Title: Delegation of insulin administration to non-registered healthcare workers in community nursing teams: an evaluation of care and practice for older people with diabetes.
Funder: Dunhill Medical Trust

Abstract: The complexity and demand on community nursing workload is increasing as people live longer with multiple health conditions (DH 2012, Spilsbury et. al. 2013, Maybin et. al. 2016). Qualified nurses have responsibility for administering insulin to an estimated 10,800 people with diabetes who cannot do this themselves, and over 50% require multiple injections per day (Livingstone 2013). With diabetes increasing faster than predicted (Diabetes UK 2016a, Zimmett 2017) and significant community nurse staff shortages (Jackson et. al. 2016) this represents a considerable challenge for community nursing services. Extending healthcare assistant (HCA) roles is recommended as a solution to meeting demand (Imison 2016). Delegation of insulin administration (IA) to HCAs is acknowledged by guidance issued by Diabetes UK (2016b), although the extent of this practice is unknown. Small-scale pilots report mixed findings (Owen 2009, Cook 2015, Dutton et. al. 2018,). However, no independent evaluation has been conducted. Research is needed to ensure that IA delegation develops in a way that is acceptable, safe and beneficial to older people (NPSA 2010, Milligan 2011, Forbes et. al. 2018). This 18-month study aims to evaluate delegation of insulin administration (IA) to non-registered healthcare workers caring for older people with diabetes in community nursing services in England and inform the feasibility of a future national study. The study objectives are to: 1. Explore (i) the views and experiences of older people and carers receiving insulin injections (ii) other key stakeholders (including registered nurses and HCAs) and (iii) identify any benefits or risks relating to IA delegation 2. Collect data to inform sampling and questionnaire development for a future national study of the prevalence and safety of IA delegation 3. Explore the feasibility of document analysis to assess organisational procedures for IA delegation (including training and governance arrangements) against national guidance and patient safety regulations (Diabetes UK 2016b, NPSA 2010). 4. Assess the feasibility of collecting health economic data related to IA delegation to inform a future economic analysis A case-study design (Yin 1994, Bergen and While 2000, Stenner et. al. 2010) will explore IA delegation in three adult community nursing teams across England. Semi-structured interviews (n= 54) will take place with key stakeholders at each site (objectives 1-2,4). Organisational policy documents and data related to insulin delegation will be analysed (Objectives 3-4). Findings will be disseminated to NHS organisations, patient groups, clinicians and academics and will inform the development of a larger scale national evaluation.

Lay abstract: There are a growing number of older people with diabetes who require care support from community nursing teams in order to remain at home. Often these older people are experiencing other conditions alongside diabetes, such as memory loss or arthritis, which means that they cannot give themselves insulin injections. Insulin is a medicine needed to control blood glucose (sugar) levels in order to prevent worsening health. As insulin carries a high risk of causing harm if it is not used properly, it is important that healthcare staff are trained and competent to give it. In some community nursing teams, local procedures allow registered nurses (District Nurses) to hand-over (delegate) this job to non-registered healthcare workers (Healthcare assistants) who need additional training and supervision in order to give insulin injections. Delegating the administration (giving) of insulin is thought to help District Nurses provide an efficient service, as insulin normally has to be given at least once/twice daily, requiring multiple visits. This is important because there are growing numbers of older people needing care at home and a shortage of nurses to provide care. It is also thought to help patients, as insulin administration can be timed close to meals. While two pilot schemes have been reported, it is not known how widespread insulin delegation is in the UK and there has been no independent evaluation to guide its development or assess safety. This research project will evaluate the delegation of insulin administration in three sites across England. By talking to patients and/or carers in these sites we will develop a better understanding of what older people think are the important issues and identify any benefits or concerns they have. We will also talk to healthcare assistants, nurses and diabetes specialists and other stakeholders to gain a broad understanding of this practice, identify what works well and if there are any aspects that need to be improved. National guidance has been written to support organisations to develop local programmes to train and support health-care assistants to give insulin to patients. We will explore how this guidance might help to assess NHS planning and regulation for the safety of insulin delegation. The project will take 18 months to complete and findings will be used to develop a larger scale national project to evaluate the safety and efficiency of this practice and inform future national guidance.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE;METABOLIC AND ENDOCRINE