https://orcid.org/0000-0001-8575-9670
Figures
Abstract
Aim
To explore multiprofessional hospital staff’s experiences and perspectives of insulin use and safety review in older or frail adults with diabetes undergoing surgery.
Method
Twenty-three semi-structured interviews amongst multiprofessional staff supporting four surgical wards (elective and emergency) at a single NHS Trust in a rural county in England. Interviews were recorded, transcribed and analysed using framework analysis approach.
Results
Six main themes identified: (1) Transitioning through care: Misalignments across insulin related interacting components contribute to insulin errors (2) Coping with complexity, changes and ambiguity; at clinical, operational and organisational levels (3) Staff knowledge and confidence gaps affect insulin safety (4) Fostering patient empowerment; patient empowerment can be hindered by staff assumptions and inflexibility of hospital environment (5) Staff support systems; communication, power dynamics influence insulin safety (6) System learning as a cultural challenge; absence of systems approach and reactive to harm.
Conclusion
This study provides valuable insights into reported complexities of managing insulin-related interacting components during surgical admission. Findings could inform how managers, leaders and organisations approach and consider multiple components implicated in safe hospital insulin use to build system resilience. Future research can build on insights from this study to develop interventions supporting system-based approaches to hospital insulin safety.
Citation: Lange Ferreira C, Habte-Asres H, Forbes A, Winkley K (2025) “It is a false safety net”: A qualitative exploration of multiprofessional staff experiences of insulin management in hospitalised older or frail adults with diabetes undergoing surgery. PLoS One 20(10): e0332088. https://doi.org/10.1371/journal.pone.0332088
Editor: Gaetano Santulli, Albert Einstein College of Medicine, UNITED STATES OF AMERICA
Received: April 14, 2025; Accepted: August 25, 2025; Published: October 7, 2025
Copyright: © 2025 Lange Ferreira et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: This work was supported by the Foundation of European Nurses in Diabetes (FEND), a registered charity in England, through a doctoral research fellowship awarded to C.L.F. The SHINE study also received smaller grants from the Herefordshire and Mid-Powys Diabetic Care Fund, the Novo Nordisk UK Research Foundation (NNUKRF), and the Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care Staff Development Fund. These grants were awarded to C.L.F. These grants supported specific research costs, including participant thank-you vouchers, professional transcription services, and professional graphic design. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. There was no additional external funding received for this study.
Competing interests: The authors have read the journal’s policy and declare the following competing interests: A doctoral research fellowship funded by the Foundation of European Nurses in Diabetes (FEND), a charity registered in England, provided salary support for C.L.F. to undertake this work. FEND had no direct role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. H.H.-A. has received speaker honoraria from AstraZeneca and Bayer. C.L.F., A.F., and K.W. have no other competing interests to declare. This does not alter the authors’ adherence to PLOS ONE policies on sharing data and materials. There are no patents, products in development, or marketed products associated with this research.
1. Introduction
An estimated 588.7 million people live with diabetes across the world, and this is estimated to increase to 852.5 million by 2050 [1]. As the prevalence of diabetes is rising, so is the number of hospital inpatients with diabetes [2]. In England, 1 in 14 people are estimated to live with diabetes; amongst hospital inpatients 1 in 6 beds is occupied by a person with diabetes; in some hospitals that figure reaches 1 in 4 [3,4]. Many of these patients have been admitted for reasons other than their diabetes and are therefore under the care of hospital staff who are not diabetes specialists. Internationally, there is recognised variability in the care people with diabetes receive in hospital [3,5,6]. A high proportion of people with diabetes in hospital are older adults [7] living with multiple long-term conditions and polypharmacy. Such patients can be even more vulnerable and may require extra assistance to manage their insulin therapy [8].
