Published August 2023
It’s best practice for people with diabetes to look after their health by injecting their own insulin. As people get older, however, they are likely to have other conditions that make this harder or unsafe to do. Dr Karen Stenner, from the University of Surrey and Principal Investigator of the CINDI Project, set out to evaluate the emerging practice of registered nurses delegating insulin injections to Healthcare Support Workers in community nursing teams. Could this alleviate workload pressures and bring benefits to patients and nursing teams alike?
It couldn’t have been more timely to do this researchDr Karen Stenner
Many people living with diabetes need regular injections of insulin to control their blood sugar levels.
When older people with type II diabetes living in the community need help with their insulin injections, and don’t have family or friends to help them, their insulin management becomes the responsibility of community nursing teams.
Around 10,000 people with diabetes in England rely on registered nurses to administer their insulin. Community nursing teams are often small so this can lead to a heavy workload at peak times, especially in the morning. Insulin is a high risk medication, so non-registered Healthcare Support Workers (HCSWs) in the team cannot give these injections unless it’s under delegation from a registered nurse.
Over the last 10 years, a number of NHS Trusts have put in place insulin delegation programmes so they can safely pass insulin management on to HCSWs in their community nursing teams. The programmes involve setting up safety regulations and training HCSWs, often buddying them with a registered nurse until they’re confident and competent enough to be able to give insulin injections to patients by themselves.
Evaluating insulin management delegation
Despite being around for some time, no independent research has been done to explore the safety and effectiveness of these programmes. With more and more Trusts wanting to set up programmes of their own, we set out to evaluate this growing practice.
We took an in-depth look at three community nursing services in England who had programmes already in place. At each site we interviewed patients, nurses delegating the injections, HCSWs, managers responsible for setting up the programmes, as well as other diabetes specialists, to understand their views and experience of delegating insulin injections.
We also asked the sites to share with us how they set up their programmes, including any regulations, training regimes and resources, to uncover the key ingredients for setting up delegation safely and successfully.
Creating benefits for patients and community health services
Our evaluation showed that not only was delegation working well at each site, there were lots of reported benefits by all those involved.
For community nursing teams, the programmes helped to streamline services, alleviate workload pressures, and improve team communication. Patients told us they got their injections in a timely way and it enhanced their relationships with community teams. And there was a lot of pride among teams who set up delegation programmes because of the amount of effort needed to do it well and safely.
We also captured the benefits for HCSWs, who were really enthusiastic about taking on this extra responsibility and reported more job satisfaction. One HCSW we spoke to shared that they were inspired and felt confident enough to apply to train to become a registered nurse after learning to administer insulin safely.
It will create a clearer national picture of the appetite for and uptake of delegating insulin injections in community care
We also heard a lot about the challenges of running insulin management delegation programmes. Patient safety is paramount, and the governance and safety mechanisms put in place were critical for acceptance from nursing teams and patients alike. For example, HCSWs must have daily debriefs with a registered nurse, and patients would continue to be seen by registered nurses as well as the HCSWs providing their insulin injections.
Beyond clinical safety, other concerns raised were the potential for missed care, fair pay for HCSWs and task shifting among nursing teams. Future practice of delegating insulin injections should take these into account.
Contributing to a national framework for insulin management delegation
The DMT gave us flexibility to adapt so we could be part of something unplanned, but bigger than the project
It couldn’t have been more timely to do this research, as community health services were reliant on the contribution of HCSWs providing insulin injections during the COVID-19 pandemic. When done safely, strategies like delegation are essential for the future, helping community nursing services to keep up with rising demand.
During the project, it was really exciting to be invited to join the national insulin administration programme led by Sam Sherrington, Lead Community Nurse for NHS England. This was set up to develop a voluntary framework for implementing delegation programmes as well as national resources.
Alongside input from specialists and patient representatives, the research team developed a tip sheet sharing ways to overcome common challenges. The tips collated evidence from our research and feedback from multiple exemplar sites, and sit within the suite of guidance for health and social care organisations considering putting insulin injection delegation into practice.
NHS England has commissioned the University of Surrey to run a national survey of community nursing services. It will create a clearer national picture of the appetite for and uptake of delegating insulin injections in community care, measuring awareness of the new guidance and whether it’s being used.
The DMT is an incredibly supportive funder and gave us flexibility to change and adapt our plan so we could be part of something unplanned, but bigger than the project – working with Sam Sherrington and NHS England. They have a very friendly approach to grant management with someone always there to talk to.
Find out more
Read more about the project and team.
The findings from our study have now been published in the Journal of Advanced Nursing.