IntroductionThe management of diabetes carehas changed in recent times inresponse to the significant increasein numbers of people developing the condition, which has made thehospital diabetes outpatient modelunsustainable. The drive to move themanagement of long-term condi-tions into primary care1 and theincreasing focus on commissioningproviders who give best value formoney have meant that many aspectsof diabetes care are being performedby a wider group of practitioners,some of whom may be unregistered.It makes sense to delegate routinesimple tasks to less qualified (and less expensive) health care staff andreserve complex care to those whohave experience and qualifications(but who are more expensive); how-ever, it may be difficult to identifywho is competent to deliver the service required, and be assured thatquality is maintained as well as at acompetitive cost (i.e. best value). Asdiabetes care is delivered in a varietyof environments including those outside the National Health Service(NHS), ensuring that people withdiabetes are seeing the right peopleat the right time is a challenge.

This article describes the devel-opment of a competency frameworkfor diabetes nursing in the UK thatdefines various aspects of diabetescare and the competencies requiredto deliver these (i.e. what isexpected) by different levels of registered and unregistered practi-tioners. The framework provides acareer structure for nurses who wishto develop a diabetes specialism, anda commissioning tool for identifyingthe most appropriate staff who are required to provide a diabetesservice. It can be helpful in businessplanning when justifying why moreexpensive staff are needed to per-form a particular service and whyresources are needed for trainingand development; it can also be aframework for providers of diabetescare to benchmark themselves and

demonstrate their competency todeliver the service required. In therest of Europe, a similar competencyframe work may be useful in ensur-ing standardisation across differentcountries about what is expected inthe provision of diabetes nursing, nomatter in which country the care isdelivered and by whom.

Diabetes nursing historyDiabetes nursing developed as a specialism in the UK in the 1970s,and was particularly related to insulintherapy and the conversion to u100insulin. Diabetes specialist nurses(DSNs) were few in number, usuallybased in hospital outpatient services,with a background of working as the manager (or ‘sister’) of the acutediabetes ward. The number of DSNshas grown over the years but, in theUK, there is still no single recognisedqualification for the role. Minimumrecommendations for nurses apply-ing for their first DSN post weredefined in 1991 stating that theyshould be registered nurses with aminimum of three years’ practice,and have a proven interest in dia-betes management, teaching andcounselling. Senior DSNs would havebeen required to have practised as aDSN for a minimum of three years;and be willing to undertake a dia-betes diploma or a related degree.2

The role of the DSN has evolvedin recent years in response to theincreasing number and expectationsof people with diabetes, the avail-ability of new therapies and devices,and government directives influenc-ing the health economy. Wider poli-cies such as the European WorkingTime Directive have influenced the role, with nurses developingskills that traditionally were medicaltasks.3 Many DSNs are now ‘special-ist diabetes specialist nurses’ in areassuch as structured education pro-grammes, insulin pump therapy, andcardiovascular risk management.They are working more autono -mously in nurse-led clinics, with asurvey conducted by Diabetes UK

and the Association of BritishClinical Diabetologists4 finding thatbetween half and two-thirds of DSNresponders were independent pre-scribers. More than three-quartersconducted independent nurse-ledclinics, and 93% of responders were involved in patient care.Furthermore, structured patienteducation was planned and deliv-ered by 90% of the DSNs surveyed.

The changing workforceHowever, a significant amount ofdiabetes nursing intervention is notnow given by DSNs. The majority ofpeople with type 2 diabetes, andsome people with stable type 1 dia-betes, are managed in primary carewith the support of practice nurses.People with diabetes receive supportfor their condition from nurses inresidential homes, hospices, prisons,community clinics, general hospitalwards, and other health care settings. Non-NHS providers ofhealth care are being encouraged toprovide services too. Some elementsof diabetes nursing are given byunregistered practitioners (e.g.health care assistants and diabetestechnicians), such as some compo-nents of the annual diabetes review,taking blood, basic education pro-grammes and the teaching of bloodand urine monitoring. There are,therefore, a lot of different peopleproviding various aspects of diabetesnursing, including some who havesimilar roles but who have differentjob titles. There needs to be a cleardefinition about who can do what.

