The role of Diabetes Specialist Nurses (DSNs)

The DSN role typically involves a high degree of autonomy (especially in community settings) and a range of responsibilities, including clinical care, patient and professional education.

DSNs are fundamental in supporting independence and diabetes self-management for people with diabetes and they play a crucial role in preventing – long-term complications, support patients with complex needs which will otherwise impact on their quality of life, including mental health as well as costly the NHS for preventable complications. DSNs play a key role in supporting primary care teams with specialist expertise to reduce emergency hospital appointments (Diabetes UK, 2011). There is growing body of evidence to support that DSNs are key to cost effective care and improve patient satisfaction (Diabetes UK, 2016). 

Hicks et al (2012) showed that nurse consultant and DSN-led services in the community are clinically effective; patients achieved significant positive clinical outcomes in HbA1c, cholesterol reduction and demonstrated an increased confidence in the patients’ ability to self-manage.

Qualifications, knowledge and skills

New models of care require DSNs to treat, refer, order diagnostic investigations, prescribe medications and create a patient centred care plan. Competencies are crucial to ensure staff are well equipped to manage complex caseloads. 

Career pathways and development in diabetes haven’t been easy to navigate and with a wide range in variety of job titles and job descriptions it has impacted on recruitment to this type role.  (Diabetes UK, 2019; Gosden et al, 2010). 

DSNs should be registered nurses and have practised for a minimum of three years and have proven interests in diabetes management and teaching and counselling. DSNs new to their post are required to undertake have undertaken a diabetes diploma and/ or be working towards or have a related degree.  Senior DSNs should have worked for a minimum of three years as a DSN and are expected to be working towards, or already have a master’s degree.

Diabetes UK (Diabetes UK, 2019)  launched a framework (see Table 1)  to advise on standardising job titles, differentiate levels of practice, inform academic provision and provide a standardise approach to the development of diabetes-specific nursing skills through competency assessment. 

Table 1: Diabetes Specialist Nurse job titles, minimum qualifications & competencies (Diabetes UK, 2019)

A collaborative approach between TREND-UK (Training, Research and Education for Nurses in Diabetes), Diabetes UK, WAND (Welsh Academy of Nurses in Diabetes), and representatives for DSNs and HEIs from England and Wales, has developed the competency framework. It incorporates diabetes-specific nursing outcomes within a clear pathway for career development.

The framework defines the development of knowledge, skills and competence needed to support people living with diabetes. It is recommended that nurses provide evidence to demonstrate their level of knowledge, skill and current practice. It should also link to personal development and support re-validation ensuring it is in line with the Nursing and Midwifery Council view of competence and skills.

From the Diabetes UK DSN workforce survey (Diabetes UK, 2016); 99% said that they have a lot of autonomy in their role, with 89% delivering nurse-led clinics, around half trained as nurse prescribers and a quarter providing professional leadership in the role of lead nurse. The survey (Diabetes UK, 2016) also showed a highly-committed workforce under immense pressure as demand for diabetes services rises without a corresponding increase in DSN numbers. 39% consider their current caseload unmanageable and 78% have concerns that their workload is having an impact on patient care and/or safety. 57% will be eligible to retire from the profession within 10 years or fewer. 

Key messages

• DSNs work wholly in diabetes care and may be employed in primary or secondary care, or in both.
• The title of DSN should only be used if a practitioner has the appropriate qualifications, skills and competences aligned to the Knowledge and Skills Framework (NHS Employers 2019)  and specific diabetes competencies in the Career and Competency Framework for Nurses in Diabetes (TREND-UK, 2019).

References

• British Diabetic Association (1999) Recommendations for the Structure of Specialist Diabetes Care Service. London: British Diabetic Association
• Diabetes UK and NHS Diabetes (2011) Commissioning Specialist Diabetes Services for Adults with Diabetes. A Diabetes UK Task and Finish Group Report.October 2010
• Diabetes UK (2016) Diabetes Specialist Nursing 2016 workforce survey – a workforce in crisis (PDF)
• Diabetes UK (2019) Career & Education Framework for Diabetes Specialist Nursing (PDF)
• Gosden C, James J, Anderson U, Morrish N (2010) UK workforce survey of DSNs and nurse consultants. Journal of Diabetes Nursing (14): 250–7
• Hicks et al (2012) Evaluation of nurse consultant-led intermediate diabetes care services in England. Practical Diabetes; 29 (2): 54 – 57
• TREND Diabetes. Integrated Career and Competency Framework for adult diabetes nursing (PDF)

Specialists involved in the delivery of diabetes care must work in multidisciplinary teams for care to be truly effective. They should have received extensive training accredited at a national level.

Specialist teams should comprise of consultant diabetologists, diabetes specialist nurses, diabetes nurse consultants, diabetes specialist dietitians, diabetes specialist podiatrists, Diabetes specialist pharmacists and clinical psychologists who will also collaborate with many other specialists who might be incorporated into the team. 

Specialist teams provide direct care for people with diabetes with complex needs that cannot be met within the skill competencies of the general practice team.

Specialist teams may be based in hospitals or community settings, but will need to provide care, support and education in all locations for the local population. In some teams key members focus on different aspects of the service. 

The way that specialist diabetes services are organised, and the staff leading the delivery of the different aspects of specialist care, will vary from area to area, depending on the skills of local hospital, community and primary care staff. It is recognised that staffing requirements, facilities and resources will vary from area to area. However, providers of specialist diabetes services have a crucial role to play in either delivering or supporting the delivery of all levels of care across the whole integrated diabetes model of care. 

