The Evolution of Nursing Practice in Diabetes Care
The role of the nurse in caring for patients with diabetes has evolved over our history. As understanding of the impact of diabetes in the inpatient setting gained momentum, nurses have moved from managing comorbidities, such as diabetes, as a secondary priority to caring for diabetes alongside and equal to the patients’ primary diagnoses. Leading and executing evidence-based nursing, which takes into account clinical expertise, research, and best practices, nurses have been integral in the advancement of inpatient diabetes care and can continue to shape the future.
To acknowledge the efforts of so many nurses who have and continue to advance inpatient diabetes care, this National Nursing Week, we want to recognize how far we have come and highlight the evolution of nursing practice in diabetes care.
The History of Nursing in Diabetes Care
1776 – Nurses executed testing for diabetes including tasting urine or placing urine with ants to determine if the ants followed the path of the urine. Primitive testing was conducted by nurses labeled as “water tasters” whom specialized in identification of the presence of diabetes through these methods.
1797 – High-fat, high-protein diets were first implemented over eating starchy foods. This was discovered by tasting the sweetness of urine after different diets were consumed. Because meats and fats produced less sweetness of urine, nurses began to feed patients less carbohydrates and more meats.
1870 – Food rationing in Paris led to the discovery of decreased sugar in the urine. This led nurses to begin to individualize diets for diabetics decreasing caloric intake.
1920s – Elliot P Joslin, MD combined the fasting diet with regular exercise. Although this treatment approach also led to starvation, he introduced principals of exercise as a treatment option that is still used today. Joslin founded the Joslin Diabetes Center, which helped to establish the diabetes specialist nursing role.
1924 – Elizabeth Hughes Gossett, at the age of 11, developed diabetes. She lost 45 pounds and was starving with the traditional treatment of strict diet and exercise available at the time. She was the first patient to receive insulin in the United States after her mother contacted Dr. Banting, who invented insulin in 1921. Nurses were essential in teaching her the signs of hypoglycemia, how to inject insulin, and reinforced diets low in starches. Elizabeth lived to the age of 73. At the time, those who could afford insulin and nursing care started to be able to survive diabetes.
1924 – Commercialized syringes were introduced by BD Company, which nurses were responsible for sterilizing through boiling, sharpening needles on stones, and maintaining for patient use.
1925 – Nurses performed the first commercialized test for diabetes called “Clinitest” by adding 5 drops of urine and 5 drops of water into a tube and then dropping a tablet inside that created a chemical reaction and color change that identified the presence of sugar in urine. The result in color diagnosed diabetes. Blue was good, dark green indicated diabetes, and brown indicated no insulin was being produced. Home testing soon followed. Although “Clinitest” was developed in 1925 it did not become widely available until 1950, which was followed up by test strips that changed color when urinated on or dipped in urine.
1940 – Nurses began administering insulin to patients in inpatient settings beyond specialized clinics.
1953 – Robert Semple and M.D. Aberd published research on the microvascular complications of diabetes linking diabetes to neuropathies, heart disease, vascular complications, and poor wound healing. They looked at surgical patients, both with and without diabetes , comparing diminished pulses to poor healing of wounds, laying the groundwork for the discovery of the importance of improved inpatient glycemic management and the acute consequences of poor management. Nurses specializing in wounds began to educate on the importance of controlling blood glucose in inpatient and outpatient settings.
1970 – Nurses used the first glucose meter using blood placed into the reflectance meter in which a moving needle indicated the blood glucose value.
1978 – Home glucose meters were first invented. These started requiring 30mL of blood, which nurses were responsible for collecting. Today meters only need 0.3mL for accurate testing. Nurses also began to instruct patients with diabetes on home glucose monitoring and care, which included sliding scale insulin.
1980s -In the 1980s intermediate-acting insulins were introduced. These insulins brought us one step closer to physiologic dosing in that doses were given prior to breakfast and dinner, covering basal metabolic needs and the spike in blood glucose related to meals. At this time, sliding scale insulin remained the standard in inpatient diabetes treatment for non-critically ill patients.
1987 – In the 1980s, the American Diabetes Association began establishing uniform criteria for the key components of an effective diabetes education program. In 1987, the Association began recognizing programs that met all of the criteria, which included tactic impacting nursing care.
1989 – The first Standards in Diabetes Care was introduced providing guidelines for nursing care relating to diabetes care.
2000 – At the turn of century, a number of advances occurred in inpatient diabetes care. Fast-acting Insulin was introduced with Eli Lilly and Company’s Lispro, and the first analog basal insulin, Lantus, was introduced by Sanofi Aventis US. The introduction enabled Basal-Bolus-Correction therapy that can more closely mimic true physiologic dosing. Around this time, nurses also began to use standardized diabetes protocols for the diagnosis of diabetes, including standards to assess blood sugar values and hemoglobin A1C, as well as paper protocols to deliver the ordered intravenous or subcutaneous insulin doses. Beyond following the protocols, as the frontline caregivers, the role of nurses also was extremely important in helping to identify and initiate protocols when appropriate.
2006 – EndoTool receives FDA clearance using advanced algorithms for intravenous insulin dosing. Computer based titration of intravenous insulin is a new inpatient treatment that starts to gain momentum and demonstrate safer outcomes as well as improved satisfaction among nurses.
2007 – The RABBIT 2 Trial supported the use of physiologic dosing in the inpatient hospital setting, initiating a recommendation and shift to basal-bolus-correction therapy.
2015 – Following best practices of care for physiologic insulin dosing for non-critical care patients, EndoTool receives FDA clearance using advanced algorithms for subcutaneous insulin dosing, providing another solution to aid nurses in glycemic management.
Over the course of history, we’ve certainly come a long way in advancing inpatient diabetes care thanks in a large part to so many nurses, but yet we still have a long way to go. With many hospitals relying on paper protocols for intravenous insulin titration and sliding scale insulin for subcutaneous insulin, it will take the support of nurses to instill best practice of care to further advance diabetes care. History is made in the present, and nurses are shaping how we care for diabetes for improved outcomes.
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Semple, R. & Aberd, M.D. (1953). Diabetes and peripheral artery disease, a clinical study. Science Direct. 261(6770):1064-1068.