The Development of a Standardized Framework for Primary Nurse Specialists in Diabetes Care in China: A Delphi Study.

BACKGROUND
The number of patients with diabetes has been increasing rapidly according to a 2014 report by the International Diabetes Federation. Diabetes has become one of the most challenging public health problems, and there will be an estimated 143 million patients with diabetes in China by 2035. This puts considerable pressure on nurses who specialize in the care of patients with diabetes in China and increases related social and financial burdens. Clinical practice has proven that strengthening the core competencies of nurses and establishing an evaluation system of core competencies improve both healthcare quality and patient quality of life. However, no core-competence system framework currently addresses the unique characteristics of nurses in China.


PURPOSES
The purpose of this study was to construct a core-competence system framework for primary nurse specialists in diabetes care.


METHODS
A brainstorming approach was conducted that worked to conceptualize the core competencies of nurse specialists in diabetes care in China. Next, a study group organized this information and conducted a seminar; 50 experts and patients with diabetes were invited to develop the first draft of the framework. Afterward, the 50 experts were selected to participate in the Delphi survey. Most indicators were retained after a three-round Delphi process, and the superiority chart was used to determine the weights of the six dimensions.


RESULTS
Forty-seven experts completed the consultation. The experts' rate of response ranged from 94% to 100%, the authority coefficient was .91, and the Kendall's coefficients of concordance in Grades 1-3 were .793, .418, and .542, respectively. An increasingly detailed, three-grade system framework was developed, including six first-grade indicators (diabetes professional knowledge, diabetes-related knowledge, communication skills and health education ability, specialized skills, clinical judgment, and specialty development capacity), 23 second-grade indicators, and 87 third-grade indicators. The weights of the six first-grade indicators were .221, .149, .192, .209, .160, and .069, respectively.


CONCLUSIONS
The core-competence system framework includes six core competencies, which represent the main characteristics of primary nurse specialists in diabetes care who are highly recommended by experts. It is important to keep in mind that this is only a theoretical framework and thus must be further tested in clinical practice settings in China.This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and provide guidelines for training and career development paths for nurse specialists in diabetes care. The study group focused on constructing a system framework based on the British core competence framework to ensure that the developed framework was based on evidence and applicable in terms of training and assessing nursing staff at various levels (Trend, 2011).

Background
The International Diabetes Federation estimates that 642 million people worldwide between 20 and 79 years old will have diabetes in 2040 (Ogurtsova et al., 2017). Diabetes has become one of the most challenging public health problems. With a dramatic increase in the prevalence of diabetes, China now has the largest number of people with diabetes in the world (Guariguata et al., 2014;Whiting, Guariguata, Weil, & Shaw, 2011). Because of serious dangers and complex management, diabetes places a particularly high burden on nurse specialists in diabetes care as well as on society and national finances (Bermudez-Tamayo et al., 2017). As a country with more than 90 million people with diabetes (Yang et al., 2010), China needs to do more than simply increase the numbers of nursing staff engaged in diabetes care. The clinical practice of developed countries such as the United States and United Kingdom has shown that the knowledge and skills of nurse specialists in diabetes care are key to improving the healthcare of patients and enhancing the quality of patient self-management (American Association of Diabetes Educators [AADE], 2011;Trend, 2011). Therefore, strengthening the core competencies of nurse specialists in diabetes care is the most urgent task.
The AADE (2011) established a training and evaluation system and set up the National Certification Board of Diabetes Educators. Certification is intended to improve the quality of self-management education, clinical care, and management of people with diabetes. In addition, the United Kingdom developed a career and competency framework for diabetes nursing (Douglass & Ruddle, 2009;Hicks, 2010;Trend, 2011). The British "integrated career and competency framework for diabetes nursing" model reflects this framework. There are five levels of competency for, respectively, unregistered practitioners, competent nurses, experienced or proficient nurses, senior practitioners or expert nurses, and consultant nurses. Areas of competence in the British system include prevention and early detection of Type 2 diabetes to facilitate patient self-care, care for diabetic individuals with mental illnesses, provide nutritional guidance, monitor biochemical indices, ensure the safe administration of therapies, identify and treat blood glucose, manage complications, manage gestational diabetes, support diabetic individuals who reside in prisons or young offender units, care for diabetic individuals living in residential or nursing homes, and care for patients with diabetes at the end of life.
China has the largest population of people with diabetes in the world (International Diabetes Federation, 2017). The most important difference is that patients with diabetes in China are educated and managed primarily in hospital settings, which puts considerable pressure on nurse specialists in diabetes care, especially in the areas of communication, education, and follow-up care. To date, there is no standardized framework for evaluating care implementation. Therefore, developing a comprehensive framework that provides criteria for competency evaluation, training, and guidance for the professional development of nurse specialists in diabetes care is critical. As a recently joined member of the International Council of Nurses, the Chinese Nursing Association, in establishing an effective framework, would help boost international communication and collaboration in diabetes care. Regrettably, lack of experience inhibits China from constructing a higher level, complex framework. Thus, this study aimed to construct a core-competence system framework for primary nurse specialists in diabetes care to lay the foundation for development of a multilevel framework that improves the quality of clinical nursing care.