Insulin management in hospital is complex, due to the high number of interacting components at the patient, healthcare professional and context level. Insulin related errors in hospital happen frequently, with errors reported across high, low and middle income countries [9–13], at all stages of the medication use process (i.e., prescribing, transcription, dispensing, preparation, administration, monitoring and management) [10,14]. Insulin errors are associated with dysglycaemia, inpatient related harm such as hospital acquired diabetic ketoacidosis (DKA), hyperosmolar hyperglycaemic state, severe hypoglycaemia and even death [5,11]. Hyperglycaemia in the perioperative context has been associated with increased risk of post-operative infections, complications and mortality, and 28-day hospital readmission following surgery [15–18]. Insulin errors cause significant anxiety and distress to patients and can be associated with longer length of hospital stay [5].
Suboptimal diabetes care and insulin management in the UK perioperative context were highlighted by the Highs and Lows report from the National Confidential Enquiry into Patient Outcomes and Death [19]. Clinical guidelines to standardize the care of people with diabetes undergoing surgery have been developed [20,21]. Multi-component whole-perioperative pathway approaches and interventions which include multi-stakeholder working groups, staff education and patient empowerment have demonstrated effectiveness in improving the outcomes of patients undergoing surgery, with reductions to hospital length of stay, 30-day readmission, and post-operative complications [22].
However, despite high numbers of inpatients with diabetes in hospital, diabetes and insulin related knowledge and confidence amongst hospital healthcare professionals is often inadequate [5,23–25]. Equally, implementation gaps between recommendations, guidelines and actual care delivered are a persistent challenge [11,12,22,24]. The perioperative care pathway is particularly challenging, given the high number of transitions of care between teams and spaces in the hospital through to discharge.
Over the years, several initiatives and interventions to address hospital insulin safety have been implemented, with varying degrees of success [2]. Many of these have focused on prescribing elements of insulin use. Engaging stakeholders, developing the underpinning programme theory and considering contextual factors are recognized as essential to successful intervention development [26]. However, there has been a noticeable lack of theory development or involvement from key stakeholders in their development [27].
This study therefore aimed:
- To explore the experiences of National Health Service (NHS) staff in relation to insulin use and safety review in surgical settings, in the context of the older/frail adults with diabetes undergoing a surgical admission.
- To identify key factors associated with insulin safety and insulin use errors, from the perspective of NHS staff.
2. Methods
2.1. Design
This qualitative study is part of a wider co-design project to develop an intervention for Safe Hospital Insulin Use amongst older or frail adults undergoing a surgical admission to hospital (SHINE) [28]. This paper reports on semi-structured interviews with healthcare professionals as part of the initial phase of the SHINE Study. Reporting adheres to Standards for Reporting Qualitative Research (SRQR) [29] (S1 File).
2.2. Procedure
This study was conducted on four surgical and frailty wards (emergency and elective units) of a NHS general hospital. A consultant-led diabetes specialist inpatient team with diabetes specialist nurses was in place from Monday to Friday. The research site had not yet undergone a Diabetes Care Accreditation Programme (DCAP) but participates in the National Diabetes Inpatient Safety Audit (NDISA) [30]. Further details of the site are provided using The Joint British Diabetes Societies for Inpatient Care (JBDS-IP) [31] self-assessment checklist in S2 File.
2.3. Participants
Participant inclusion criteria were clinical and non-clinical staff involved in hospital care/transfer of care/insulin incident or safety review of older/frail adults with diabetes undergoing surgical admission for a minimum of 3 months so they had familiarity of local contextual factors. The study was promoted via recruitment posters at the hospital site; disseminated through official communication methods such as the Trust newsletter and email. The lead researcher (CLF, a female diabetes specialist nurse and qualitative researcher) attended meetings with clinical leads and the diabetes team to disseminate study information. Participants were provided with an information sheet and written informed consent was obtained prior to participation. A one off ‘thank-you’ £15 voucher was given to participants participating out of work hours.
Sample.
