In 2016 I fulfilled a commitment that began three years before when a disability support organisation in Albury, NSW contacted me. They wanted to know … is it legal for support workers to be trained to give insulin to a person with intellectual disability and could I provide the training?
My response was yes … and yes.
This organisation had tried unsuccessfully to get local training for their staff to administer insulin. They were told it was illegal for support workers to give insulin and nurses able to potentially do the training received legal advice they needed to be a Registered Training Organisation to do so.
I didn’t hear anything further until earlier this year when they sent an email asking if I could still do the training – it was costing them $750 a week for an agency Registered Nurse to come in twice a day to give the person their insulin. They felt the money would be better spent putting in place comprehensive diabetes care support for the whole organisation would be better value for money in the longer term.
Wow. Three years down the track and they hadn’t found anyone willing to train their staff in Victoria or New South Wales – Albury sits on the border of both states.
I see a lot of people with disability in my clinical practice and receive many calls from all over Australia seeking advice on disability focussed diabetes care. I’d like to say this was the first time I had heard of this sort of situation but sadly it is a story I commonly hear and affects every state and territory in Australia.
It isn’t illegal for people with disability to have support workers trained to give them their insulin. They are unregulated care workers and if an organisation provides the appropriate education, skills evaluation, policy/procedure infrastructure, are happy to delegate the care to the support workers and provide a care plan addressing the specific needs of the individual it is legal and appropriate.
In fact, you could argue that denying to set-up such a process is a breach of Article 25 of the World Health Organisation’s UN Convention on the Rights of Persons with Disabilities. This article states people with disability must be able to access healthcare of the same standard as those without disability[1] and it is discriminatory to refuse access to quality healthcare based on a person’s disability. Access to contemporary insulin management is a human right and something people without a disability are able to do with relative ease.
There are a number of flow-on issues with support workers not able to give insulin injections or support including:
- Delays in insulin therapy commencing
- Less prescribing of non-insulin injectables
- Increased risk of hypoglycaemia as the nurse leaves after administering the medication, leaving support staff to address hypoglycaemia management and prevention
- Lack of education and care planning to support care staff in hypoglycaemia management
- High glycosylated haemoglobins (HbA1c)
- Increased likelihood of labeling a person’s diabetes as brittle
- Continuation of older less stable insulin regimens
- Lack of dose titration and intensification with multiple daily injections
- Falls from increased need to go to the toilet due to effect of hyperglycaemia
- Restrictions to a person’s activities as they wait for a nurse to arrive
- Increased risk of diabetes related complications because of elevated HbA1cs.
I can’t support these statements with evidence because people with intellectual disability are almost universally excluded from randomised controlled trials and there are few quality studies on diabetes care of the intellectually disabled. However, they are based on real situations I’ve seen in the people with disability I see in my clinics here in South Australia.
So, a traveler I became last week, taking my energy, ideas and resources to Albury for a week of infrastructure building and training to support this organisation to deliver quality diabetes care and insulin administration by their support workers. A six-hour education program gave staff an understanding of diabetes, lifestyle and pharmaceutical based care, blood glucose monitoring, insulin therapy, other health issues and the new diabetes care strategy being put in place. In the next few weeks the participants will sit three tests and achieve a pass mark of over 75% on top of the review of blood glucose monitoring technique using the Accu-Chek Guide meter and insulin delivery device I conducted.
I reviewed the seven individuals with diabetes supported by the service, created diabetes care plans and systems for active diabetes support and primary care follow-up. Plans are in place for one person to have their insulin changed from Mixtard 30/70 to the more contemporary NovoMix 30 – the GP had been unwilling to change the insulin until the support staff were trained. Hopefully this will address unpredictable lows and the responding highs that may be caused by the extended action time of the Mixtard insulin.
All of this was possible because a disability support agency continued to seek a solution to the barriers to their support staff learning how to administer insulin. Well done to them.
To say it is illegal for support workers to give insulin is wrong. To find a way to support them to put the appropriate process in place to safely deliver quality diabetes care is the right and decent thing to do if you want to prevent perpetuating discrimination of people with disability.
Jayne Lehmann is a Diabetes Nurse Specialist providing specialised solutions for people with an intellectual or physical disability to access quality diabetes care, including the administration of insulin injections by support workers.
To find out more about the diabetes/insulin training options: Click here
Contact Jayne on: www.edhealth.com.au
Mobile: 0412 102 048
Reference: [1] http://www.who.int/mediacentre/factsheets/fs352/en/
Hi Jayne,
I am also a private CDE, and am often asked to supply training. My response has often been no, based upon the fact that the duties of a support worker generally do not list ” injection of a S4 medication”, and therefore I am highly suspicious of the legal ramifications.
