The documents included in the review provided sufficient information to trace the interprofessional evolution of the diabetes educator role from the inauguration of ADEA until June 2017. The evolution is described according to four drivers which became evident throughout the analysis. These drivers are presented as sub-sections and will be prefaced by an overview of the evolution of the diabetes workforce in adopting an increasingly interprofessional profile and function.
The evolution of the diabetes workforce: Moving towards interprofessional roles
ADEA was established in 1981. In a paper published in 1984,
Diabetes education in Australia, the author and first ADEA president described the unstructured manner in which diabetes education was provided by designated nurses in the hospital setting in 1970s and the circumstances that led to the inauguration of ADEA. The first outpatient Diabetes Education Centre in Australia was established at the Royal Newcastle Hospital in 1974. In the decade that followed, there was significant growth in the clinical area of diabetes education and it became recognised as a health care specialty [
17]. Although the author acknowledged the tendency for diabetes education to be provided using a team-based approach, role boundaries in diabetes education were delineated, ‘All newly diagnosed diabetics both type I and type II received guidance with their individual meal plans from the dietitians and diabetes education from the nurse educator’ ([
17], p. 22). ADEA’s membership which was 300 strong, included nurses, podiatrists, dietitians, medical officers, psychologists, pharmacists, occupational therapists and ‘lay diabetes educators’ ([
17], p. 23).
In 1986, ADEA introduced the certification trademark Credentialled Diabetes Educator (CDE) [
18]. In 1989,
The Role Statement of the Diabetes Nurse Educator was published [
19,
20], which suggested diabetes education was considered part of the nursing remit. In 1991,
National Standards of Practice for Diabetes Educators was published. It referred to the ‘multiplicity of professional backgrounds and experiences of diabetes educators’ ([
21], p. 1) however it did not specify those health professions eligible for ADEA credentialling.
In 1994,
National Guidelines for the Safe Practice of Diabetes Nurse Educators was published. As the title suggests, this document related specifically to nurse diabetes educators and discussed the ethico-legal dilemmas that may be encountered in practice. While the document stated, ‘diabetes management is increasingly considered to be team care’ ([
22], p. 4), no other non-medical health professions were mentioned.
In 1996,
National Core Competencies for Diabetes Educators was published. At that time, ADEA recognised nurses, dietitians, podiatrists, psychologists and social workers as the professions providing specialised care for people with diabetes. This document referred members to the legal, ethical and professional standards of their primary disciplines to guide diabetes education practice [
23]. The document detailed five units of competency. Unit 1.4 described a competent diabetes educator as one that, ‘Maintains and applies clinical skills appropriate to the educator's clinical discipline and their specialist function, for example, nurses: insulin dosage adjustment or correct injection technique, dietitians: diabetes dietary prescription, podiatrists: wound management’ ([
23], p.3). The role boundaries between the different primary professions working in the diabetes education realm were delineated here.
In the 1990s, the Dietitians Association of Australia approached ADEA for approval for eligibility for credentialling. Approval was granted and in 1999 the first dietitian successfully became a CDE (Per Communication, 30th August, 2016). In 2001
Role of the Diabetes Educator in Australia was updated. The revised document acknowledged that since the publication of the first role statement for nurse diabetes educators in 1989, there had been a growth in the size and diversity of the ADEA membership [
19].
In 2001,
Credentialling of Diabetes Educators 2000 was published. It stated that diabetes educators must have a base qualification as either RN, dietitian, podiatrist, psychologist, medical officer or Aboriginal health worker. In 2003, the
National Standards of Practice for Diabetes Educators document was updated. This document listed the professions able to practise diabetes education as nursing, dietetics, podiatry, psychology, medicine, physiotherapy and Aboriginal health workers [
24]. In 2005 a joint statement between the Dietitians Association of Australia (DAA) and ADEA was published. This document indicated that at the time, role overlap in diabetes education had increased: ‘ ... opportunities for expanded spheres of practice have resulted in the practice of diabetes education becoming more
interdisciplinary in nature’([
25], p.1). As such, the roles of the dietitian and diabetes educator required clarification.
The first podiatrist achieved CDE status in 2004 (Per Communication, 3rd October, 2016). In 2005,
All about diabetes educators – a guide for General Practitioners, was published. This article stated that only RN CDEs were qualified to sign National Diabetes Services Scheme forms, confirming a person’s diagnosis of diabetes [
26]. In 2007 registered pharmacists accredited to conduct medication management reviews were deemed eligible to achieve CDE status [
27]. In 2007
The Credentialled Diabetes Educator in Australia – Role and Scope of Practice was updated. It stated, ‘In light of the expanding role of Credentialled Diabetes Educators, the ADEA completed a review of the health disciplines that it recognises as eligible for credentialling in 2007’ [20, p.7]. The findings of the review were that RNs, dietitians, registered pharmacists (accredited to conduct medication management reviews) and medical officers were CDE eligible. Podiatrists, who had previously been approved CDE eligible, were not listed. Consistent with the previous role and scope of practice documents, the 2007 version stipulated that each CDE’s role, scope of practice and provision of clinical care is congruent with that of their primary profession.