Purposive sampling was employed to recruit staff representing different professional groups and different roles in managing and reviewing insulin use in hospital. Inclusion of different ranges of age, roles, and professional experience were considered important to obtain a comprehensive perspective. Sample size was guided by Malterud’s Information power (IP) Model [32]. Given the study’s narrow aims and objectives, use of pre-established theory, and the quality of dialogue that could be established through in-depth qualitative interviews with an experienced researcher, it was considered 20–25 participants would be sufficient to achieve the study’s aims.
2.4. Data collection
Study recruitment took place between 12 April and 13 November 2024. CLF conducted 23 interviews aided by a piloted topic guide, sample questions can be found in S3 File. All 23 interviews were held via MS Teams according to participants’ preferences, lasted between 30–80 minutes and were audio-recorded with permission.
Consideration was given to trustworthiness criteria in qualitative research [33]. To ensure credibility, in depth interviews were used to generate rich data, and analytical debriefings with the research team occurred. For dependability, the analysis framework was underpinned by previously established guidance in using and applying framework analysis [34–36]. Regular discussion and reflection amongst the research team and use of a codebook provided a transparent process with a clear audit trail. With regards to confirmability, study findings are supported with anonymized extracts of participants’ contributions. As CLF was employed by the research site and thus worked in the same setting as participants, reflexive journals were kept throughout the study to document their thoughts, ideas, and personal interests. These were discussed amongst the wider research team (AF, HH-T and KW) who were all diabetes specialists and clinical academics without connections to the research site, in order to identify any potential personal biases.
2.5. Ethical considerations
NHS Health Research Authority ethical approval was obtained from East Midlands-Derby Research Ethics Committee (24/EM/0022) prior to study commencement. The job roles/titles of participants or specific site/specialty worked at have not been presented to minimise risk of individuals being identified.
2.6. Data analysis
Initial verbatim transcripts were checked against original audio recordings for accuracy by CLF and then uploaded to NVIVO 14 software to support data management. Ritchie and Spencer’s five step Framework Analysis Process [36] was used to analyse the data, as it allows for incorporation of prior knowledge and theory. CLF listened to all original audio recordings and read and re-read transcripts to familiarise themself with the data. CLF then undertook line by line coding of six interview transcripts, one from each of the different professional groups. This generated initial codes which were grouped into 13 categories. All researchers (CLF, KW, AF and HH-T) then met several times to review selections of transcripts, discuss codes and identify initial categories. An initial thematic framework with six categories and subcategories was then developed. Framework development incorporated a-priori knowledge and theory from Complex Systems thinking, Safety 2 and Resilient Healthcare principles [37] and a scoping review undertaken which identified and mapped hospital-related insulin errors and associated interacting components [13]. CLF applied the framework from a generated codebook to all the data transcripts. HHT, reviewed the analysis codebook and independently coded a proportion of the transcripts. KW and AF also reviewed a sample of transcripts during the analysis process. Regular research team meetings occurred to discuss differences in data interpretation and assess usability of the coding framework. As suggested by Gale et al [34] the ’other’ code was used for each category to ensure data that may not fit the framework was not missed. On completion of coding, CLF entered the data into framework matrices for each theme. Themes were then mapped and interpreted and became the results of the study. This process is illustrated in S4 File.
3. Results
3.1. Participant characteristics
Of the 23 participants, the majority (52%) were in nursing roles, 17% were doctors, and remaining staff were in pharmacy roles (9%), allied health professional roles (9%) and patient safety & governance roles (13%). There was representation from junior clinicians and clinical managers and leaders from each professional group. Three participants worked in the diabetes specialist team. Seventeen described their ethnic background as White, five as Asian and one as North African. Further participant characteristics can be found in Table 1.
3.2. Themes emerging from the data
Findings are presented under six main themes (and sub-themes) which emerged from the data and are represented in Fig 1. Additional quotes can be found in Table 2.
Theme 1: Transitioning through care: access to information relevant to diabetes & insulin.
Safe insulin use in hospital was presented by participants as an interconnected dynamic and adaptive challenge across the patient journey from pre-op to admission, theatre, recovery, ITU, ward care and discharge.
