Diabetes is prevalent in people with chronic kidney disease and is the leading cause of blindness, end-stage renal disease (ERSD), and non-traumatic lower limb amputation in Canada (1). People with diabetes, compared to the general population, are more likely to be hospitalized for multiple medical conditions (1). In our Kidney Care Clinic (KCC) at the Sunnybrook Health Sciences Centre, a chart review showed that 48% of our patients with chronic kidney disease also had diabetes and 43% of these patients had an A1c (glycated hemoglobin) >7% (2). Increased support for diabetes care for our patients with both chronic kidney disease and diabetes is therefore required to further reduce their risks for dialysis and complications of diabetes as well as to prevent unnecessary hospitalizations and emergency room (ER) visits. In this report, I will summarize my fellowship experience and outline my future plan for sustainability of learning and outcomes.

1. Rationale

Diabetes is a complex and complicated chronic disease. In my clinical practice, I can clearly see how diabetes imposes significant burdens on the individual patients and their families as well as financial costs to the health care system. For over 14 years, I have been working with our team to provide care for our KCC patients but due to barriers, gap still exists in their diabetes care particularly glycemic control. The challenges reported by our patients are lack of timely access to their primary care physicians, endocrinologists, diabetes educators as well as limited understanding of diabetes and self-management strategies. The primary barriers faced by our KCC team are lack of expertise in diabetes care and time constraints. In May 2014, I applied for a clinical fellowship to assist in bridging this gap in care to meet the needs of our patients by expanding my Nurse Practitioner (NP) scope of practice. My learning goal was to enhance my knowledge and skills in diabetes management within NP scope of practice and in the context of interprofessional collaboration. My learning objectives were to 1) increase knowledge of oral antihyperglycemic agents and all types of insulin 2) understand the effects of physical activity on blood glucose levels and general health in patients with diabetes 3) gain a general understanding of nutrition therapy in patients with both chronic kidney disease and diabetes and 4) obtain skills in clinical assessment and teaching/counselling/motivational interviewing required for initiating, adjusting, and monitoring effectiveness of oral antihyperglycemic agents and insulin for individualized patient.

2. Learning Activities and Outcomes

To maximize my learning, I structured the required 450 hours to have adequate hands-on practice as well as for self-directed learning and formal education. For my clinical experience, I attended diabetes clinics at Noojmowin Teg Health Centre/ Aundeck Omni Kaning, Brampton Civic Hospital, St. Michael’s Hospital, and Sunnybrook Health Sciences Centre. These clinics are interprofessional clinics with teams that are cohesive and high functioning; the NPs and RNs practice full scope and have significant clinical expertise in diabetes care. During the fellowship, I continued to work with our KCC team to implement new knowledge and skills acquired to provide diabetes care to our patients. For education, I spent approximately 200 hours for reading, searching for new literature, working on presentations to be presented to health care professionals (HCPs), and attending Endocrine rounds and conferences.

After 5 months of intensive learning, at a personal level, I gained tremendous knowledge and skills in diabetes care and achieved my learning goal. I acquired knowledge and skills related to prescribing/adjusting/monitoring therapies for a variety of patient populations such as First Nations patients, predialysis patients, chronic hemodialysis patients, cancer patients, and patients with renal transplantation. I learned to conduct comprehensive assessments and formulate care plans for patients as well as to provide education to patients and their families. In our KCC, I collaborated with our team to screen for and diagnose prediabetes and diabetes as well as to initiate/adjust/monitor lifestyle and pharmacological therapies. With the added skills and knowledge, I have gained confidence in delivering comprehensive care to our patients with both diabetes and chronic kidney disease.

At the program level, I have noticed an increase in awareness of diabetes care and screening for prediabetes and diabetes among our HCPs since my fellowship. At a result of the additional diabetes care, our KCC patients and their families verbally reported that they were very satisfied with the care and education received.

At the organizational level, since my fellowship, there has been a noticeable increase in collaboration among our Endocrinology program, SUNDEC, and Nephrology program and in the referrals to the RADAR clinic and SUNDEC. Greater collaboration among our programs will further improve patient care, reduce some of the demands that our KCC currently places on these services as well as prevent unnecessary hospitalizations and ER visits.

Future Plan: Strategies for Sustainability of Learning and Outcomes

To sustain the skills and knowledge gained from my fellowship, I will continue to develop my subspecialty in diabetes care as an NP. Over the next few months, I will be directly involved with the hemodialysis and predialysis patients whose care we share with the Endocrinology program and SUDEC through working with the diabetes team in the hemodialysis unit and in the RADAR clinic. I will also continue to engage in self-directed learning such as attending available local, national, provincial, and international conferences.

At the program level, I will continue to work with our KCC team to ensure that our patients with diabetes and chronic kidney disease receive timely, accessible and comprehensive diabetes care. These services are to provide bridging diabetes care for patients with suboptimal glycemic control until they are assessed by their primary care physicians, endocrinologists, or diabetes educators. In addition, our team will continue to complement diabetes care through reinforcing diabetes self-management strategies.

At the organizational level, I will continue to collaborate with the Endocrinology program and SUNDEC to further promote care for our mutual patients. As a member of the Diabetes Nurse Champions Committee, I will continue to provide nursing leadership and ongoing education to nurses on diabetes care. Finally, my future goal is to work with our Diabetes Champions Committee to develop and implement the role of Diabetes Nurse Champions in ambulatory settings.

Conclusion

This clinical fellowship has provided me with a platform to gain knowledge and skills to expand my NP scope of practice to aid in bridging gap in care for our patients as well as to promote diabetes care within our Nephrology program and our organization. Although my fellowship is now successfully completed, I will continue to advance my skills and knowledge in diabetes care through self-directed learning. I truly had an enriching learning experience. I strongly encourage my colleagues, RNs and NPs, who are seeking for innovative approaches to improve patient care to apply for the Advanced Clinical Practice Fellowship (ACPF) program offered by the RNAO.

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