Diabetes Educators: Assessment of Evolving Practice

Susan Barlow, RD, CDE

John Crean, PhD

Alissa Heizler, RD, CDE

Kathy Mulcahy, RN, MSN, CDE

Jane Springer, RN, BSN, CDE, CCRC

From Amylin Pharmaceuticals, San Diego, California.

Correspondence to Kathy Mulcahy, RN, MSN, CDE,Amylin Pharmaceuticals, Inc, 9360 Towne CentreDrive, San Diego, CA 92121([email protected]).

Acknowledgment: The authors would like toacknowledge the following people for their supportand assistance in the development of thispublication: Gayle Lorenzi, RN, CDE; Susan Strobel,PhD; Maury Gloster, MD; Jim Ruggles, PhD; KimMaciel, BS; and Megan Coakley, BBA.

DOI: 10.1177/0145721705276572

Assessment of Evolving Practice

359

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Assessment of Evolving Practice

Abstract

A survey evaluating the professional characteristics and

practice patterns of diabetes educators was distributed

across the United States. The specific survey aims were

to assess whether (1) there continues to be a growing

trend among US health professionals who consider

themselves diabetes educators to obtain certification as

certified diabetes educators (CDEs), (2) duties/services

associated with diabetes self-management training

(DSMT) and medical/medication management differ

between diabetes educators who are CDEs versus those

who are non-CDEs, and (3) educator practice patterns

differ across the major geographic regions of the United

States. Of the 507 diabetes educators completing the sur-

vey, 83% identified themselves as CDEs. Diabetes edu-

cators responding to similar surveys done in 1992 and

1999, 51% and 63%, respectively, identified themselves

as CDEs. In this survey, a similar percentage of CDEs

and non-CDEs employed DSMT practices of relatively

low complexity (eg, general diabetes education) where-

as a significantly higher percentage (P < .001) of CDEs

employed DSMT practices of relatively high complexity

(eg, insulin pump training). Significantly (P < .001)

more CDEs provided medical/medication management

services compared to non-CDEs. Finally, the practice

patterns among CDEs were minimally influenced by

region of the country. These results suggest that (1) the

trend toward increased certification among diabetes edu-

cators has continued, (2) certification is associated with

a greater likelihood of delivering complex DSMT serv-

ices and medical/medication management, and (3) this

pattern is consistent across the nation as a whole.