1.1. Sub-theme: Access to the right information at the right time: Participants described the importance of having up-to-date status information on the patient at all stages of treatment. Failure to handover the right information as participants transitioned through services was thought to be a major cause of insulin errors:
“And (...) I can fully say that, yeah, I haven’t given insulin on time because of not realising the patient is on insulin or not having it handed over; You know, drama on the ward; and you know the high high acuity, you know, sometimes other things will take priority.” (P18; nurse)
Staff spoke about problems accessing certain IT systems, finding the right guidance on the intranet, and a general lack of record integration across departments. The quality of clerking on admission was also variable. Staff reported being uncomfortable relying on often out of date General Practitioner reports which might not have correct dosage information, or on frail patients for accurate information when they were not always the best “historians” (P21, doctor). Patient factors such as clinical status, communication or cognitive impairment, which may be more prevalent in older adults or those with frailty posed additional challenges to staff obtaining accurate information for managing insulin safely. Inaccurate or missing information resulted in patients missing or getting their insulin much later in the day.
1.2. Sub-theme: Dispersed staff responsibility: Multiple tasks being undertaken by different professionals across the care pathway led to no one being fully responsible for overseeing insulin management:
“The trouble is, we’ve seen so many people we can’t follow up everybody (…) to see whether they’ve stopped their diabetes medications or whether you know they’ve done this or that; because it again, it’s a surgical thing, but the surgeons aren’t doing it (…) (P22; allied health professional)
Against a backdrop of operational pressures, staff were sometimes confused as to who had spoken to the patient when they were put on new medications or different insulin regimens in hospital. Patients needed to be educated about these changes for their own safety, but it was not always clear who had responsibility for doing this.
Theme 2: Coping with complexity, changes and ambiguity.
Participants described how working within a dynamic environment with constant change, unpredictability, and ambiguity impacts on insulin safety.
2.1. Sub-theme: Operational complexity: Having to align patients’ insulin doses, their mealtimes and their surgery was particularly complex. When patients were transitioning between theatre and the ward, it was difficult to ensure timely coordination of insulin and meals. In some cases, patients from cancelled operations still ended up missing their meals. In addition, ward routines such as drugs round timings did not always align with insulin administration times:
“So on the drug round, (…) Say you are there at 8:00 o’clock and you had an insulin at 7 (...) hopefully, the night staff have given it at 7. But what I’m trying to say is sometimes until you go into that drug round, you might have missed one. If it falls out of the normal drug round.” (P13; nurse)
Expectations by patients that the hospital would just take care of them, meant many older adults commonly did not bring their own insulin devices with them, or brought insulin that was out of date. However, accessing the right insulin was often difficult, particularly out of hours, which sometimes caused critical delays.
2.2. Sub-theme: Organisational pressure: The socio-economic backdrop impacting NHS services was evident as staff discussed how they were “always in a time of crisis” (P14; nurse). It was clear that patient flow and high workloads could lead to clerking mistakes, which could introduce insulin errors from admission to discharge:
“I do worry that maybe they rush, instead of actually taking their time. (...) And I think that’s (...) quite evident when clerking patients. (...) A lot of insulin (...) gets missed off clerking. (...) they’re just so busy going from patient to patient, ward to ward” (P7, safety & governance)
Pressures associated with moving high numbers of patients through the hospital system, with patients on trolleys in corridors whilst awaiting a ward bed, made insulin management challenging. Patient flow and staffing pressures could also lead to delayed full medicines reconciliation or adaptations in discharge procedures which meant discrepancies were not identified in a timely manner. Rotating junior doctors, the main insulin prescribers, constantly faced stress and uncertainty of prescribing in a new environment. In addition, high staff turnover and a reliance on agency staff, also complicated attempts to standardize procedures or deliver local education on insulin care and safety.
Theme 3: Staff knowledge and confidence gaps; Wanting more training.
Professionals felt empowered when they had up to date knowledge, skills and confidence, but identified common knowledge gaps and fears regarding insulin management in hospital.
