Delegation of insulin administration to non-registered healthcare workers in community nursing teams: an evaluation of care and practice for older people with diabetes
The complexity and demand on community nursing workload is increasing as people live longer with multiple health conditions. A growing number of older people with diabetes have other conditions, such as memory loss or arthritis, which prevents themselves from administering their own insulin injections. Therefore, qualified registered nurses have responsibility for administering insulin to an estimated 10,800 people with diabetes who cannot do this themselves. With diabetes increasing faster than predicted and significant community nurse staff shortages, this represents a considerable challenge for community nursing services.
In some community nursing teams, registered nurses delegate insulin administration to non-registered healthcare workers, such as healthcare assistants, who are trained to administer insulin injections. With a national shortage of nurses, delegating insulin injections to healthcare assistants may improve service efficiency and may also benefit patients. Furthermore, extending the role of non-registered healthcare worker roles is recommended as a solution to meeting demand. However, insulin carries a risk of injury/death if misused, therefore delegation of this task requires sound governance. Organisations are developing insulin administration delegation programmes to meet service demand, although the extent of this practice is limited, and no independent evaluation has been conducted on this practice.
Research is needed to ensure that delegation of insulin administration develops and is evaluated in a way that is acceptable, safe and beneficial to older people. It is important to understand what patients think are the important issues and identify any benefits or concerns amongst staff or patients. Furthermore, it is important to gain perspectives on what works well and identify any aspects that need to be improved.
Aims and objectives
1. What are the benefits and disadvantages, if any, for patients, staff and services when non-registered healthcare workers give insulin injections to older people with diabetes?
2. What are the most feasible types and methods of data collection that will enable a large scale, national evaluation of healthcare practice relating to insulin administration delegation practice to be conducted in the future?
The study objectives
1. Explore (i) the views and experiences of older people and/or carers receiving insulin injections (ii) other key stakeholders (including, managers, registered nurses and non-registered healthcare workers) and (iii) identify any benefits or risks relating to insulin administration delegation.
2. Collect mixed method data to inform the development for a future national evaluation study, with specific focus on sampling and questionnaire data needed to explore the prevalence and safety of insulin administration delegation.
3. Explore the feasibility of document analysis to assess organisational procedures for insulin administration delegation (including training and governance arrangements) against national guidance and patient safety regulations.
4. Assess the feasibility of collecting health economic data related to insulin administration delegation to inform a future economic analysis.
Karen is a lecturer in the School of Health Sciences with extensive experience in health services research. Her research interests include the evaluation of extended roles in medicines optimisation and non-medical prescribing. She has published widely on the impact and implementation of prescribing by nurses and other healthcare professionals, with a focus on long-term conditions. Current interests include the expansion of prescribing rights to allied health professions and the impact of delegation of medicines administration to non-registered healthcare workers. She is experienced in multi-site studies and mixed method approaches. She is a member of the University of Surrey ethics Committee.
Jill is a nurse and social scientist and her research focuses on supporting staff to care well for patients. Jill qualified as a Registered nurse at Addenbrookes in Cambridge and studied History at UCL, before undertaking her Masters in Nursing at King's College London and completing her PhD at the University of Southampton. She completed her PGCE at the London School of Hygiene and Tropical Medicine in 2007. Jill was deputy Director (2007-2010) and Director (2011-2014) of the Policy Research Programme's National Nursing Research Unit at King's College London.
Jill was awarded an OBE in June 2014 for services to nursing and healthcare. In 2013 she was in the Health Services Journal ‘Top 100 leaders’ and was also included on Health Service Journal’s inaugural list of Most Inspirational Women in Healthcare the same year.
Jill is passionate about creating positive practice environments for NHS staff and supporting staff in the work they do caring for patients and her programme of research has highlighted the links between staff experiences of work and patient experiences of care- https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/081819213/#/ This was one of the first studies to demonstrate relationships between staff wellbeing and patient experience at the team and individual level demonstrating that staff wellbeing is an important antecedent of patient care performance.
Jill's doctoral work examined what supported and what prevented newly qualified nurses implementing their ideals and values in practice, highlighting how ideals and values of new nursing students can become compromised and crushed in poor work environments. She also recently completed the first national evaluation of Schwartz Centre Rounds in the UK: “A Longitudinal National Evaluation of Schwartz Centre Rounds®: an intervention to enhance compassion in relationships between staff and patients through providing support for staff and promoting their wellbeing” [https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/130749/#/] she has developed a short film from this work: Understanding Schwartz Rounds: Findings from a National Evaluation https://www.youtube.com/watch?v=C34ygCIdjCo
Other recent studies include an evaluation of patient and staff experiences and safety outcomes of a move to 100% single hospital bedrooms. [https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/10101342/#/] and interventions to support healthcare staff including Schwartz Center Rounds and to improve relational care for older people in hospital [https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/1212910/#/] The single room evaluation work is now being replicated in Australia; Holland and Denmark.