at Istanbul Universitesi on December 20, 2014tde.sagepub.comDownloaded from

http://tde.sagepub.com/

Diabetes education, as a health care disci-

pline, has a history similar to any innova-

tive concept, moving through a

continuum from a revolutionary health

care discipline based on need to an evolu-

tionary one, adapting to the current health care environ-

ment. As the discipline of diabetes education changes, it

is natural for the role of the diabetes educator to change

as well.1,2 The expansion of services provided by the dia-

betes educator over the past several decades is a clear

indication that this process is under way. Diabetes edu-

cators now routinely perform a wide array of services

such as medication management and physical exams in

addition to the traditional role of providing patient edu-

cation. Accordingly, the American Association of

Diabetes Educators (AADE) and the American Nurses

Credentialing Center have developed a process for certi-

fying advanced diabetes care practitioners by developing

the Board Certification for Advanced Diabetes

Management (BC-ADM) credential. This represents a

necessary step in maintaining the quality and integrity of

the health care discipline.3-6 The standardization and cer-

tification of diabetes educator practices has influenced

diabetes standards of care, evidence-based medicine, and

measurement of health care outcomes.7-9 These changes

in health care validate the best practices for treating an

epidemic disease that overwhelms the primary care sys-

tem and affects populations worldwide with its increas-

ing incidence and prevalence.10-14

Although the scope of practice of the diabetes educa-

tor has been well defined by a multidisciplinary task

force of the AADE,15 the impact of differing licenses,

credentials, geography, and other variables on education

practice patterns is unclear. Only 2 studies published to

date have systematically evaluated these issues. In 1992,

108 members of a metropolitan New York AADE chap-

ter were surveyed to evaluate the scope of diabetes edu-

cator practices and compare practice patterns between

registered nurses (RNs) and registered dieticians (RDs).16

Of the RNs surveyed, more than 50% frequently provid-

ed the more traditional elements of patient education (eg,

education regarding foot care, insulin injection, blood

glucose monitoring). However, more than 20% frequent-

ly provided services within the medical management

domain (eg, medication adjustment, insulin adjustment,

physical examination, and ordering of lab tests). The

scope of practice for RDs was considerably narrower

compared to RNs with respect to education and medical

management, with RD services typically limited to gen-

eral diabetes education and diet prescription. In 1999, a

similar survey (N = 97) described practice patterns in

Georgia and compared them to those reported in the

1992 New York survey.17 The 1999 Georgia findings indi-

cated that the overall practice patterns of the Georgia

educators were similar to those of their New York coun-

terparts, with RNs providing a wider range of diabetes

services compared to RDs. However, the Georgia RNs

and RDs provided a broader scope of education and

medical management services in 1999 when compared

to their New York counterparts in 1992. The trends

described in these 2 surveys reflect changes in diabetes

health care standards of practice and treatment guide-

lines that may have a significant impact on diabetes edu-

cator practice patterns.

The New York and Georgia surveys provided valuable

insight regarding potential variables, such as health care

discipline (ie, RN vs RD) and geography, which may

influence practice patterns. It is noteworthy that the New

York survey was conducted before the publication of the

landmark Diabetes Control and Complications Trial,18

the AADE “1999 Scope of Practice for Diabetes

Educators and the Standards of Practice for Diabetes

Educators,”15 and the American Dietetic Association’s

“Nutrition Practice Guidelines for Diabetes,”19,20 while

the Georgia survey was conducted several years after

these pivotal publications.

The certified diabetes educator (CDE) credential

ensures a standardized level of knowledge, skills, and

experience related to the disease of diabetes and diabetes

education, which can positively influence delivery of

health care to people with diabetes.21 Another influence

on the discipline of diabetes education has been the

establishment of the National Standards for Diabetes

Self-management Education (DSMT),22 which defines

10 areas of diabetes knowledge and skills that individu-

als with diabetes must master to effectively manage the

disease. These content areas include the following:

• describing the diabetes disease process/treatment options;

• incorporating appropriate nutritional management;

• incorporating physical activity into lifestyle;

• using medication management where appropriate for thera-

peutic effectiveness;

• monitoring blood glucose and urine ketones (when appro-

priate) and using the results to improve glycemic control;

The Diabetes EDUCATOR

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362

Volume 31, Number 3, May/June 2005

• preventing, detecting, and treating acute complications;

• preventing (through risk reduction behavior), detecting, and

treating chronic complications;

• goal setting to promote health and problem solving for daily

living;

• integrating psychosocial adjustments into daily life; and

• promoting preconception care and managing pregnancy/

gestational diabetes (if appropriate).

Delivery of these knowledge and skill sets is accom-

plished using an individualized education process.

Effective DSMT must include the following compo-

nents:

• assessment,

• development and implementation of an educational plan,

• evaluation of the plan’s success,

• documentation of all educational encounters.

Diabetes educators are assuming more complex roles

in the health care arena. As echoed by Cypress et al,16 a

systematic definition of practice patterns is needed to

identify certification requirements as well as promote the

continued growth and integrity of diabetes education.

Moving forward, it is important to evaluate whether the

trends observed by Kaufman et al in 1999 have contin-

ued.17 This study surveyed diabetes educators across the

United States to (1) evaluate the trend of CDE certifica-

tion; (2) assess the relationship between practice patterns,

overall scope of practice differences, and certification

status (ie, CDE vs non-CDE); and (3) evaluate the poten-

tial influence of geography on practice patterns.

Research Design and Methods

Survey Instrument

The survey used in this study was developed to evalu-

ate current trends in the practice patterns of health care

professionals involved in the education, care, and man-

agement of persons with diabetes. A multidisciplinary

team of experienced diabetes care practitioners devel-

oped the survey content based on responsibilities and

services falling within the domain of the diabetes educa-

tor. Consistent with previous surveys, the range of

responsibilities and services assessed fell into 2 broad

categories: DSMT and medication/medical management.

Respondents indicated their involvement in the various

practices listed in the survey during the past 12 months.