3.1. Sub-theme: Feeling anxiety about insulin management: Many participants in the interviews described diabetes management and insulin as challenging, and even “overwhelming” (P2; nurse). Some reported fear of causing hypoglycaemia, especially in the older population, which could lead to reluctance to adjust insulin in the context of hyperglycaemia. Some staff lacked confidence with newer diabetes technologies; leading to a reluctance to adjust and proactively manage insulin:
“I do think there’s a culture around insulin. Oh I can’t. I can’t adjust it. You know, I’m not allowed to. (...) And I know a lot of people are this, you know, insulin and warfarin, I think are the two drugs that a lot of people have a lot of anxiety about.” (P3; non-medical prescriber)
3.2. Sub-theme: Staff knowledge and gaps: Healthcare professionals described how difficult it was for them to remain up to date with clinical changes and developments, particularly “when you’re not doing just diabetes” (P12; AHP). Specific knowledge gaps included monitoring and fluid management whilst on Intravenous insulin (IV); transitioning safely from IV to Subcutaneous insulin, and using insulin pumps:
“I think there’s a definite (...) educational gap for a lot of people around what (...) [insulin pumps] can do, what they can’t do… because if you don’t really know, then you get a bit suspicious and frightened of them, don’t you? So you avoid them and you do whatever you used to do before.” (P21, doctor)
Participants remarked at the lack of focus on diabetes and insulin management during their undergraduate training. Staff reflected that learning was often ad hoc, arising from mistakes in clinical practice. Most staff wanted more mandatory hospital training but also protected learning time to capitalize on this training. For many though, training was not thought to be an organisational priority:
“The education is always the first thing to be cancelled. (...) it will always have a lower priority than operational issues. Which (...) in times of crisis is it is understandable, but when we’re always in a time of crisis (...).” (P14, nurse)
Theme 4: Fostering Patient Empowerment.
Staff recognised the value of empowering patients to self-administer their insulin in hospital for better patient experiences, although implementing this could be challenging.
4.1. Subtheme: Inflexible hospital procedures: Whilst the hospital has a self-management policy for insulin therapy, there were several service barriers hindering patient empowerment. A system update to the EPMA system had made it harder to prompt and record self-administration. Hospital policies and cultures such as locking away their medication on admission, and having to adhere to prescribed meals and mealtimes took away patient control:
“As soon as they come through the door, we whip everything away from them. We lock it all in a cupboard.”; “I think... We do take a lot of their autonomy away, patients’, when they come into hospital, not just with insulin, but with everything.” (P3; non-medical prescriber)”
In addition, allowing self-administration of insulin could lead to situations of conflict where patients’ prior knowledge and their new regimen in hospital did not match, and there was little guidance for staff on how to navigate the situation effectively.
4.2. Sub-theme: Staff attitudes towards self-administration: A hierarchical culture within the hospital which failed to recognise patients as experts in their own insulin management restricted their opportunities further. Assumptions were made about whether older patients could manage their own insulin without even checking with them:
“But even patients who come in, I think they’re assumed, oh, they’re frail, I’ll do their insulin. They couldn’t possibly do their insulin. And I think we massively underutilize the self-administration policy, we don’t assess enough patients.” (P13; nurse)
Fluctuations in a patient’s clinical and cognitive status required constant monitoring, and whilst it was sometimes safer for staff to administer insulin at points, the process of giving back control when patients became able again was not adequately embedded into practice.
“They could be completely fine at managing their insulin at home. They come into hospital, have surgery, they become delirious and then the nursing staff take over with their insulin. And then (…), even when the patient has regained that capacity, then we aren’t very good at going. Oh, OK, right. You can self-administer your insulin (...)” (P13; nurse)
Theme 5: Staff support systems.
Accessing support, advice and encouragement on diabetes and insulin management from colleagues and specialists was clearly valued by the staff and assisted with effective treatment.
