.65% (95%CI: -1.07%, -.22%)). The rate of eGFR decline in the usual care group was 1.36ml/min/m2/year versus 0.23 ml/min/m2/year (difference 1.14ml/min/m2/year (95%CI -0.34, 2.63; P=0.14). Conclusion: The interdisciplinary bariatric management compared to usual care resulted in greater weight loss and improved glycaemia and differences were sustained for up to 2-years

A position statement on screening and management of prediabetes in adults in primary care in Australia.

Prediabetes has a high prevalence, with early detection essential to facilitate optimal management to prevent the development of conditions such as type 2 diabetes and cardiovascular disease. Prediabetes can include impaired fasting glucose, impaired glucose tolerance and elevated HbA1c. This position statement outlines the approaches to screening and management of prediabetes in primary care. There is good evidence to implement intensive, structured lifestyle interventions for individuals with impaired glucose tolerance. The evidence for those with impaired fasting glucose or elevated HbA1c is less clear, but individuals should still be provided with generalised healthy lifestyle strategies. A multidisciplinary approach is recommended to implement healthy lifestyle changes through education, nutrition and physical activity. Individuals should aim to lose weight (5-10% of body mass) using realistic and sustainable dietary approaches supported by an accredited practising dietitian, where possible. Physical activity and exercise should be used to facilitate weight maintenance and reduce blood glucose. Moderate-vigorous intensity aerobic exercise and resistance training should be prescribed by an accredited exercise physiologist, where possible. When indicated, pharmacotherapy, metabolic surgery and psychosocial care should be considered, in order to enhance the outcomes associated with lifestyle change. Individuals with prediabetes should generally be evaluated annually for their diabetes status