Fit for purposeIn recent years, there has been anincreased emphasis in UK healthcare on defining what skills areneeded to provide a service, but alsoat the lowest cost (i.e. best value).The ‘Agenda for Change’5 and thesupporting ‘Knowledge and SkillsFramework’6 changed the emphasison working in the NHS to a focus onemploying and developing the rightgrade of staff to meet the needs of

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Are you fit for purpose? The development of acompetency framework for diabetes nursing in the UK

the service required (which maymean that there is less need forexpensive specialist staff resulting in a greater number of less [but adequately] skilled and less costlystaff being employed). For diabetes nursing, this means that not all diabetes nursing care needs to begiven by relatively expensive, highlyspecialised DSNs.

Recognition of defining the com-petencies needed for a service isidentified in documents such as theSkills for Health ‘Introduction toWorkforce Planning’, with its open-ing statement setting the scene: ‘getting the right people with theright skills and competencies in theright place at the right time’.7Demonstrating and outlining com-petencies are essential for providersand for those commissioning them.This process can provide a clearframework to avoid unsafe practicetoo (e.g. ensuring unregistered practitioners are not used to per-form specialist tasks). It also recog-nises the responsibility of everyoneinvolved in diabetes care to be com-petent in their area of work, andhow the routine task performed byan unregistered practitioner canimpact on the patient experience aswell as the effectiveness of the widerdiabetes team.

Development of the competencyframeworkThe first edition of ‘An IntegratedCareer and Competency Frameworkfor Diabetes Nursing’8 was publishedin 2005. More than 40 generalist andspecialist nurses and people with diabetes worked together to define

diabetes nursing and to identify thekey competencies required.

The draft framework was sent tomore than 250 nurses from all professional backgrounds, patientgroups, civil servants and DiabetesUK representatives, inviting feed-back which was used to finalise thedocument. Relevant groups, such asthe Skills for Health project9 and thePaediatric Diabetes Nursing Group,were kept informed during theframework’s development. Theresult was a competency frameworkdeveloped by nurses, for nurses.

In 2009, the document wasrevised by TREND UK (Training,Research, Education for Nurses inDiabetes UK),10 which is a smallgroup of four nurse consultants indiabetes who liaise with the manydiabetes related nursing forums inthe UK. Although a comprehensivecollection of competencies forhealth care is available through theSkills for Health initiative, the orig-inal diabetes competency frame-work was well received as it was specific to diabetes nurses, and thecontent is compact and quick toread. The second edition was published in January 2010,11 with10 000 copies distributed at thenational Diabetes UK conferenceand in diabetes nursing journals. Inresponse to the dynamic nature ofdiabetes nursing, a third editionwas published earlier this year,12

with five more competency areasidentified. Publication was sup-ported by a number of pharmaceu-tical companies. It has been recog-nised by the Diabetes UK Task and Finish group for diabetes health care professional education,with the recommendation that all

disciplines of the diabetes multi dis-ciplinary team develop a similarcompetency framework.

Competence has been defined as‘the state of having the knowledge,judgment, skills, energy, experienceand motivation required to respondadequately to the demands of one’s professional responsibili-ties’.13 Simply, competencies are theskills needed to perform a job andshould be observable and measura-ble. The competency levels identi-fied in the framework relate to thecompetency levels recognised bySkills for Health (Table 1).

Twenty-two competency topicareas have been identified in theframework. Some are task specificand some are related to a group ofpeople with diabetes with specificneeds (Table 2).

All of the competencies are laidout, where possible, on a singlepage, outlining what is expectedfrom each level of staff for that topic(Table 3). Where relevant, the com-petency relates to the equivalent inthe Skills for Health document.