Study Design and Sample
Theoretical basis This study was based on the British "integrated career and competency framework for diabetes nursing" model (Trend, 2011). To address the role of nurse specialists in diabetes care in China as educators, the framework referred to some relevant studies of the AADE (2011) and the Australian Diabetes Educators Association (2008). In addition, domestic nurses in emergency care, peripherally inserted central catheter care, intensive care units, and other specialties (Fan & Xi, 2011;Yao, 2012) provided basic information for this study. The concept of core competencies Twenty experts were invited by the Steering Committee to a brainstorming session to clarify the definition of core competencies of nurse specialists in diabetes care and to discuss the contents and outline of core competencies. A system framework of three grades was proposed for primary nurse specialists in diabetes care. First-grade indicators consisted of the dimensions of the core competencies. Second-grade indicators were drawn from the main competencies in the dimensions of the framework; and third-grade indicators, from the detailed content of the competencies.

Creating the research group
Development of the first draft of the framework After the brainstorming phase, the Project Execution Team organized the information and held a seminar to determine the first draft of the core competence framework. The 50 participants in this seminar included three diabetologists, 37 nurse specialists in diabetes care, five nursing managers, and five patients with diabetes.

Expert panel selection and recruitment
Fifty diabetes experts from 28 provinces and municipalities joined the expert panel to (a) balance the differences among regions and (b) maximize information diversity to make the framework more universal and comprehensive. The experts included clinical diabetes nurse specialists, nursing managers, and diabetologists who had 10 years or more of experience in diabetes treatment and care.

Data Collection
The Project Execution Team applied the Delphi method (Aljamal, Ashcroft, & Tully, 2016) to carry out three rounds of consultation between October 2015 and March 2016. In the first round, experts gave their advice on the first draft of the framework, with advice focused mainly on the deletion, addition, or modification of indicators. In the second round, experts continued to provide new suggestions and assigned a value to all of the indicators based on a 5-point Likert scale from 5 = very important to 1 = not important. Afterward, group members readjusted and formed new indicators based on the following screening criteria: mean > 3.5, coefficient of variation < 0.25, and expert approval rate > 70% (Guo, 2005;Wu, 2011). The third round mirrored the process in the second round and assigned weights to the first-grade indicators using the superiority chart (Cabral et al., 2005). All of the opinions were summarized to form the core competencies of primary nurse specialists in diabetes care.

Data Analysis
Microsoft Excel 2007 (Microsoft, Redmond, WA, USA) and IBM SPSS Statistics 17.0 software (SPSS, Inc., Chicago, IL, USA) were used to conduct data analysis and processing. Data were presented as means and standard deviations for continuous variables. In general, the authoritative coefficient (Cr) is composed on the basis of expert judgment (Ca) and of familiarity with the questions (Cs). The formula is Cr = (Ca + Cs) / 2. The value of Ca and Cs is obtained mainly through expert self-evaluation. The variables Ca and Cs reflect, respectively, the judgment and familiarity of the experts with regard to survey content. Kendall's coefficient of concordance (W) refers to the level of intraexpert agreement on all of the indicators. A nonparametric test was applied for Kendall's coefficient of concordance (W).

