The COVID-19 pandemic has further emphasized the need for specialty nurses who understand how to care for patients with chronic diseases. The demand for these caregivers is only going to intensify in coming years as healthcare delivery evolves and becomes even more complex.
It has now been a century since the discovery of insulin, a groundbreaking and world-changing event that spared millions from a death sentence. Not exactly revelatory, but it’s a fact worth pointing out for two reasons: a lot of great work has been done since, and much more work needs to be done. Diabetes rates continue to wax, while the number of endocrinologists continues to wane.
Here in 2021, the medical field is more complex than ever, as gaps in healthcare become even wider due to the ongoing COVID-19 pandemic, which acutely affects those with chronic conditions like diabetes, leaving many in the endocrinology field struggling to juggle research with treating patients. This is a true “Avengers Assemble” moment, as endocrinology teams diversify and endocrine nurses find themselves not just working shoulder to shoulder with physicians, but their patients as well.
“Diabetes nurses are often perceived solely as patient educators,” says Kerri Doucette, RN, RDN, CDCES, diabetes nurse specialist at Glytec in Charlotte, N.C. “This role has changed drastically. Today, diabetes nurses directly impact patient care by participating in process improvements, assisting with glycemic management support, and providing education.”
Diabetes has a very high rate of comorbid depression and distress and it can be difficult or even impossible for patients to achieve their goals if their diabetes is compounded by mental health or socioeconomic concerns, according to Kathryn Evans Kreider, DNP, FNP, BC-ADM, FAANP, associate professor at Duke University School of Nursing and nurse practitioner at Duke University Medical Center, Durham, N.C. “Endocrine nurses care for patients over the long haul so we don’t typically have the opportunity to ‘patch them up and send them along’ — we are on the journey with them long term, often seeing them every three months to try to gradually improve or maintain their health and wellness. This presents lots of challenges.”
“Diabetes nurses are often perceived solely as patient educators. This role has changed drastically. Today, diabetes nurses directly impact patient care by participating in process improvements, assisting with glycemic management support, and providing education.” – Kerri Doucette, RN, RDN, CDCES, diabetes nurse specialist, Glytec, Charlotte, N.C.
Indeed, adding to these challenges is the COVID-19 pandemic. Patients with diabetes and coronavirus have elevated blood glucose levels that contribute to their critical status and intensive care units are almost at their breaking points, which makes the need for endocrine nurses even more dire. “Diabetes nurses are specialists that can serve as expert consultants in this area,” Doucette says. “My team collaborated with the Tele-ICU to provide glycemic surveillance workflows for ICUs, using glycemic alerts for timely responses and recommendations.”
Melanie Duran, BSN, RN, CDCES, an inpatient diabetes care and education specialist at University of New Mexico Hospitals, Albuquerque, tells Endocrine News the novel coronavirus presented her with an opportunity to offer support and help address the many challenges of managing insulin in patients with COVID-19. She says that there is a debate on using IV insulin, in room versus out of room (length of tubing and absorption), using SubQ to decrease trips in the room whenever possible, and balancing increased insulin requirements with tube feedings and critical care management. “One of the things we have been particularly challenged with is the combination of factors that increase insulin requirements, including steroids, tube feed, and acuity of illness,” Duran says.
And again, Kreider points to the fact that COVID-19 has forced a lot of patients inside, which has increased rates of depression and anxiety, on top of other unhealthy behaviors such as overeating and lack of motivation to exercise.
Roadblocks and Detours
On a given clinic day, Kreider sees about three or four patients an hour. She says that 70% of her patients are seen for diabetes, while the other 30% are there for general endocrine conditions. “We have an excellent team of physicians, advanced practice providers, nurses, and staff that make our clinic run smoothly,” she says. “High points during the day are when patients are doing really well and meeting their health goals. Low points are when we continue to meet roadblocks with progress or when patients are suffering from significant health issues or socioeconomic factors that are difficult to overcome.”
“Endocrine nurses care for patients over the long haul so we don’t typically have the opportunity to ‘patch them up and send them along’ — we are on the journey with them long term, often seeing them every three months to try to gradually improve or maintain their health and wellness. This presents lots of challenges.” – Kathryn Evans Kreider, DNP, FNP, BC-ADM, FAANP, associate professor, Duke University School of Nursing; nurse practitioner, Duke University Medical Center, Durham, N.C.
In fact, everyone agrees that when those low points do happen, it’s important to recognize that the patients with poorly controlled diabetes may have extenuating circumstances that steer them into these roadblocks and prevent them from meeting their goals. “The [low points] come when patients have limited resources or are readmitted repeatedly, not because they lack knowledge on how to manage their disease, but rather lack resources or programs that meet their unique needs,” Doucette says.
So, when a patient’s progress is impeded, endocrine nurses are able to carve out a detour. “Patients with diabetes often feel such a sense of self-blame,” Duran says. “My biggest goal is to help them recognize that we all can make changes, whether medication-related, lifestyle-related, or both, to help them achieve their goals. I also love it when I can identify patients who may benefit from additional medication options or technology tools like CGMs. Diabetes has moved beyond just insulin, but many patients aren’t aware of this.”