The futureThe competency framework forhealth care professionals workingwith people with diabetes will continue to evolve as demands ofworkload encourage service re-design to increase capacity, as moretreatments are developed, and aseconomic pressures drive econo miesof scale and innovation.

There are numerous diabetescourses available in the UK, someaccredited by higher educationinstitutes, some sponsored throughpharmaceutical companies, andsome provided by local diabetes

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• Unregistered practitioner• Competent nurse• Experienced or proficient nurse• Senior practitioner or expert nurse• Consultant nurse*

*In 2000, the consultant nurse role wasintroduced in the UK to enableexperienced nurses to advance theirclinical practice.14 These posts incorporateeducation, strategic leadership andresearch elements in diabetes nursing, aswell as a significant contribution to expertclinical practice.

Table 1. Levels of competency recognised bySkills for Health9

• Screening, prevention and early detectionof type 2 diabetes

• Promoting self-care• Mental health• Nutrition• Urine monitoring• Blood glucose monitoring• Oral therapies• Injectable therapies• Hypoglycaemia• Hyperglycaemia• Intercurrent illness

• Managing diabetes in hospital: generaladmission

• Managing diabetes in hospital: surgery• Pregnancy: pre-conception care• Pregnancy: antenatal and postnatal care• Hypertension and coronary heart disease• Neuropathy• Nephropathy• Retinopathy• Prison and young offender units• Residential and nursing homes• Palliative care and end-of-life care

Table 2. The 22 competency areas identified in the 2011 competency framework for diabetesnursing12

teams; all have variable proportionsof theory and practice based tools toinform and develop skills. Withbudget cuts in the NHS, if scarceresources are to be used on training,providers of diabetes education willneed to be very clear about the com-petencies being prepared for andhow their courses will address this.However, attending a course doesnot automatically confer compe-tency. Health care professionals providing a diabetes service willneed to develop this through sec-ondments, placements and learningon the job. Evidence of proficiencycould include case histories, self-appraisal via a reflective diary, 360-degree feedback, verification ofpractice and structured observationof practice by accredited and expe-rienced others.

Health care professionals willneed to demonstrate they are ‘fitfor purpose’!

SummaryIn the current NHS climate, it isessential that diabetes nursing is fitfor purpose and that the differentlevels of competency required forvarious levels of service are recog-nised by commissioners. The‘Integrated Career and CompetencyFramework for Diabetes Nursing’defines comprehensively what isexpected for five levels of compe-tency for 22 aspects of diabetes care,as well as providing a career pathwayfor nurses who wish to develop acareer in diabetes nursing.

Jill Hill,Diabetes Nurse Consultant,Birmingham CommunityHealthcare Trust, Diabetes teamoffice, Saltley Health Centre,Cradock Road, Birmingham B8 1RZ, UK; email: jill.hill@bhamcommunity.nhs.uk

Declaration of interests Jill Hill has received payment from anumber of pharmaceutical compa-nies related to diabetes for con-tributing to advisory boards andgiving lectures.

ReferencesReferences are available online atwww.practicaldiabetes.com.

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For the safe use of blood glucose monitoring and associated equipment you shouldbe able to:

1. Unregistered • Perform the test according to manufacturer’s instructions and practitioner local guidelines

• At the request of a registered nurse, perform the test unsupervised • Document and report the result according to local guidelines • Recognise and follow local quality assurance procedures, including

disposal of sharps • Recognise hypoglycaemia and be able to administer glucose • Understand the normal range of glycaemia and report readings

outside this range to the appropriate person

2. Competent As 1, and:nurse • Actively seek and participate in peer review of their own practice

• Interpret the results and report readings outside the acceptablerange to the appropriate person

• Teach the test procedure to a person with diabetes or their carer• Identify situations where testing for ketones is appropriate

