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
Barlow et al
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rDiabetes Educators
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.
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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;
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The Diabetes EDUCATOR
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• 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
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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
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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.
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The Diabetes EDUCATOR
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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
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• 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.
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