In 2008, registered podiatrists were deemed CDE eligible [
28]. The first pharmacist achieved CDE status in 2009 (Per Communication 30th August, 2016). In 2012, accredited exercise physiologists became CDE eligible [
29]. In 2014, an application was made to ADEA to repeal the requirement for pharmacists to have medication management accreditation in order to be considered eligible for CDE status [
18].
In 2015, direct entry midwives and physiotherapists were approved as CDE eligible [
18]. Also in 2015, the joint position statement between the Dietitians Association of Australia and ADEA was updated. This was the earliest document included in this review that emphasised the interdisciplinary nature of the diabetes educator role and diabetes self-management education (DSME):
Regardless of primary health discipline background, all CDEs are eligible to undertake all aspects of DSME. The extent of DSME provided by a CDE does not depend on their primary health discipline but is dependent on individual self-determined role and scope of practice ([
30], p.8).
It stated that all CDEs are qualified to sign NDSS forms and eligible to claim Medicare, DVA and private health insurance rebates where applicable, for DSME services.
In 2015, the
Role and Scope of Practice for Credentialled Diabetes Educators in Australia was updated. Like the preceding version, this document emphasised that the role and scope of practice of a CDE is influenced by factors including legislation, professional experience, training, competency, workplace policies and others. Unlike preceding versions, which referred to discipline-dependent scope of practice, this document referred to ‘individual scope of practice’ ([
13], p.14).
In 2016, there had been a notable increase in CDEs of dietetics and podiatry background in the preceding year [
31]. A Communiqué was sent to all ADEA members entitled,
Working for All Members. It stated:
ADEA values and supports all its members and does not privilege or promote one discipline over another ... In creating messaging to government National Office and the Board seek expert advice. It is important that feedback is brief and very targeted. Trying to sell different versions of CDE weakens the message significantly, creates confusion and dramatically reduces interest in the topic as the key message is lost ... As you would be aware, especially in a political reality where there are continued major cuts to health care funding, any perception of division within a representative organisation is likely to result in ADEA’s issue not being prioritised. Division adversely impacts the authority of the organisations’ standing with the relevant government department and can undermine the arguments for change [
32].
This was a significant and overt action by ADEA to reduce perceived interprofessional role boundaries within the membership. While this communiqué demonstrated that the ADEA promoted an inclusive, interdisciplinary culture within the diabetes educator workforce, it exemplified the perception of enduring interprofessional boundaries. The communiqué discussed ADEA’s work advocating that CDEs of all disciplines have the right to authorise patient access to additional blood glucose test strips (BGTS) via the National Diabetes Services Scheme. ADEA was successful in this endeavour and stated that, ‘If the ADEA’s position was that only nurse CDEs should be able to authorise BGTSs, then ADEA would have been at risk of losing credibility and not being heard.’ [
32]. This indicates that, at the micro level at least, there were enduring perceptions of interprofessional role boundaries in the diabetes educator world and ongoing attempts to protect task domains.
The non-medical prescribing era
Insulin is one of the main medications used to manage diabetes. In 1994 ADEA published
National Guidelines for the Safe Practice of Diabetes Nurse Educators. This document addressed several ethico-legal considerations for nurses providing diabetes education and stated that diabetes nurse educators were, ‘... responsible for teaching the patient insulin technique including appropriate insulin adjustment. It is important for individual educators to clarify, and have documented practice guidelines, with respect to medication adjustment, with their employing body’ ([
22], p.5). At this time, insulin was a schedule III drug, which meant it could be purchased from a pharmacy without a prescription. This document further stated, ‘nurses cannot prescribe insulin. Therefore any medication adjustment must occur under the standing orders of the doctor’ ([
22], p.10).
The
National Core Competencies for Diabetes Educators was published in 1996. It provided examples of clinical tasks undertaken by diabetes educators specific to their primary discipline. Unit 1.4 stated that a diabetes educator, ‘Maintains and applies clinical skills appropriate to the educator's clinical discipline and their specialist function, for example, nurses: insulin dosage adjustment or correct injection technique ... ’ ([
23], p.3). Insulin adjustment was considered part of the nurse diabetes educator’s role at that time.
