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The DCCT substantiated the commitment to education, the value of a multidiscipli-nary team, and the expanded role of nurses and dietitians. Since the DCCT report in 1993 (22), the roles and responsibilities of diabetes educators have changed greatly. The study validated the need for dietitians and nurses to increase their involvement in patient management in order to achieve optimal glucose control (23,24). Investigators in the study realized that intensive management was far more than increased frequency of monitoring or additional injections of insulin. It required careful follow-up to monitor progress toward individualized goals and support to reinforce management skills. Such complexities extend beyond the scope of sole practitioners whose training may be limited to medical management. In order to achieve metabolic outcomes with intensive therapy, health care professionals skilled in the teaching-learning process and behavioral strategies were needed. Inclusion of these individuals and adoption of this model is relatively new to diabetes, and as it evolves, it will require shifts in how diabetes providers view their roles and relationships both with patients and each other (25).

Diabetes educators have been recognized as essential providers of diabetes care in the United States and are gaining recognition throughout the world. A diabetes educator

Table 2

National Standards for Diabetes Self-Management Education (DSME)

Standard 1. The DSME entity will have documentation of its organizational structure, mission statement, and goals and will recognize and support quality DSME as an integral component of diabetes care.

Standard 2. The DSME entity will determine its target population, assess educational needs, and identify the resources necessary to meet the self-management educational needs of the target population(s).

Standard 3. An established system (committee, governing board, advisory body) involving professional staff and other stakeholders will participate annually in a planning and review process that includes data analysis and outcome measurements and addresses community concerns.

Standard 4. The DSME entity will designate a coordinator with academic and/or experiential preparation in program management and the care of individuals with chronic disease. The coordinator will oversee the planning, implementation, and evaluation of the DSME entity. Standard 5. DSME will involve the interaction of the individual with diabetes with a multifac-eted education instructional team, which may include a behaviorist, exercise physiologist, ophthalmologist, optometrist, pharmacist, physician, podiatrist, registered dietitian, registered nurse, other health care professionals, and paraprofessionals. DSME instructors are collectively qualified to teach the content areas. The instructional team must consist of at least a registered dietitian and a registered nurse. Instructional staff must be Certified Diabetes Educators (CDEs) or have recent didactic and experiential preparation in education and diabetes management. Standard 6. The DSME instructors will obtain regular continuing education in the areas of diabetes management, behavioral interventions, teaching and learning skills, and counseling skills.

Standard 7. A written curriculum, with criteria for successful learning outcomes, shall be available. Assessed needs of the individual will determine which content areas listed below are delivered.

Standard 8. An individualized assessment, development of an educational plan, and periodic reassessment between participant and instructor(s) will direct the selection of appropriate educational materials and interventions. Standard 9. There shall be documentation of the individual's assessment, education plan, intervention, evaluation, and follow-up in the permanent confidential education record. Documentation also will provide evidence of collaboration among instructional staff, providers, and referral sources.

Standard 10. The DSME entity will utilize a continuous quality improvement process to evaluate the effectiveness of the education experience provided and determine opportunities for improvement.

is a health care professional who has mastered a core of knowledge and skill in the biological and social sciences, communication, counseling, and education and who has experience in the care of patients with diabetes. The role of the diabetes educator can be assumed by various health care professionals, including, but not limited to, nurses, physicians, dietitians, social workers, podiatrists, exercise physiologists, and pharmacists. In order to assure high professional standards and to identify for the patient competencies and quality education, the American Association of Diabetes Educators (AADE) (26) and the Australian Diabetes Educator Association have established

Table 3

Standards of Practice for Diabetes Educators

Standard I. Assessment. The diabetes educator should conduct a thorough, individualized needs assessment.

Standard II. Use of resources. The diabetes educator should strive to create an educational setting conducive to learning with adequate resources to facilitate the learning process.

Standard III. Planning. The written educational plan should be developed from information obtained on the needs assessment and based on the components of the educational process. The plan is coordinated with other members of the team.

Standard IV. Implementation. The diabetes educator should provide individualized education based on a progression from basic survival skills to advanced information for self-management.

Standard V. Documentation. The diabetes educator should completely and accurately document the educational experience.

Standard VI. Evaluation and outcome. The diabetes educator should participate in an annual review of the quality and outcome of the education process.

Standard VII. Multidisciplinary collaboration. The diabetes educator should collaborate with the multidisciplinary team of health care professionals and integrate their knowledge and skills to provide a comprehensive educational experience.

Standard VIII. Professional development. The diabetes educator should assume responsibility for professional development and pursue continuing education to acquire current knowledge and skills.

Standard IX. Professional accountability. The diabetes educator should accept responsibility for self-assessment of performance and peer review to assure the delivery of high-quality diabetes education.

Standard X. Ethics. The diabetes educator should respect and uphold the basic human rights of all persons.

Source: The 1999 Scope of Practice for Diabetes Educators and the Standards of Practice for Diabetes

Educators. American Association of Diabetes Educators. Diabetes Educ 2000;26:53-59.

standards and scopes of practice for diabetes educators (27). The AADE Standards of Practice for Diabetes Educators are presented in Table 3.

The Scope of Practice provides definitions of diabetes education while providing statements of beliefs regarding the educational process. The primary focus for the diabetes educator is the patients and their families. The content of the educational experience should include the following topics:

• Pathophysiology of diabetes

• Pharmacologic interventions

• Self-monitoring

• Prevention and management of the acute and chronic complications

• Psychosocial adjustment

• Problem-solving skills

Stress management

• Use of the health care delivery system

The Scope of Practice and Standards of Practice provide a framework for health care professionals who teach people with diabetes. In recent years, the scope of practice for diabetes has expanded to involve advanced practice roles that may have been previously considered to be medical management. In order to meet the needs of all individuals who require diabetes education in the prevention and treatment of the disease, diabetes educators will need to be recognized and accepted by a variety of disciplines. In order to assure that the educational process is effective, those providing this service must be trained in the proper steps of delivery, as well as the use of behavioral strategies.

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