Survey Distribution

The survey was distributed broadly across the United

States via 3 routes. Surveys were initially e-mailed to

approximately 160 diabetes educators who had been

invited to and/or participated in educational advisory

board meetings across the United States from February

2000 through February 2003. These initial recipients

were asked to complete the survey as well as forward it

to their diabetes educator colleagues, the membership of

local AADE chapters, and other health care profession-

als involved in the education, care, and management of

persons with diabetes. The latter strategy helped ensure

that the survey was received by a more heterogeneous

population, avoiding the possible bias associated with

sampling a homogeneous group (eg, diabetes educators

who attend advisory boards). Finally, the survey was dis-

tributed at 17 AADE chapter meetings during 2002 and

early 2003.

Data Analysis

Respondent demographics/characteristics. The

percentage of respondents within each US Census

Figure 1. Survey items.

Question 1: Which services have you provided in the conduct of your usual dutiesover the past 12 months (check all that apply)?

DSMT responses (practices ranked from most to least complex)❏ Pump training❏ Initiation of multiple daily insulin injections❏ Pen device training❏ Insulin initiation❏ Diet/exercise training❏ Self-monitored blood glucose training❏ General diabetes education

Medication/medical management responses (no ranking)❏ Clinical evaluation/management❏ Adjust medication

Question 2: Over the past 12 months, if you have made diabetes medicationadjustments, which medications have been adjusted? Choose 1 answer.

Medication/medical management responses (position of activity does not imply adegree of greater or lesser complexity)

❏ Adjust both oral diabetes medication and insulin❏ Adjust only insulin❏ Adjust only oral diabetes medication






364


Bureau–defined region was compared to the percentage

of the total US population within those same regions to

evaluate whether the respondents represented a balanced

sample with regard to geographical location.

CDE certification trends. The percentage of CDEs

in the current sample was compared to the percentages

reported in the 1992 and 1999 surveys and to the total

number of US CDEs for those same years. This retro-

spective comparison examined whether the trend noted

in 1999 (increased percentage of CDEs relative to 1992)

continued. If the results of this survey demonstrate a con-

tinuation of the trend, then a parallel trend should be

observed in the total number of US diabetes educators

actually known to have been certified during these years.

Thus, comparison with a concurrent source of data (ie,

total number of US CDEs) is one method of evaluating

the validity of the trend across survey studies.

Credentials and practice patterns. CDEs and non-

CDEs were compared relative to their health care license

(RN, RD, LVN/LPN, NP, RPh, and PA) as well as place

of practice (hospital inpatient, hospital outpatient, hospi-

tal inpatient and outpatient, individual MD clinic, and

community clinic). CDEs and non-CDEs were also com-

pared based on the percentage of items indicated in the

DSMT and medication/medical management categories

(Figure 1). In the DSMT category, items were ranked

along a continuum from the most to least complex to

evaluate whether there were differences between CDEs

and non-CDEs based on the presumed level of knowledge

and skill required to deliver each of the DSMT services.

Geographic influence. Respondents were grouped

into 1 of the 4 Census Bureau geographic regions

(Northeast, South, Midwest, and West) based on state of

residence. The survey responses were then assessed

across regions.

Statistics

The survey yielded bivariate data; thus, χ2 values were

computed to evaluate the statistical significance for

group comparisons on each of the designated items. For

each comparison, a χ2 value was calculated according to

a 2 × 2 (CDE status × bivariate survey response) or 4 × 2

(region × bivariate survey response) tabular design. The

Bonferroni correction (α = .05/number of comparisons =

12) was used to control for the inflated risk of type 1

error associated with multiple, post hoc comparisons.

Based on this correction, the criterion for statistical sig-

nificance was set at P < .001.