In March 2000, insulin was rescheduled from schedule III to a schedule IV drug. Consequently, as of December 2000 only a medical practitioner could prescribe insulin [
33,
34]. This legislative change meant RN diabetes educators’ autonomy was diminished significantly. Subsequently, a group of RN CDEs in New South Wales successfully lobbied for the right to issue a seven day supply of insulin to patients in accordance with a prescription from a medical practitioner [
34,
35]. This delineated the boundaries between RN and non-nurse diabetes educators, in New South Wales at least.
The
National Core Competencies for Diabetes Educators was updated in 2001. Like the 1996 version, five units of competency were defined, unit 1.4 providing examples of discipline-specific diabetes educator practices, ‘nurses: insulin dosage adjustment or correct injection technique ... ’ ([
36], p.3). This indicates that in 2001, insulin adjustment was considered part of the nurse diabetes educator role, despite insulin being rescheduled to a prescription-only medication the previous year.
In 2004, ADEA published
National Standards for the Development and Quality Assessment of Services Initiating Insulin Therapy in the Ambulatory Setting which outlined a number of standards. Structure Standard 2.1 stated, ‘Registered Nurse Diabetes Educators and Dietitian Diabetes Educators who undertake a coordinating and primary role in the ambulatory initiation of insulin therapy have a minimum of 12 months supervised, relevant clinical experience’ ([
37], p.23).
In 2007,
The Credentialled Diabetes Educator in Australia: Role and Scope of Practice was published. It stated that some CDEs have a role in ‘specific aspects of diabetes care, such as insulin initiation and stabilisation’ ([
20], p.11). There was an apparent decline in the emphasis on the RN CDE’s role in insulin adjustment. In 2008, the
National Core Competencies for Diabetes Educators was updated. This version omitted references to specific clinical applications such as insulin adjustment [
38].
In June 2009, legislation was passed enabling podiatrists in Victoria, with relevant endorsement, to prescribe schedule IV drugs according to a formulary [
39]. In 2010, an article was published in the Diabetes Management Journal,
Nursing roles in initiating and adjusting insulin. The author and past ADEA president discussed circumstances in which RNs were able to prescribe insulin: with endorsement as a nurse practitioner (NP) or with a service protocol [
40].
In 2014, ADEA published the
Australian Credentialled Diabetes Educators and Prescribing of Insulin and Glucose Lowering Agents - Scoping paper. Whilst the document stipulated that ADEA did not endorse prescribing practices, it did state, ‘Some CDEs, such as a registered nurse or pharmacist, may through delegation or referral from an authorised medical practitioner accept secondary prescribing responsibilities ... ’ ([
43], p.13). A subsequent document published in 2015,
Australian Credentialled Diabetes Educators and Prescribing of Insulin and Glucose Lowering Agents, further detailed the actions required to progress ADEA’s ambition to extend the scope of practice of CDEs to include non-medical prescribing. It stated that, ‘The difference between the role of the nurse practitioner (diabetes) and future RN CDE with prescribing rights should be delineated’ ([
43], p.5).
In 2015, the Role and Scope of Practice for Credentialled Diabetes Educators in Australia was updated. Unlike the preceding version this revision stated explicitly, ‘The current scope of practice of the CDE does not include prescribing or titrating of any medications, unless there is legislated change or endorsement of these functions by state and territory governments’ ([
13], p.18). Legislation appears to be the most salient factor guiding the perceived roles and scopes of practice of diabetes educators and yet with the legislative changes affecting the different CDE eligible professions that have occurred over time, the role boundaries and scopes of practice of diabetes educators of different backgrounds have become arguably more ambiguous.
Expansion of the Medicare benefits schedule era
Medicare is Australia’s publicly funded national health insurance system which has been in place since 1975. In its early years, Medicare benefits were almost exclusively accessible by the medical profession [
44]. Throughout 1985–86, the Layton Inquiry was undertaken, which, in part, sought to determine whether the Medicare Scheme should be expanded to enable other, non-medical health services to access benefits for their services. Some 22 non-medical health professions made submissions, seeking inclusion in the Medicare Scheme. The Australian Medical Association opposed the expansion of the Medicare Scheme. The outcome was that Medicare benefits would remain as they were: available to the medical profession and optometry with very restricted benefits for dental services [
45,
46].
Almost 20 years later, in 2004, podiatrists, dietitians, mental health nurses and dentists were included in the Medicare Benefits Schedule (MBS), as it came to be known. These professions could apply for a Medicare provider number and provide services attracting partial Medicare rebates to patients, for patients with a specific type of referral from a medical practitioner [
47]. This was a significant event for the health professions concerned, as it enabled them to bulk bill or offer significantly subsidised services in the private sector. Subsequently, ADEA CDEs were included in the MBS [
48,
49]. The MBS has since expanded further to include more non-medical health services [
45,
46].