5.1. Sub-theme: Value of support: Participants valued having support from a range of colleagues including the specialist diabetes team and pharmacy. Camaraderie within teams helped facilitate better communication and knowledge transfer. Participants spoke of the importance of creating safety cultures where staff feel it is acceptable to ask questions. However, professional hierarchies sometimes had a negative impact on insulin safety. For example, previous negative experiences when checking with colleagues could affect staff confidence to challenge in the future:
“Because the clinician should say, you’re right to check, let’s just have a quick look. Sadly, they don’t. They don’t always get that response (…), it can be a very negative response, and it can actually be quite a (...) damaging response for the confidence of that person who’s raising it…. So that’s gonna knock their confidence…To do that again.” (P7, safety & governance)
5.2. Sub theme: Over-reliance on specialists: Some participants noticed an over-reliance on the diabetes team which led to a decreasing expertise in other staff groups and fostered a perception that diabetes care should only be done by the professionals perceived to be responsible for it. This led to delays when the team was not available, which then compromised safety:
“And I think generally speaking, over the last five years or so because people now have just relied so heavily on the diabetes team (...) we’ve just, we now (…) probably wouldn’t even know what to turn around and put them on to.” (P17; pharmacist)
Theme 6: System learning following insulin related incidents.
Most participants felt it was important to be proactive and review incidents appropriately to identify and implement methods of improving insulin safety.
6.1. Sub-theme: Absence of systems approach: Many participants felt a system-based approach to safety was not embedded within their organisation. Instead, the service appeared to have a “culture of being reactive to harm” (P14; nurse). Participants were therefore frustrated by witnessing missed opportunities to prevent harm:
“(...) You can almost see things becoming a trend or becoming a pattern and you’re escalating it, but it it’s not until it gets to a point where someone’s really ill or… a significant, what I would see as a significant harm happens that you sometimes get a response (...).” (P1, nurse)
Barriers to reporting incidents, included lacking time to submit reports and confusion about completing patient safety and governance questions. Staff also feared repercussions, feeling that reporting mistakes tended to elicit a punitive “you have done something wrong, you have made a mistake” (P14; nurse) approach from the service. Safety reviews were referred to as archaic and limited to personal reflections by a single member of staff with no wider systemic factors considered. Several staff members felt strong leadership was required to affect any cultural shift in the service:
“…I think the senior management also have to like, learn that they have to like put their initial impression on the side when they are kind of investigating these things….and that should not impact that person, future experiences and interactions with you.” (P8; doctor)
6.2. Sub-theme: Learning from what goes well: Staff recognised the need for more system sharing of learning from incidents to enable systemic improvements in insulin safety:
“... Need to... Do a little bit more of system sharing and learning,(...) We need to empower people to think how... (...) where do I go with it and who do I share it with? (...)” (P5; safety & governance)”
Staff emphasized the importance of disseminating safety information more widely for those who cannot attend safety reviews. There was also a reliance on digital communication, which participants acknowledged may not be as accessible to busy frontline workers. Staff wanted to move away from negativity and towards adopting appropriate acknowledgement and recognition for staff. Professionals were able to identify different factors which enhanced insulin safety, which were related to patient empowerment, identifying diabetes and insulin management, education, leadership, tools and technology, workforce, tasks, and are summarized in Fig 2.
4. Discussion
This study has highlighted the complexities of insulin management in practice as experienced by hospital staff. Participants revealed an array of problems with a disjointed system and identified patient and contextual elements impacting on inpatient insulin safety.
Despite having a perioperative pathway guideline at the study site, there was still a lack of patient-centred joined up working and several gaps between recommendations/work as imagined, and care delivered/work as done. Implementation gaps in perioperative inpatient diabetes care recommendations have been recognised previously [19,22,23]. Initiatives such as the Ipswich Perioperative Pathway of Patients with Diabetes (IP3D), can improve outcomes and efficiency [22]. A peri-operative care passport for people with diabetes and support from a perioperative diabetes specialist nurse were among key components. Whilst the importance of diabetes specialist staffing can provide a high return on investment there is still significant variability in hospitals across the UK, and obtaining permanent funding for the resources to implement such pathways can be challenging [38]. Our participants also spoke about the difficulty of implementing guidelines, for example, with regards to perioperative use of intravenous insulin infusions. Indeed, the impact on safety of misalignments and adaptations in the management of IV insulin in practice has been reported previously, across international literature [11,39,40]. Clearly a better understanding of what actually happens in practice is needed to develop more resilient systems of care which support flexible standards and safe adaptations in response to unpredictable events.