Key contributions of specialist staff include:

• supporting primary care staff to provide high-quality diabetes care 
• provision of ongoing education and training in diabetes for primary healthcare professionals
• direct provision of support to GPs and their staff in the delivery of diabetes care (ie within GPs’ premises) through joint practice-based clinics and virtual clinics 
• support to GPs in the delivery of care to people living in residential settings and hard-to-reach groups (eg homeless people)
• support for general practice in the introduction of new therapies and treatment regimens
• provision of group education for people with diabetes
• easy access to specialist diabetes podiatry and dietetic services provided in community settings, such as polyclinics (ie as close as possible to where people live)
• easy access to specialist advice (consultant diabetologist and/or diabetes specialist nurse) on the management of individual patients – including the provision of email/telephone advice to GPs and/or practice and community nurses (the aim would be to enable GPs and their staff to continue, where appropriate, to care for the patient in the community.)
• training for, and ongoing support to, those GPs and their staff who provide extended primary care services for their own patients and those registered with neighbouring practices, such as insulin initiation, group education and foot clinics.

Suggested diabetes service structure for multi-disciplinary team working

Using the recently published ‘Best Practice in the Delivery of Diabetes Care in the Primary Care Network’(Milne et al 2021) whilst primarily focusing on the development of care within Primary Care Networks (PCNs) it has produced guidance on service delivery at all levels of care and divided primary, community and secondary care services into four tiers. The best practice guide suggests which patients should attend which tier of service and which health professionals should form the multi-disciplinary team (MDT) in that relevant tier. 

Tier 1 diabetes care (GP Practice-based) 

Patient case type examples

Those on oral agents and stable within individualised treatment target ranges. May include care to those needing GLP-1 and GLP-1/GIP initiation/titration or insulin initiation/titration. 

MDT

Nominated GP, Practice nurse with a special interest in diabetes, or an RPS advanced level 1 pharmacist.

Tier 2 Diabetes Care at PCN level

The Diabetes Support Team will manage their own caseload and referrals for complex cases unable to be managed at tier 1 care and/or not meeting individualised treatment targets. These practitioners will also provide support and supervision for care homes and will advise others in the community MDT e.g. district nurses/active case managers.

Patient case type examples

Those unable to be managed at Tier 1 care and/or not consistently meeting individualised treatment targets. Injectable therapies: GLP-1 and GLP-1/GIP or insulin initiation/titration where extra support is needed. Women of childbearing age, newly diagnosed Type 2 People with painful neropathy, erectile dysfunction, or hypertension. People with diabetes and mental health problems. 

MDT

GP with a special interest (GPWSI), Lead PCN Nurse for diabetes, Community Diabetes Specialist Dietitian and RPS Advanced Level 2 Pharmacist.

Tier 3 Diabetes Care (Integrated Care from Associated Secondary Care Trust or Community Care provider 

Patient case type examples

Referrals for complex cases unable to be managed at Tier2 Diabetes Care Targeted clinics e.g. treatment intensification on 3 oral medications or more and diabetes not controlled, technology (community-managed flash glucose monitoring devices), Frailty, Renal: up to stable Chronic Kidney Disease (CKD) stage 4, Type 1 needing community management (e.g. care home, learning disabilities), GP/PCN support. 

MDT

Community Diabetologist or service level agreement for Diabetologist from local secondary care trust, Senior DSN/Consultant Nurse, Senior Diabetes Specialist Dietitian, RPS Mastery Level Consultant Pharmacist.

Tier 4 Diabetes Care (Secondary Care Trust) 

Patient case type examples

patients with complications cardio- and peripheral vascular disease, retinopathy and neuropathy (especially those with uncontrolled neuropathic pain or autonomic neuropathy)
Inpatient diabetes Foot diabetes MDT, Type 1 diabetes , unstable/rapidly deteriorating CKD 4 and 5, those on renal replacement therapy, Antenatal diabetes, Children and young people, people with uncertain diagnosis, bariatric surgery, islet cell transplantation.

Care Providers: Consultant Diabetologist, Registrar, Senior DSN/Consultant Nurse, DSN, Senior Diabetes Specialist Dietitian, Diabetes Specialist Dietitian, Pharmacists, health care assistants.

Reference

Milne N, Avery L, Ali SN, Alicea S, Beba H, Kanumilli N (2021) How to deliver best practice in diabetes care across Primary Care Networks. Diabetes & Primary Care 24: Early view publication

Sustainability in diabetes care is crucial—not only to maintain high-quality services, but also to reduce the environmental impact of managing diabetes.

Health care contributes significantly to global greenhouse gas emissions. For example, the NHS in England accounts for about 4% of the UK’s emissions.

Sustainable nursing means using resources wisely and reducing waste, such as cutting down on single-use plastics from monitoring devices and packaging. Recycling, reusing, and working with industry initiatives can help.

Delivering diabetes care sustainably also means embedding education and support into routine services, ensuring fair funding, and showing clear outcomes. Social sustainability involves co-designing education that is culturally sensitive to reduce health inequalities.

Strategic planning with staff involvement, leadership support, and the right infrastructure helps new sustainable practices grow and last. For example, the Sanofi insulin pen recycling programme supports this goal.

From a patient’s perspective, sustainability matters beyond the environment. Research shows air pollution raises the risk of type 2 diabetes, and climate change-related food insecurity may increase processed food consumption and obesity.

Extreme temperatures also affect people with diabetes. Heatwaves can lead to more diabetes-related hospital visits, while cold weather increases risks like poor blood sugar control and higher mortality.

Improving sustainability in diabetes care can directly benefit patients’ health. This is why it should be a key focus for nursing practice.