Around the time that CDEs were first included in the MBS, several professional associations approached ADEA seeking eligibility for credentialling. In 2006, ADEA reported, ‘A number of disciplines approached ADEA for eligibility for CDE® and the review has been conducted to assess eligibility against agreed criteria’ ([
50], p. 8)
. Pharmacists were added to the CDE eligibility list in 2007, podiatrists in 2008, exercise physiologists in 2012, direct entry midwives and physiotherapists in 2015. In 2016, ADEA reviewed the process and standards used to evaluate applications for CDE eligibility made by professional bodies [
32]. The criteria used to determine the eligibility of professions, while referred to as ‘relevant and robust’, are not available to the wider public [
31].
The competency movement
The competency movement began in the 1990s when the commonwealth government sought to introduce a nationally consistent approach to the training and qualification of workers across a range of industries. Competency standards serve as a quality assurance measure, reflecting the appropriate application of sound knowledge and skills within a particular vocational context [
51,
52]. In 1994, ADEA instigated the development of competencies for diabetes educators and in 1996, published
National Core Competencies for Diabetes Educators. Subsequently a paper entitled,
The process of developing and validating national core competencies for diabetes educators, was published in a peer-reviewed journal [
51]. The authors define the field of diabetes education as
interdisciplinary. ADEA’s
Core Competencies document provided examples of clinical competencies, defined according to primary discipline: ‘ ... nurses: insulin dosage adjustment or correct injection technique; dietitians: diabetes dietary prescription; podiatrists: wound care’ ([
23], p.3).
In 2005, the Productivity Commission released a research report,
Australia’s Health Workforce, which examined the issues affecting Australia’s health care workforce. The report described factors inhibiting health workforce innovation such as entrenched custom and practice, limiting role flexibility and impeding the ability of the workforce to meet its full potential [
3]. It was acknowledged that traditional health care roles and boundaries have their place, ensuring high quality patient care, however historical and rigid work practices can, ‘ … impede transferability of skills across professional boundaries; prevent appropriate recognition of prior learning; constrain the move to a more competency-based education and training system; and discourage the further development of multidisciplinary care approaches’ ([
3], p.29).
Furthermore, it indicated that professional bodies often implement strategies such as setting entry criteria and developing codes of conduct, which are primarily designed to uphold standards of quality and safety. These strategies, however, may also be driven by the desire to protect the professional task domain and associated income [
3]. In an appendix within ADEA’s
Role and Scope of Practice [
20] document, there is reference to the Productivity Commission’s 2005 Report:
The Productivity Commission Report is calling for professional boundaries and discipline specific practice to be broken down, for more interdisciplinary practice and for work place innovation. On the other hand, many disciplines and their governing or professional bodies are advocating recognition of advanced specialisations. In defining the role and scope of practice of the Credentialled Diabetes Educator, ADEA must be ready to embrace these possible changes ... ([
20], p.18).
ADEA’s mentoring program was launched in 2008 [
53]. A previous publication,
Credentialling of Diabetes Educators 2000, stated that mentoring partnerships
may be established between diabetes educators of different primary professions. In 2016, cross-discipline mentor partnerships were not just permissible, but were recognised as, ‘ ... a way to learn and experience new ideas in a two-way partnership’ ([
31], p. 41).
In 2012, the National Prescribing Service (NPS) published the
Competencies Required to Prescribe Medicines report. The report presented a competency framework for potential non-medical prescribers [
54]. The
Health Professionals Prescribing Pathway Project Final Report published in 2013 referred to the NPS competency framework and discussed non-medical prescribing practices which were already taking place by professions such as podiatry, nursing and dentistry. The report did not refer to competencies specific to particular health professions, but rather a more general discussion about the key qualities and skills which are indicative of competence in prescribing [
55].
ADEA’s most recent
Role and Scope of Practice for Credentialled Diabetes Educators in Australia [
13] document contained comparisons between the scopes of practice of diabetes educators in Australia, America and Canada. In America there are two diabetes educator certification pathways: the National Certification Board of Diabetes Educators and the American Association of Diabetes Educators (AADE). The professionals eligible for AADE certification include registered nurses, registered dietitians, registered pharmacists, physicians and physician assistants. There is a three-tiered approach to certification, with each tier corresponding to different levels of competencies. Each of the three certification levels can be obtained by any of the eligible professions. The system employed by the Canadian Diabetes Educator Certification Board is similar to ADEA’s, whereby diabetes educators are bound by the competencies specific to their primary profession. At the conclusion of ADEA’s international comparison, it stated,
Currently there exists debate about the level of competency for each discipline undertaking accredited courses in diabetes education and management. Many members would like to see a level playing field and competency outcomes developed for each of these courses. ADEA will explore this issue with the education facilities that offer the diabetes education and management course ([
13], p. 25).