My nursing career began on the wards in an acute unit at the Homerton University Hospital, London, in 2015, while I completed the registration and probationary requirements. My interest then turned to specialisation in diabetes, and by 2018 I was working as a specialist diabetes nurse for Barts Health NHS Trust, at Newham Hospital in London, where I still work today.
The position of antenatal specialist diabetes nurse at Newham Hospital had just been created by Barts Health NHS Trust for treatment of diabetes to begin at the pre-pregnancy stage with women who were living with type 2 diabetes, continuing through each stage of pregnancy, right through to postnatal care.
The importance of matching all the discrete stages of treatment to the London borough of Newham demographic, however, could not be underestimated – as the following data suggest. According to the 2021 Census, the ethnicity spread of the residents in the area was as follows (Office for National Statistics, 2022):
- Asian: 148 187 (42.2%)
- White: 107 947 (30.8%)
- Black: 61 302 (17.5%)
- Other: 17 175 (4.9%)
- Mixed: 16 419 (4.7%).
People from South Asian, Black African, African Caribbean and Chinese backgrounds are at a higher risk of developing type 2 diabetes from a younger age (Pham et al, 2019; Diabetes UK, 2023). The borough of Newham is diverse and deprived, with around 10% of non-English speaking residents (Newham Borough, 2020). The borough has one of the highest rates of type 2 diabetes in pregnancy in England. This poses great challenges to any NHS Trust and health professional from the offset.
The way my own specialism has developed, therefore, has led to a practice methodology that in London, at least, is unique. In fact, in most NHS trusts in the UK there is no dedicated type 2 diabetes specialist nurse to care for women with diabetes throughout the peripartum period. And given that National Institute for Health and Care Excellence (2020) guideline states that health professionals should encourage women of childbearing age to attain an HbA1c level of less than 48 mmol/mol, to reduce the risk of miscarriage, congenital malformation, neural tube defects, macrosomia/intrauterine-growth restriction (IUGR), intrauterine fetal death and stillbirth, the consequences of complications arising from poorly managed diabetes are stark.
Supporting women and colleagues
The duration of my relationships with many women – where diabetes is the cause of conceptual complications – can sometimes extend to a period of diabetes management that lasts up to 2 years or more. So in such instances, when the postnatal period is reached, it is a truly triumphant moment of joy, not only for the mothers, but for me too.
I also provide diabetes training to junior doctors and midwives, as well as to colleagues in obstetrics, because not all will be familiar with the more specialised aspects of diabetes treatment. In addition, I work with patients separately to help them develop their own individualised support packages, as well as to establish a high level of trust. When this is successful, it quickly translates into their improved capacity for retaining information and consequently to more effective self-management.
This policy of providing education also makes women more aware of not only how diabetes can affect them and their unborn babies, but also how it might affect their children later on in life. So, from the outset, my work is not simply about the treatment of a medical condition, it is also about long-term ill health prevention. It is about treatment and education.
Clinics, ward rounds and telephone calls
I hold two clinics every working week for pre-pregnancy counselling, twice weekly diabetes antenatal clinics and once monthly postnatal follow-up clinics.
I also follow up very closely on all women through a system of a weekly telephone call – and some with more than one call. I also provide my work mobile number so that patients can reach me between 8am and 4pm Mondays to Fridays, except bank holidays.
I make daily ward rounds to monitor women admitted for delivery, as seeing a familiar face usually eases the additional stress they might be experiencing on top of the usual anxieties over such issues as induction of labour, elective C-sections, or just giving birth itself. It is also part of my role to support midwives on the management of women with diabetes when they are admitted for delivery. I always take this as an opportunity to share diabetes knowledge with my colleagues on the maternity wards. Empathy and psychology are invaluable tools in my work.
Pre-pregnancy care
For my pre-pregnancy clinic, I ensure that women are not on pregnancy contra-indicated medication, because it is important to emphasise which diabetes medications are not safe in pregnancy. I usually make a recommendation to their GP to prescribe 5 mg folic acid, check that they are up to date with their retinal screening, and go through their lifestyle preferences. At the same time, I try to reinforce their understanding of their diabetes medication management. Their improved understanding of the impact of diet and exercise will also contribute significantly to their ability to gain better control of their diabetes, and also to maintain a healthy weight which, of course, can only help with conception. So the encouragement of physical health is as important as mental health.
Women in my pre-pregnancy clinic are also encouraged to understand the importance of attaining a good HbA1c level before conception.
Once the women have gained confidence, and are doing all they can to see a less risky pregnancy through to term, this tends to be reflected in the positive way in which they then become more engaged with me and the diabetes specialist doctor. This is a good sign because it is crucial for them to understand that the knowledge and information provided during pre-pregnancy consultations is also relevant throughout their pregnancy, as well as afterwards, because it will benefit their lifelong health.
It is not always a straightforward process to create in patients a high level of awareness and understanding of the importance of making immediate changes to certain behaviours. A lot of the women that I look after at Newham Hospital are isolated and vulnerable. Many are new to the UK and will not necessarily have yet developed a social network; some will not necessarily be allowed to. Others have experienced years of failed attempts to conceive, or pregnancy loss, or other serious complications. Often my role involves trying to help with other needs the woman might have at the initial consultation, where it is vital to establish trust and confidence.
Antenatal clinic
The diabetes antenatal clinic is a continuum for the women from my pre-pregnancy clinic, but will be a new experience for pregnant women who are just joining. Women who do not attend pre-pregnancy counselling are usually less prepared and, being more exposed to health complications, are more likely to suffer miscarriages early on in their pregnancies as a result.
The group of women with diabetes who are pregnant far outnumber the ones in the pre-pregnancy clinic, by a factor of three to one. This is concerning, considering the percentage of women living with diabetes who are unprepared for pregnancy (NHS Digital, 2021). So I closely support and monitor this group of women, ensuring that they manage their blood-glucose levels to near-normal levels to lower the risk of threats that diabetes poses to mother and fetus.
In this group, I use two different online platforms to review the women's blood-glucose management. Both platforms give me access to their blood-glucose results, as and when the women check these at home. Both platforms are linked to an app on their smartphones that allows me to see real-time results when I log on to the system. The platforms also highlight higher readings, which then enable me to prioritise contact feedback in my system of follow-up telephone calls. I review all readings posted on a daily basis. All women are different and so each one's case will vary quantitatively, as well as qualitatively. This demonstrates the importance of providing specialised individual care and treatment in this ethnically diverse and deprived part of London.
The specialised nature of my work as a diabetes nurse might be seen to be straightforward - treating patients with diabetes from a medical, as well as an educational, standpoint. In practice, however, my work is rarely solely about managing diabetes before and during pregnancy. These women are also in a high-risk category, often enduring other health and social challenges and frequently in need of other help or advice on other aspects of their lives. Consultation times can also be variable, ranging from 15 to 60 minutes on any one occasion.
Achievements
I often find myself dealing with unexpected issues with women with diabetes at all stages – from pre-pregnancy to after childbirth. However, I am pleased to say that the National Pregnancy in Diabetes Audit Report in October 2021 (NHS Digital, 2021) showed that providing pre-pregnancy-led care has led to women conceiving with good glycaemic control. Forty per cent of women had good glycaemic control pre-pregnancy in Newham Hospital, whereas the overall figure for England and Wales was 20%.
I was delighted to win a Gold Award in the Diabetes Nurse of the Year category of the BJN Awards 2023.