Our sample highlighted the need for more standardized training on diabetes and insulin management. Internationally, knowledge and confidence gaps in insulin knowledge amongst the workforce have previously been identified [5,23,25,40]. In our study, there was a fear of causing hypoglycaemia reported among staff, recognising the increased risks associated with hypoglycaemia in the older or more frail population. Increased risks of hypoglycaemia are recognised for older adults, and often hypoglycaemia avoidance is a goal of care in this population [41]. The hospital environment has many factors that increase hypoglycaemia risks [31]. This coupled with additional factors which may be more prevalent in the older population such as physiological changes, presence of multiple healthcare conditions, frailty, polypharmacy, nutritional, communication deficits, reliance on others for care [41] increase the challenge to safely manage insulin therapy in this population. Balancing hypoglycaemia avoidance whilst maintaining target glucose post-operatively and avoiding symptomatic hyperglycaemia is complex [2].
Previous research suggests anxiety associated with causing hypoglycaemia may prevent nurses from adhering to insulin management protocols [42] and that consequences of hypoglycaemia are perceived as more significant than those of hyperglycaemia [23] However, staff turnover in hospitals as well as the rapid pace of developments in diabetes and insulin management, make it a challenge to deliver continuing education on insulin safety [25]. Equally, there is wider concern about the lack of multi-professional undergraduate preparation for diabetes inpatient care [43,44]. Clearly, pre and post qualification training for all professionals needs to target the complex system, cultural and relational aspects implicated in hospital insulin management. Training also must acknowledge the additional considerations of managing insulin safely in the older population, especially given the rising prevalence of older adults with type 1 diabetes [41]. This will empower staff to apply knowledge in practice, make safe adaptations to care, manage unpredictability and have the confidence to challenge suboptimal or outdated practices. Simply relying on top-down approaches to improve safety will not work in complex adaptive systems [45]. Novel educational and reflective approaches aimed at empowering training and junior prescribers to deal with ambiguity and complexity of insulin prescribing and change culture and practices for safer and enhanced experiences of care have been reported [44].
Staff in this study reported how difficult it can be to access accurate insulin dosing information from older people who may be clinically unwell or frail on admission, and reported concerns about quality of clerking and limitations of using electronic records for dosage information. There may be an opportunity to consider how preparedness for hospital admission can be enhanced amongst the older population/their carers to improve hospital insulin safety; noting that staff in this study reported patients did not always bring their insulin to hospital, assuming the hospital would have it.
A recent audit study in a UK hospital highlighted how insulin prescribing errors on admission occur frequently and this was often linked to the source of information for insulin management which was used on admission and thus warrants review [46]. Transition between services also presents a high risk for medication errors in other studies [40,47]. For example, ineffective communication at surgical transitions of care (e.g., between ward and theatre) has been implicated in insulin errors which have resulted in intraoperative hypoglycaemia [40].
Several participants acknowledged that, although rarely reported, insulin timing administration errors were frequent in practice; nurses reported difficulties with administering insulin on time. Mismatches in the coordination of administration of meal delivery, glucose monitoring and bolus insulin administration and delayed insulin administration have been identified in other studies [24,48,49]. Whilst US studies attempting to improve timing of insulin administration in hospital have shown this is a complex problem, there are efficiency and cost savings and improved patient safety when system approaches are implemented [24,50]. Further efforts to understand and improve nursing and hospital practices with regards to timely administration of insulin are needed.