3. Experienced or As 2, and:proficient nurse • Interpret results and assess other parameters and take appropriate

action, including initiating further tests such as HbA1c orurine/blood ketones

• Teach people with diabetes or their carer to interpret test resultsand take appropriate action

4. Senior As 3, and: practitioner • Use results to optimise treatment interventions according to or expert nurse evidence-based practice, while incorporating the preferences

of the person with diabetes • Initiate further tests such as HbA1c or random blood glucose • Initiate continuous blood glucose monitoring and interpret the results • Develop specific guidelines for use in different situations • If a registered non-medical prescriber, prescribe medications, as

required, within own competencies and scope of practice • Assess the competencies of other health care professionals

5. Consultant As 4, and:nurse • Identify service shortfalls and develop strategies with the local

commissioning bodies to address them• Initiate and lead research through leadership and consultancy• Work with stakeholders to develop and implement local guidelines

for blood glucose monitoring frequency, promoting evidence-basedpractice and cost-effectiveness

• Work in collaboration with higher educational institutes, and othereducation providers to meet educational needs of other healthcare professionals

• Influence national policy concerning availability and appropriateuse of blood glucose monitoring

• Identify and implement systems to promote their contribution anddemonstrate the impact of advanced level nursing to the healthcare team and the wider health and social care sector

• Identify the need for change, proactively generate practiceinnovations and lead new practice and service redesign solutionsto better meet the needs of patients and the service

This competency links with the Skills for Health (2009) competencies HA8 and HA9.

Table 3. Competency statement relating to blood glucose monitoring: one of the 22 statementsprovided in the competency framework for diabetes nursing.12 (Available at www.trend-uk.org)

5.4. BLOOD GLUCOSE MONITORING

References1. Department of Health. Our health, our care, our say:

a new direction for community services. London:Stationery Office, 2006.

2. Castledine G. The role of the diabetes specialistnurse: Nursing Forum presentation. In Royal Collegeof Nursing Forum Presentation and DiabetesSpecialist Nursing Working Party Report. DiabetesSpecialist Nursing Working Party (eds). London:Royal College of Nursing, 1991.

3. European Working Time Directive. www.healthcareworkforce.nhs.uk/workingtimedirective/ [accessed27 June 2011].

4. James J, et al. Diabetes specialist nurses and roleevolvement: a survey by Diabetes UK and ABCD ofspecialist diabetes services 2007. Diabet Med2009;26:560–5.

5. Department of Health. Agenda for Change:Modernising the NHS Pay System. London:Department of Health, 1999.

6. Department of Health. The NHS Knowledge andSkills Framework (NHS KSF) and the DevelopmentProcess. London: Department of Health, 2004.

7. Skills for Health. Introduction to WorkforcePlanning. 2009. www.healthcareworkforce.nhs.uk/resources/latest_resources/introduction_to_workforce_planning.html [accessed 27 June2011].

8. Diabetes Nursing Strategy Group. An IntegratedCareer and Competency Framework for DiabetesNursing. London: SB Communications Group,2005.

9. Skills for Health. www.skillsforhealth.org.uk[accessed 27 June 2011].

10. TREND UK (Training, Research, Education for Nurses in Diabetes UK). Website: www.trend-uk.org.

11. TREND UK. An Integrated Career and CompetencyFramework for Diabetes Nursing, 2nd edn. London:SB Communications Group, 2010.

12. TREND UK. An Integrated Career and CompetencyFramework for Diabetes Nursing, 3rd edn. London:SB Communications Group, 2011. Available at:www.trend-uk.org.

13. Roach MS. The Human Act of Caring: A Blueprint forthe Health Professions, 2nd edn. Ottawa: CanadianHospital Association Press, 1992.

14. Department of Health. Nurse Consultants HealthService Circular (HSC 1998/161). London: DoH,1998. Available at: tinyurl.com/yfrgd8p [accessed27 June 2011].

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