Expert information
Of the 50 consultants who participated in the Delphi survey, three did not reply and two provided incomplete information; thus, five were excluded. Demographic data on the remaining 45 included mean age, 44.69 AE 6.48 years; years of work experience in diabetes care, 15.75 AE 4.81; nursing managers, 13 (28.9%); diabetologists, 5 (11.1%); and diabetes nurse specialists, 27 (60%). In terms of education, three (6.7%) were educated to the college level, 28 (62.2%) held undergraduate degrees, 11 (24.4%) held a master's degree, and three (6.7%) held a doctoral degree.

Rate of response of experts
Fifty questionnaires were distributed, and 45 valid questionnaires were received via e-mail. The response rate for each round was 94%, 100%, and 95.7%, respectively.

Authoritative coefficient
The assignments of Ca and Cs are shown in Table 1. With the judgment coefficient of .91 and the familiarization coefficient of .90, the authority coefficient of experts was .91.

Kendall's coefficient of concordance (W)
Kendall's coefficient of concordance (W) values for the second and third rounds of expert consultations are shown in Table 2.

Selection of Indicators
Three rounds of Delphi consultations In the first round of consultations, experts indicated a high level of recognition on first-and second-grade indicators. In addition, three third-grade indicators were eliminated, three third-grade indicators were added, and the descriptions of some indicators were modified based on expert opinions. In the second round, three second-grade indicators and 15 corresponding third-grade indicators were deleted on the basis of analysis methods, clinical applicability, and expert opinions.
In the third round, one second-grade indicator and five corresponding third-grade indicators were deleted. The study process is shown in Figure 1.
After three rounds of Delphi consultation, a three-grade system was constructed, consisting of six first-grade indicators, 23 second-grade indicators, and 87 third-grade indicators. The relationships among these are shown in Table 3.

Weights of the dimensions
According to the results of the consultation, the weights of the six dimensions (diabetes professional knowledge, diabetesrelated knowledge, communication skills and health education ability, specialized skills, clinical judgment, and specialty development capacity) were . 221, .149, .192, .209, .160, and .069, respectively.

Discussion
The Indicator Selection of the Framework After three rounds of consultation, some indicators were deleted or added according to the analysis methods, clinical applicability, and expert opinions. Moreover, the expressions of some indicators were modified. For example, the content of "psychological knowledge" was revised from "mastering the conception of psychology," "understanding the application of psychology in nursing work," and "be able to use the psychological assessment instrument" to "learn common psychological problems in patients with diabetes" and "become familiar with the care regimen of common psychological problems" to make the framework more suitable to clinical requirements. However, the expert approval rating was only 70% for several indicators, including "ability to judge social support" and "understand the relevant laws and ethics." These indicators were retained for one or both of the following reasons: (a) These competencies facilitate the provision of individualized care and improve clinical safety, and (b) in the current healthcare environment in China, the indicator is necessary for competency among specialty nurses to meet changing healthcare demands. The final first-grade indicators represented the six dimensions of the core competencies of primary nurse specialists in diabetes care. "Diabetes professional knowledge" included five aspects (epidemiology, classification and characteristics, pathophysiology, complications, and hypoglycemia) with 16 indicators. "Diabetesrelated knowledge" included three aspects (nutrition, exercise, and psychology) with 12 indicators. "Communication skills and health education ability" included four aspects (communication, assessment, organization and planning, and expression and explanation) with 17 indicators. "Specialized skills" included two aspects (specialized nursing skills and emergency response capacity) with 12 indicators. "Clinical judgment" included four aspects (clinical evaluation, judgment of social support, analysis of potential risk, and mastery of relevant laws and ethics) with 13 indicators. "Specialty development capacity" included five aspects (teaching, training, team coordination, continuous nursing, and learning) with 17 indicators.