Current studies include the Impact of Covid on Nurses (ICON) (Burdett Trust; Florence Nightingale Foundation and the Colt Trust) and NIHR studies:
Care Under Pressure 2: Caring for the Carers a realist review of interventions to minimise the incidence of mental ill-health in nurses, midwives and paramedics: www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR129528/#/ and
Strategies to address unprofessional behaviours among staff in acute healthcare settings: a realist review: www.journalslibrary.nihr.ac.uk/programmes/hsdr/NIHR131606/#/
I received my PhD from the University of Surrey in 2001 and worked as a post-doctoral researcher at King's College London for 9 years, initially in Public Health Sciences and then in the Florence Nightingale School of Nursing and Midwifery.
Since leaving Kings' I worked for NHS Evidence (previously part of the National Institute for Health and Care Excellence) conducting rapid online reviews.
I joined The University of Surrey again in 2010, working as a Research Fellow in the Department of Health Care Management and Policy. At this time I undertook a large scale systematic review investigating patients access to their electronic medical records and online services in primary care.
Over the years I have been fortunate enough to work on various mixed methods research projects, focusing on long-term conditions and access to services. Studies included the investigation of factors impacting on patients' access and uptake of after stroke services in London, the care of ethnic elders in care homes, and early interventions for frail older people.
Since moving to Health Sciences I have continued to follow my research interest in access to services for specific patient groups in relation to primary/ community care delivery.
Colin is a Research Fellow within the School of Health Sciences. He is based in the Long-Term Conditions and Ageing Research Cluster. The vision of this group focuses upon dementia care, frailty and multi-morbidity in older people, non-medical prescribing, self-management of long-term conditions, workforce preparation and models of care. Colin is an Early Career Researcher who's current work focuses on the impact of delegation of medicines administration to non-registered healthcare workers.
His research interest are wide reaching and include the use of physical activity and exercise in healthcare and self-management of long-term conditions. Colin completed his BSc (Hons) in Sports Therapy from London Metropolitan University, an MSc in Clinical Exercise Science at the University of Portsmouth and completed his PhD at the University of Stirling focusing on exercise referral schemes and their use in combating non-communicable disease. Colin has provided sports therapy support to semi-professional and professional football teams and worked within the NHS as a paediatric respiratory therapist.
Dr Kirsty Winkley
King's College London & Florence Nightingale Faculty of Nursing & Midwifery.
Head of Nursing and Quality - Shropshire Community Health NHS Trust
Resources for community nursing services and those with an interest in insulin delegation
The CINDI Project 10 TIPS on Starting Insulin Delegation
The 10 tips on starting insulin delegation is a resource that has been created to inform the future development of insulin delegation by healthcare organisations.
How the tips sheet was developed
The 10 tips were derived from experiences and research evidence on delegation from the following sources:
- Review of the literature on delegation of medicines administration from nurses to healthcare support workers in community settings. The paper is freely available: Delegation of medication administration from registered nurses to non-registered support workers in community care settings: A systematic review with critical interpretive synthesis.
- Findings from the CINDI project.
- Webinars featuring exemplar sites with experience of setting up an insulin delegation programme (Delegation of Insulin Administration Webinars | Diabetes UK).
The above sources were analysed, and a list of common practices were identified, along with strategies that organisations found helpful in supporting implementation of insulin delegation. The list was then consolidated following feedback from the CINDI project research team to form a draft tips sheet. This was then sent for validation and feedback from a range of informants, including: patient representatives, healthcare support worker representative, diabetes specialist nurses, delegation specialist, service managers, head of community nursing and a quality and improvement implementation specialist.
How to access the tips sheet
The CINDI Project 10 TIPS on Starting Insulin Delegation is free to use but we ask you to have regard to the following conditions on its use:
- Do not distribute this to anyone else – if anyone asks for a copy please ask them fill in the 10 tips on starting insulin delegation resources questionnaire (via the download link below).
- If you use the guidance, or any part of it, we would be grateful if you would please:
- Acknowledge the authorship team.
- Send copies of any reports/papers that are produced to Dr Karen Stenner (firstname.lastname@example.org).
- Let us have any comments/suggestions that you feel might improve these resources so that your experience can be incorporated into subsequent updates.
Research groups and centres
Our research is supported by research groups and centres of excellence.