Promoting safe self-administration of insulin can play a key role in improving timing and safety of hospital insulin administration, reduce harm and improve patient satisfaction and experience [51]. However, data from the latest UK National Diabetes Inpatient Safety Audit (NDISA) shows only 63.4% (90/142) hospitals surveyed had such a policy for promoting self-administration in place [52]. In this study site, despite having a self-administration policy, it was not always implemented effectively. Indeed, the older age of patients in particular, appeared to decrease staff motivation for encouraging self-management. Further research is therefore needed to develop and maintain the safe effective implementation of self-management initiatives, particularly in older or more frail populations.
Staff in our study also spoke about dispersed ownership of diabetes care and responsibility across care pathways, which hindered coordinated and timely diabetes care as well as preventing system improvements. Similar issues have been reported in a qualitative study by Rousseau et al., [25] who suggested safe insulin therapy requires interventions by several different professionals, but that these staff may not have or perceive they have overall responsibility for glycaemic management. This study also highlighted the importance of existing relational infrastructure, politics, power dynamics and culture on insulin safety. The role hospital culture plays in patient safety has been recognised in previous research [53] Indeed, the importance of strong leadership, continuous learning and improvement and a compassionate culture where staff can speak freely is key to NHS patient safety strategy [52]. This study and others, show how in practice, these aspects are challenging to change and embed; yet are an essential element for multi-component interventions targeting patient safety [39].
From our interviews, it appears many insulin errors may remain unreported. This variability in reporting and underreporting diabetes related harms has been previously identified as an issue in the UK [43,52]. However, this study found the way insulin incidents and safety were often explored in hospital did not always consider the multiple interacting components in insulin use, instead focusing on the behaviour of one or two individuals. Multiple methods are required to obtain patient and staff feedback on actual insulin errors and to drive improvements to strengthen system resilience. Equally it is important to share learning and good practice when insulin management is done well within this complex adaptive system [39,45]. Staff interviewed in this study felt this was not done enough in their service, suggesting an opportunity to engage and involve staff in enhancing hospital insulin safety.
4.1. Study strengths and limitations
This is the first known qualitative paper to capture day-to-day reported experiences and perspectives of multiprofessional staff caring for older adults with diabetes across the surgical pathway. However, data collection was based on a single UK site, and thus our findings may not be transferable to healthcare professionals working in other UK hospitals or indeed internationally. The nursing profession made up over 50% of the sample and so their experiences of insulin use may be over-represented in the data. In addition, staff who did not want to participate in the study may have different views to those who were interviewed. Finally, the lead researcher (CLF) worked clinically at the research site and was known to some, but not all of participants recruited. However, reflexivity techniques and a team approach were employed, with data analysis interpretations regularly discussed with the other co-authors to attenuate any bias.
5. Conclusions
This study provides staff insights into some of the multiple interacting components which influence insulin safety in the care of older or frail adults undergoing surgical hospital admission. Some of these factors may be applicable to wider hospital settings.
The use of research methodologies and engagement with a diverse range of stakeholders will help better understand care misalignments, unpredictability and staff adaptations in practice. This will support the design, implementation and evaluation of flexible interventions which can increase hospital insulin safety.
Supporting information
S1 File. Standards for Reporting Qualitative Research (SRQR) checklist.
https://doi.org/10.1371/journal.pone.0332088.s001
(PDF)
S4 File. Preliminary codes, initial thematic framework and final themes and subthemes.
https://doi.org/10.1371/journal.pone.0332088.s004
(PDF)
Acknowledgments
We would like to thank all the NHS Staff who took part in this study, for sharing their views and personal experiences, without which this study would not have been possible.
We are grateful to the Diabetes Specialist Team, Medicines Safety Officer and clinical managers and leads at Wye Valley NHS Trust who supported and promoted this study and helped with recruitment.
We would like to thank Dr Jyothish Govindan for his support to SHINE Study and helpful discussions during this study.
We would like to thank Dr Samantha Coster, Publication Coach at King’s College London, for her help and support editing the manuscript.
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