It is important for nurses to teach patients how to self-inject from the point they are prescribed the medication, says Theresa Smyth, honorary visiting professor in diabetes care at Birmingham City University and a diabetes nurse consultant.

‘It’s rare I actually do an injection,’ Professor Smyth says. ‘We try to make sure people do the injections themselves – especially the first one, as you don’t want people to think it didn’t hurt just because you gave it to them.’

However, nurses could be required to administer injections in primary, community and residential care if the patient has a disability or a mental health condition that means they cannot self-administer, she adds.

How should injections be given?

Injection Technique Matters (ITM) guidance says medications should be administered to the skin into the subcutaneous fat layer using a 4mm needle. Injections should be given into either the abdomen, outer aspect of the thighs, back of the arms or buttocks. For insulin, the needle should be left in situ for a count of ten before being withdrawn.

If a patient is slim, injections can be administered into a lifted skin fold, which should be released after the needle is withdrawn, the guidance says. This prevents giving an intramuscular injection.

It is safe to administer insulin into the abdomen in the first trimester of pregnancy, but either side of the abdomen or another area should be used in later trimesters. GLP-1 RAs are not recommended during pregnancy, according to the RCN.

Injections should be administered into clean skin with clean hands. Alcohol wipes are not recommended as alcohol causes the skin to contract and can make the injection more painful and harden the skin. The injection site must also be continually rotated to avoid lipohypertrophy.

Best practice involves dividing each area – the abdomen, thighs, back of the arms and buttocks – into smaller subsections and rotating injections between them on a weekly basis.

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When administering injections into the same subsection, the injection site should be moved in a clockwise or anti-clockwise direction – getting closer to the next subsection with each injection and making sure every injection is at least a finger’s breadth away from the last one.

Needles must be disposed of in an approved healthcare waste sharps container immediately after every injection.

What are the signs of poor injection technique?

Repeatedly injecting into the same small area can cause lipohypertrophy – a thickened, rubbery area of fatty tissue that develops in the subcutaneous layer – which can result in poor drug absorption, says independent nurse consultant in diabetes Debbie Hicks, who co-authored the ITM guidance and is director of Trend Diabetes.

Lipohypertrophy is a common problem, Ms Hicks says, adding that research suggests it affects about 50% of patients who inject insulin. ‘Lipohypertrophy can be avoided by using a good rotation system, a new needle every time and using the right length of needle,’ she adds.

Ms Hicks advises nurses to review patients’ injection sites for signs of lipohypertrophy annually, using water-soluble gel and fingertip palpation. Additional checks should be performed if patients on insulin are having hypoglycaemic or hyperglycaemic episodes or if HbA1c levels are not lowered with GLP-1 RAs.

Patients should also be encouraged to check themselves for ‘lumpy bumpy areas’ in the shower or bath and be educated to ask for their injection sites to be checked, Ms Hicks says. Other issues may include bleeding and bruising at the injection site, notes the ITM guidance. There is no evidence this has a negative effect on blood glucose levels, but it could be a sign of poor self-injection technique. Patients should be advised to apply gentle pressure for a few minutes to stop the bleeding, but not to rub the area.

If nurses are concerned about poor self-injection technique, they should observe the patient assembling the pen, attaching the needle, dialling the dose, performing an ‘air shot’ and giving the injection themselves.

How can nurses ensure patients are psychologically ready for self-injection?

To mitigate fears over self-injection, Professor Smyth says she always shows patients the injector pens before they need to use them.

‘Patients imagine a long needle. So showing them the pen and the 4mm sized needles and how small they are eliminates that fear. Once the needle goes through the skin, they realise it doesn’t hurt like they thought it was going to,’ she says.

Nurses can also use distraction therapies, stories, imagery or devices – including an injection port that means the skin is not punctured with every injection, according to ITM guidance.

What can nurses do to ensure safety when injecting patients?

According to the RCN’s sharps safety guide, employers must provide nurses who administer diabetes injections with safety engineered needle devices to prevent needle stick injuries. They are also legally obliged to provide training, information and instruction ‘when new technology such as safer needle devices or new procedures are introduced’.

‘Before a nurse gives any injection, they should be shown how to give it,’ Ms Hicks confirms. ‘If you haven’t had appropriate training for using safety engineered needle devices, they won’t work.’

Not only can nurses injure themselves, they can also ‘cause patient harm, because how do you know if the patient actually got the full dose of insulin?’ she says. Nurses can check their competencies against the NHS competency framework for blood glucose monitoring and subcutaneous insulin administration.