Results

Demographics

Of the 554 surveys returned by the February 2003

deadline, 507 were evaluable (partially completed sur-

veys were excluded from analysis), and 84 of the 507

Table 1

Distribution of Respondents’ Surveys

Region States US Population, % Respondents, %

Northeastern Maine, New Hampshire, Vermont, New York, Massachusetts,

Rhode Island, Connecticut, Pennsylvania, New Jersey, Delaware 19 9

Southern Alabama, Arkansas, Washington DC, Florida, Georgia,

Kentucky, Louisiana, Maryland, Mississippi, North Carolina,

Tennessee, Texas, Virginia, West Virginia 36 45

Midwestern Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri,

Nebraska, North Dakota, Ohio, South Dakota, Wisconsin 22 28

Western Alaska, Arizona, California, Colorada, Hawaii, Idaho, Montana,

Nevada, New Mexico, Oregon, Utah, Washington, Wyoming 23 19






366


respondents were non-CDEs. The 4 US geographical

regions as defined by the Census Bureau are represent-

ed (Table 1).23

Trend in Percentage of CDEs Between1991 and 2002

The number of diabetes educators obtaining CDE sta-

tus has continued, validating the trend observed by

Kaufman et al in 1999.17 Figure 2 represents the change

in the number of certifications awarded by the National

Certification Board for Diabetes Educators for 1992 (n =

6300), 1999 (n = 9000), and 2002 (n = 13 000).24

Comparison of ProfessionalCredentials, Place of Practice,and Practice Patterns

Although the groups were disproportionate in size

(CDEs = 423, non-CDEs = 84), the various health care

disciplines and places of practice were represented

across all regions (Table 2). Thus, differences in practice

patterns between CDEs and non-CDEs were not likely

the result of differences in professional licenses or place

of practice.

Evaluation of Practice Patterns

Statistically significant differences in practice pat-

terns were seen between CDEs and non-CDEs for initia-

tion of insulin, pen device training, initiation of multiple

daily insulin injections, and pump training (all P < .001;

Figure 3A). These practices were ranked as being more

complex. The groups did not differ on items that were

ranked as less complex (eg, general diabetes education,

self-monitored blood glucose training). Statistically sig-

nificant differences in medical/medication management

practice patterns were seen between CDEs and non-

CDEs for clinical evaluation/management (P < .001),

adjusting medication (P < .001), and adjusting oral dia-

betes medication and insulin (P < .001; Figure 3B).

Because LVN/LPNs are not eligible for certification as a

CDE, those respondents were not included in the above

comparisons.

Evaluation of National PracticePatterns by Region (CDEs Only)

Because of the limited sample size of evaluable sur-

veys in the non-CDE group (n = 84), analysis of the

influence of region on practice patterns was limited to

the CDE group. DSMT practice patterns were not affect-

Table 2

Professional Characteristics of Survey Respondents

CDEs Non-CDEs (n = 423),% (n = 84),% P < .001

Professional license

RN 63 46 No

RD 30 31 No

LVN/LPN* 0 7 NA

NP 5 8 No

RPh 3 5 No

PA <1 1 No

Place of practice

Hospital inpatient 30 37 No

Hospital outpatient 62 54 No

Hospital in- and outpatient 26 26 No

Individual MD practice 4 0 No

Community clinic 4 1 No

Percentages might not total 100 due to rounding. NA = not applicable.*LVN/LPNs are not eligible for CDE certification.

1992 1996 20020

20

40

60

80

100

0

5000

10000

15000

%C

DE

s

To

tal U

S C

DE

s

%CDEs

Total US CDEs

1992 1996 20020

20

40

60

80

100

0

5000

10000

15000

%C

DE

s

To

tal U

S C

DE

s

%CDEs

Total US CDEs

%CDEs

Total US CDEs

Figure 2. Certification status: survey respondents and total US diabeteseducators. CDE = certified diabetes educator.






368


ed by geographic region (Figure 3C). However, med-

ical/medication management practice patterns showed a

significantly (P < .001) lower percentage of midwestern

CDEs making adjustments to oral diabetes medications

and/or insulin compared to CDEs from other regions

(Figure 3D).

Discussion

The results of this survey suggest the following:

• The trend of increasing CDE certification, observed in 1999

by Kaufman et al,17 has continued through 2002 and is sup-

ported by the total number of CDEs for those years.

Figure 3. Variations in practice patterns: certified diabetes educator (CDE) versus non-CDE credential and geographic regions. DSMT=diabetes selfmanagement training; MDI=multiple daily insulin injections; SMBG=self-monitored blood glucose.