Duran says that in her experience, patients with unique insulin requirements are often scary to nursing staff, and she tries to educate not just the patients on their conditions, but the entire care team as well. “A bedside nurse has multiple patients, and their focus is on ensuring safety, making sure medications and care are safely administered, progressing healing, and promoting healthy coping,” she says. “My job is to partner with those nurses and spend the time they may not have to focus on diabetes and enlist their help for ongoing understanding. I may not be administering medications or performing procedures. Still, my role allows the primary nurse to focus on the aspects they need to perform without feeling like they are not giving their patient the education they need. I also work with the medical provider team to give them key insights on the patient so they can order the appropriate follow-up care and medications consistent with the patients’ situation.”
“Diabetes is complex and can intersect with every health condition,” Doucette says. “Diabetes beyond the basics is needed. Specialty, research, and quality improvement classes could use case studies that include patients with diabetes.”
In 2017, Kreider presented at ENDO in Orlando about the Duke University School of Nursing’s implementation of the first-ever endocrinology specialty training program for nurse practitioners in the country — the first to train nurse practitioners in general endocrine and advanced diabetes management. Kreider’s presentation pointed to a 2014 report from the Endocrine Society, which discussed the ever-increasing need for endocrinology services as diabetes cases rise and the population grows older.
“My biggest goal is to help them recognize that we all can make changes, whether medication-related, lifestyle-related, or both, to help them achieve their goals. I also love it when I can identify patients who may benefit from additional medication options or technology tools like CGMs. Diabetes has moved beyond just insulin, but many patients aren’t aware of this.” – Melanie Duran, BSN, RN, CDCES, inpatient diabetes care and education specialist, University of New Mexico Hospitals, Albuquerque, N.M.
“A promising solution to address this gap is to increase the capacity of primary care [nurse practitioners] to deliver specialty care,” Kreider and her team write. “The appeal for this approach is further supported in the Endocrine Society report, as the authors note that 76% of endocrinology private practices and 56% of academic practices were actively searching for nurse practitioners and other advanced practice providers to join their groups.”
Duke’s program started in 2016 and has since graduated 55 students. These nurses practice all over the country, many of them in rural or underserved areas where there is poor access to specialty care. “The training program is designed to increase competency in practice in endocrinology and to be more effective in managing the more common endocrine disorders including type 1 and type 2 diabetes, thyroid disease, hyperlipidemia, obesity, and other diagnoses seen in general endocrine practices,” Kreider says. “These topics are only covered from a primary care perspective in graduate nursing education so students are hungry for more in-depth knowledge.”
Kreider credits the physicians in her institution who have been instrumental in providing both didactic and clinical training for these nurse practitioners. “It has been an extremely collaborative effort that has been well-received and supported,” she says. “Given the current conflicts with scope of practice among MDs and advanced practice providers, it is essential to also highlight the benefits of us working together to optimize patient care. As nurse practitioners we know that the physicians are absolutely critical in providing care to the most complex patients.”
For Duran, all nursing students have the potential to be specialists in their respective fields, to identify others who show interest and encourage them to consider specialty roles. She says that she never misses an opportunity to work with nursing students, whether it’s through educational sessions or class lectures. “The number one thing nursing schools can do is bring in specialists from the community to talk to these students. Not only to give them additional tools to work with their patients and understand more about the disease, but also to spark the idea that they too may want to pursue these roles.
“I believe promoting the workforce falls by far more on the employers than the nursing schools,” she continues. “Identifying opportunities for these specialty roles will bring the nurses; it’s up to the workforce to understand the value of promoting long-term care and decreasing complications.”
Doucette agrees: “Healthcare systems do not fully recognize the value of acute care diabetes nurses. Acute care diabetes nurses are not just diabetes educators. They provide unique expertise that can improve cost-saving, quality, and safety outcomes for patients. I encourage healthcare leaders to invest in this role to improve safety and quality.”
“The partnership between physicians and nurses has never been more important than it is now. We need each other to provide effective and timely patient care. Endocrine nurses and nurse practitioners are an essential part of an effective interdisciplinary endocrine team. We have seen some of the best outcomes for patients who see both an MD and a nurse practitioner.” – Kathryn Evans Kreider, DNP, FNP, BC-ADM, FAANP, associate professor, Duke University School of Nursing; nurse practitioner, Duke University Medical Center, Durham, N.C.
Still, there’s a change on the wind. Duke’s program has paved the way for interdisciplinary care delivery that plays to everyone’s strengths. “The partnership between physicians and nurses has never been more important than it is now,” Kreider says. “We need each other to provide effective and timely patient care. Endocrine nurses and nurse practitioners are an essential part of an effective interdisciplinary endocrine team. We have seen some of the best outcomes for patients who see both an MD and a nurse practitioner.”
— Bagley is the senior editor of Endocrine News. In the January issue, he wrote about how a mouse study could unlock some of the mysteries behind curing obesity.