External Validity of the Framework
This framework, which broadly reflects the professional characteristics of nurse specialists in diabetes care, was constructed  Figure 1. The study process.   The Journal of Nursing Research Qiuling XING et al. based on the British career and competency framework for diabetes nursing (Trend, 2011). The process used in this study to select experts differed from other studies in terms of number and region (Gattinger et al., 2016;Gibson & Soanes, 2000). The number of experts was relatively high (50 recruited). Moreover, clinical diabetes nurse specialists, nursing managers, and diabetologists were involved with the aim of obtaining more information from multiple perspectives. In addition, the diverse regional backgrounds of the experts (28 provinces) were expected to ensure that regional differences were considered so that the framework was universally applicable and comprehensive. Research has shown that specialty nurses have better mastery of theoretical knowledge and skills than general nurses, which certainly affects the quality of nursing care (Yao, 2012). This framework is intended to provide a reference for clinical nursing managers to cultivate and evaluate the core competencies of nurse specialists in diabetes care to help them provide more effective patient care.

Characteristics of the Indicators in the Framework
This framework was based primarily on the British career and competency framework for diabetes nursing (Trend, 2011). In addition, guidelines from the AADE (2011) and the Australian Diabetes Educators Association (2008) and domestic experience in the emergency, peripherally inserted central catheter, intensive care unit, and other settings (Fan & Xi, 2011;Yao, 2012) were incorporated. The career and competency framework for nurse specialists in diabetes care in the British model provided particularly important insights. However, the developed model differs significantly from the British model in several respects. First, the British model is a theoretical framework that emphasizes the core competencies of five different levels of nurses (unregistered practitioners, competent nurses, experienced or proficient nurses, senior practitioners or expert nurses, and consultant nurses). In contrast, the model that was developed in this study targets only nurse specialists in diabetes care. The framework contains the basic competencies that nurse specialists in diabetes care should have and provides the basis for the future establishment of a higher level framework. Because research and leadership competencies are more suited to senior nurse specialists in diabetes care, these competencies were not included in the study framework. Second, the British framework covers competencies that focus partly on care for patients living in residential and nursing homes, confined to prisons and young offender units, and receiving end-of-life care. As patients in China are always managed in hospitals, this model did not consider patients in these categories.
Third, the two models have a number of competencies in common such as diet, exercise, blood glucose monitoring, use of antidiabetic agents, mental health, nursing for complications of the disease, and hypoglycemia prevention and treatment. However, because of differences in cultural background and health policies, certain indicators are more relevant Framework for Primary Nurse Specialists in Diabetes Care VOL. 27, NO. 6, DECEMBER 2019 to Chinese healthcare. These include emphasizing judgment in social support and potential risks and understanding the laws, regulations, and clinical ethics to guarantee the safety of patients and deal with medical stress. Furthermore, team coordination ability and learning ability were added to improve the quality of nursing care. Fourth, the dimension of competencies was made more consistent with the medical background of nurses in China by classifying basic diabetes knowledge and skills into the three dimensions of diabetes professional knowledge (classification and characteristics of diabetes, knowledge of hypoglycemia, complications nursing), diabetes-related knowledge (nutrition, kinematics, psychological knowledge), and specialized skills (insulin pump management, blood glucose monitoring). Moreover, the competencies were distinguished into three grades (dimensions, competencies, and detailed indicators), which formed a detailed hierarchical system.
Finally, diabetes education is a significant component of clinical work. Thus, the model reflected the specific characteristics of diabetes educators in terms of communication skills and health education ability.

Limitations
This study showed the development process and structure of the framework for primary nurse specialists in diabetes care. Although the research design and execution were rigorous, some limitations still exist. The result of the study was the formation of a theoretical framework, which must be verified and further improved in clinical settings. The framework was constructed for primary nurse specialists in diabetes care and offers clear standards for the training of primary nurse specialists in diabetes care only. This framework is unable to meet the demands of advanced nurse specialists in diabetes care. Thus, a multilevel core-competence system framework should be developed.

Conclusions
The core-competence system framework includes six core competencies, which broadly represent the main characteristics of primary nurse specialists in diabetes care. However, as this is a theoretical framework, it must be tested in clinical practice environments in China.