0 20 40 60 80 100

General Diabetes Education

SMBGI

Diet/Exercise Training

Initiating Insulin

Pen Training

MDI Initiation

Pump Training

CDEnon-CDE

*

*

*

*P <0.001

More C

omplex

Less Com

plex

*

Percent0 20 40 60 80 100

Adjust oral meds only

Adjust insulin only

Adjust oral meds & insulin

Med adjustment

Clin eval/management

CDEnon-CDE

*

*

*

*P<0.001

Percent

0 20 40 60 80 100

General Diabetes Education

SMBGI

Diet/Exercise Training

Initiating Insulin

Pen Training

MDI Initiation

Pump Training

% Northeast% South% Midwest% West

More C

omplex

Less Com

plex

Percent

0 20 40 60 80 100

Adjust oral meds only

Adjust insulin only

Adjust oral meds & insulin

Med adjustment

Clin eval/management

% Northeast% South% Midwest% West

*

*P<0.001

Percent

3A CDE vs. non-CDE: DSMT Practices 3B CDE vs. non-CDE:Medications/medicalmanagement

3C CDE DSMT Practices by Geographic Region 3D CDE Medications/medicalmanagement by Geographic Region






370


• Practice patterns are significantly influenced by certifica-

tion status, with a higher percentage of CDEs engaging in

complex DSMT and medical/medication management prac-

tices compared to non-CDEs.

• Practice patterns among CDEs differed minimally across

the 4 major regions of the United States.

Evaluation of the respondents’ professional disci-

plines suggests that certification was the primary vari-

able accounting for the observed differences in practice

patterns. For example, although a higher percentage of

CDEs than non-CDEs reported having an RN degree, the

difference was modest (16%) and not statistically signif-

icant. There was also little variation between groups with

regard to their place of professional practice, with the

highest percentage of respondents in both groups report-

ing the hospital outpatient setting as their place of prac-

tice.

These results, however, require interpretation with the

following caveats. First, the small sample size of the

non-CDE group precluded statistical analysis of region-

al practice patterns. Inadequate sampling of non-CDEs

across geographical regions increases the chance that

their practice patterns were indicative of a regional

nuance or other sampling bias and not representative of

the national non-CDE population. Second, the survey

instrument might have lacked sufficient specificity to

capture the full breadth of respondent characteristics,

and the differences in practice patterns might have been

an artifact of a variable(s) not assessed by the current

study. For example, the survey did not assess years of

diabetes educator experience. Thus, the group differ-

ences might have been attributable to the number of

years within the profession, with certification synony-

mous with more years of experience. Last, respondents

describing themselves as diabetes educators might have

transitioned into other health care professional roles such

as administrators, managers/directors, or academics who

did not routinely deliver services within either the

DSMT or medical/medication management categories.

Thus, the differences in practice patterns between CDEs

and non-CDEs reported here should not be taken as a

reflection of the qualifications or the competence of non-

CDEs.

Several areas warrant further investigation based on

the findings of this study. First, there is a need to more

clearly delineate differences in practice between

advanced practice clinicians (such as NPs, PAs, and

PharmDs, including those with BC-ADM) and CDEs

without advanced practice credentials. Second, a deeper

exploration of nontraditional work settings might uncov-

er a shift in practice settings from hospital to communi-

ty based and improve understanding of how the practice

of diabetes education is potentially changing. Third,

more comprehensive distribution of surveys would pro-

vide greater geographic scope, which would more accu-

rately describe regional practice variations, identify

weaknesses in diabetes education, and consequently sig-

nal the need for greater focus in some areas. Fourth,

behavioral interventions, the fundamental basis of

DSMT, need to be more clearly delineated and explored.

Both Cypress et al16 and Kaufman et al17 reported the

underutilization of behavioral interventions as an area of

weakness in diabetes education, yet it was addressed in

only a very global sense in both of their surveys (only 1

question was asked) and not well explored in this survey.

Conclusion

In this survey, a higher percentage of diabetes educa-

tors with certification reported engaging in complex

DSMT and medical/medication management practices

compared to diabetes educators with similar credentials

but without certification. This outcome suggests that cer-

tification represents an important step in the evolution of

a diabetes educator’s role. Achieving this milestone may

mark the acquisition of skills requisite for expansion of

the educator’s scope of practice to include the delivery of

more complex services.