As a CDE, I am acutely aware of all the reasons listed from the WHO, as to why insulin therapy needs to be provided, but the legality/indemnity of myself is a big barrier.
Can you provide me with the reference for the paragraph that talks about the legality of support care workers being able to inject insulin. I would very much like to look into this further. Many thanks
Hi Deborah. Thanks for your comment – I’m sure many others are going through the same considerations as you are. To answer your question, I will need to provide a rather lengthy response I’m afraid. Unfortunately the Australian Diabetes Educator’s Association position paper on this topic is currently out of date and has been under review for some years. I have consulted the past Nurses Board of South Australia and AHPRA in order to understand delegated insulin management support by support workers because there are no guidelines to use in this area of practice – to my knowledge.
The legal framework for injecting medications needs to be considered in two parts in order to understand the issues/process:
1. State and territory Drugs and Poisons legislation applies to the medication management by certain regulated health workers. The legislation is different in each state/territory. This addresses the issue of who can prescribe (in South Australia, doctors, dentists, nurse practitioners and Podiatrists who have achieved a specific process of endorsement with the Podiatry Board of Australia) and the extent of their prescribing. As regulated health workers we have very clear guidelines on the management of our practice … although less clear for the scope of practice of CDEs with a principal profession as a dietitian or exercise physiologist as they are currently not included in the legislation in the various jurisdictions.
Within this legislation there is the ability for a medical practitioner to delegate limited prescribing to CDEs. This is the process required for us to do insulin titrations within our services and via the company insulin support programs. A robust process is designed to guide the way insulin doses can be reviewed within a set framework set by the doctor. Insulin doses can be changed within that framework legally. The process needs to be documented, utilised as stated and cannot be done as a verbal agreement, so that it constitutes a delegated practice from a medical practitioner to a CDE-RN (just for jurisdiction clarity am I using the RN example.)
2. Disability support workers are unregulated health workers and therefore the legislation does not apply to their practice. If a support worker supports a client on insulin the organisation can put in place a robust process of education to address the knowledge and skills required to safely support the individual with their insulin management. In much the same way as a CDE can have an area of care delegated by the doctor, the support worker can have specific training provided and strategies of support put in place to enable the organisation/Manager to delegate the care to the support worker as an advanced aspect of care delivery. The Act highlighted above does not apply to the support worker because they are not a regulated/named health professional. However, to simply educate disability support workers to give an injection is not sufficient because they require the additional background knowledge and skills to provide the support safely. The employing organisation also needs to have confidence that the process put in place has successfully equipped the support worker to do this advanced role.
To equip support workers with the appropriate skills and supporting infrastructure the program I have designed needed to be comprehensive because of the lack of background diabetes care knowledge of support workers. The Diabetes Care in the Community Education Program provides a 2 hour general education session on diabetes, lifestyle and medication support, other health issues. Then a 2 hour workshop with theory and skills development in blood glucose monitoring and another 2 hours session on insulin management is presented. Workbooks are completed for the three sessions. I review the meter and insulin device technique of each individual during the session using an audit tool. Then participants sit a short answer test for each education session, needing to achieve at least 75% for successful completion. Organisations are encouraged to purchase the Diabetes Care and Support of People with Intellectual Disability or Acquired Brain Injury Manual (which most do), using the resources designed specifically for support workers to support the individual. I also encourage them to arrange for review by me in my clinic so a Diabetes Care Plan can be put in place. It also needs to be said that I am not delegating the care to the support workers. I provide the education, check they have learnt the skills technique on the day and have documentation signed by the organisation confirming I am not delegating care – that this is their responsibility – to ensure this is clearly set-out.
I have recently heard of colleagues providing a 1hr-1.5 hour session on insulin management to train support workers to administer insulin. This concerns me because it is unlikely to provide the support workers with the breadth of knowledge they require to care for someone on insulin and lacks a robust evaluation component on which the organisation can feel confident about their delegation of this area of health support because of the need for participants to learn the information presented. It also lacks the policy, procedure and resource support for quality diabetes care.
I hope this answers your question. Give me a call on Mobile 0412 102 048 if you want to discuss further. Jayne Lehmann RN CDE
I work in age and disability sector as a nurse educator , trainer and assessor with a RTO .the support workers have frequent insulin , glucomator and Diabetes awareness . Under the act in WA, support workers are able to deliver insulin to customers .
Thanks for that update Joanna and apologies for not replying earlier.