References

1. Allen NA. The history of diabetes nursing, 1914–1936. DiabetesEduc. 2003;29:6:976-988.

2. Young-Hyman D. Provider impact in diabetes education.

Diabetes Educ. 1999;25(suppl):34-42.

3. Valentine V, Kulkarni K, Hinnen D. Evolving roles: from diabetes

educators to advanced diabetes managers. Diabetes Educ.

2003;29:598-608.

4. Daly A. Advanced practice care in diabetes. Diabetes Educ.

2003;29:592-596.

5. Burson R. The advanced practice diabetes educator. DiabetesEduc. 2002;28:182-184.

6. Polonsky WH, Earles J, Smith S, et al. Integrating medical man-

agement with diabetes self-management training. Diabetes Care.

2003;26:3048-3053.






372


7. American Association of Diabetes Educators Position Statement.

Intensive diabetes management: implications of the DDCT and

UKPDS. Diabetes Educ. 2002; 28:735-740.

8. American Association of Diabetes Educators. White paper on the

prevention of type 2 diabetes and the role of the diabetes educa-

tor. Diabetes Educ. 2002;28:964-971.

9. Peters A, Davidson M. Application of a diabetes managed care

program. Diabetes Care. 1998;21:1037-1043.

10. Barnes C, Ziemer DC, Miller CD, et al. Little time for diabetes

management in the primary care setting. Diabetes Educ.

2004;30:126-133.

11. Tomky D, Weaver T, Mulcahy K, Peeples M. Diabetes education

outcomes: what educators are doing. Diabetes Educ.

2000;26:951-954.

12. Mulcahy K, Maryniuk M, Peeples M, et al. Diabetes self-man-

agement education core outcomes measures. Diabetes Educ.

2003;29:768-803.


Standards for outcomes measurement of diabetes self-manage-

ment education. Diabetes Educ. 2003;29:804-815.

14. Norris SL, Nichols PJ, Casperson CJ, et al. Task Force on

Community Preventive Services. The effectiveness of disease and

case management for people with diabetes: a systematic review.

Am J Prev Med. 2002;22(suppl 4):15-38.


The 1999 scope of practice for diabetes educators and the stan-

dards of practice for diabetes educators. Diabetes Educ.

2000;26:519-525.

16. Cypress M, Wylie-Rossett J, Engel SS, Stager TB. The scope of

practice of diabetes educators in a metropolitan area. DiabetesEduc. 1992;18:111-114.

17. Kaufman MW, All AC, Davis H. The scope of practice of diabetes

educators in the state of Georgia. Diabetes Educ. 1999;25:56-64.

18. Diabetes Control and Complications Trial Research Group. The

effect of intensive treatment of diabetes on the development and

progression of long-term complications in insulin-dependent dia-

betes mellitus. N Engl J Med. 1993;329:977-986.

19. Monk A, Barry B, McClain K, Weaver T, Cooper N, Franz M.

Practice guidelines for medical nutrition therapy provided by

dieticians for persons with non-insulin-dependent diabetes melli-

tus. J Am Diet Assoc. 1995;95:999-1006.

20. Kulkarni K, Castle G, Gregory R, et al, for the Diabetes Care and

Education Dietetic Practice Group. Nutrition practice guidelines

for type 1 diabetes mellitus positively affect dietician practices

and patient outcomes. J Am Diet Assoc. 1998;98:62-70.

21. The National Certification Board for Diabetes Educators. About

NCBDE certification. Available at: http://ncbde.org/about.html.

Accessed October 4, 2004.

22. Mensing C, Boucher J, Cypress M, et al. National standards for

diabetes self-management education. Diabetes Care.

2000;23:682-689.

23. US Census Bureau. Available at: http://factfinder.census.

gov/servlet/TMGeoSearchByListServlet?ds_name=PEP_2003_E

ST&_lang=en&_ts=114091540822. Accessed September 17,

2004.

24. The National Certification Board for Diabetes Educators. Data on

file (Arlington Heights, Ill). Accessed October 13, 2004.



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Diabetes Educators: Assessment of Evolving Practice