Defining the Role of the Health Education Specialist in the
United States

Linda M. Siminerio, PhD, RN, CDE

The need for health promotion and education was recognized in the United States in the 1970s in response to growing disillusionment with the limits of medicine, pressures to contain high medical care costs, and a social and political climate emphasizing self-help and individual control over health.¹ Health promotion and education were given official recognition with the Canadian Lalonde Report² and the United States Surgeon General's Healthy People report.³ Both reports addressed the notion that individuals play an important part in modifying behaviors to sustain or improve their health.

Patient education, a specific type of health education, is practiced by use of a process of diagnosis and intervention. Patient education is an expanding and evolving field and is now recognized as an essential component of health care.⁴ Patient and public education programs are among the fastest growing components of health care in the United States, expanding from 50 hospitals with a patient education program in 1970 to the present, when virtually every health institution has some type of patient education program.⁵

While no exact numbers are available, it is safe to assume that, since 1970, the number of health educators has also been increasing in the United States. More professionals are completing professional preparation programs as well as participating in training and workshop programs to develop skills in providing health education.⁶ Although there has been tremendous progress in the past decade or two, there remain many misconceptions about health education and the role of health educators. Understanding these misconceptions is important because they can be potential barriers for both health educators and, ultimately, learners. A review of the frequently reported misconceptions is provided below.

Misconception #1: Health education is the transference of knowledge.
Education is more than simply imparting knowledge. In a meta-analysis of 26 studies that examined patients' compliance with prescribed medications, the relationship between knowledge and compliance varied greatly.⁷ Research examining the effects of diabetes education has not always been positive when the single measure of study is knowledge. Study results suggest that knowledge about diabetes may be necessary, but not sufficient, for improving metabolic control. Educational programs are not efficacious in achieving long-term improvement in diabetes control unless they also promote changes in attitude and motivation.⁸ Milton summarized the controversy by stating "To care for himself effectively, the person with diabetes needs a grasp of the basic physiological principles. However, a brilliant intellect is neither necessary or sufficient."⁹ Patient educators need strong preparation on disease-specific content, but perhaps more importantly, they need preparation in teaching techniques and behavioral strategies.

Misconception #2: Health care professionals who teach patients are educators.
Although many people teach health care concepts, many of them are not prepared with the skills to provide health education properly. In diabetes education, care providers representing a variety of disciplines describe themselves as educators. Although many of these individuals claim that they provide education, often they are simply providing information on diabetes content. Just as one needs specific training in medicine or nursing to become either a physician or nurse, specific preparation in health education is needed in order to properly plan, conduct, and evaluate health education programs.

Misconception #3: Health educators are the experts, and patients should defer to them.
Both educators and patients are the experts. Educators have the expertise in specific content and the clinical aspects of the disease. However, patients are the experts in their own life. They know what they will do with the information provided and if and how it will be incorporated into their lifestyle.¹⁰ Patient education is replacing the paternalistic view that professionals know what is best for patients, make decisions for them, and do not share information with them.⁴ Effective health educators are willing to learn from their clients.

Misconception #4: Health educators are responsible for patients' learning and achieving outcomes.
This belief can be damaging to both providers and patients. Providers who judge their success on their patients' attainment of certain clinical goals are bound to be frustrated, trying to continually manage matters that are outside of their control. The most carefully designed care plan or program has no power to change outcomes unless a patient chooses to do it and to do so skillfully.¹⁰

Misconception #5: If a comprehensive health education program is provided, patients will come because it is in their best interests.
Many comprehensive health education programs have been developed in the United States, yet for a variety of reasons, patients do not or cannot come. In a study using information from the National Health Interview Survey, a special diabetes questionnaire was administered to individuals >18 years of age with physician-diagnosed diabetes. Diabetes education was defined as reported participation in a class or program about diabetes. Results of this study showed that of all of the people with diabetes, 35% had attended a diabetes education program. When examined by type of diabetes, nearly 60% with type 1 diabetes compared to one-third with type 2 diabetes attended. Of those with type 2 diabetes, roughly 50% of those treated with insulin versus only 25% of those not treated with insulin received education.¹¹

In a study investigating self-monitoring of blood glucose by adults with diabetes, it was found that only 40% of type 1 diabetes patients, one-third of type 2 diabetes patients treated with insulin, and just over 11% of type 2 diabetes patients not treated with insulin received education.¹² In the Michigan Community Diabetes Care Study comparing care and education from 1981 to 1991, improvements were noted in the areas of blood glucose monitoring, insulin administration, hypertension control, exercise recommendations, and smoking control. Negative changes occurred in the percentage of type 2 diabetes patients who received education. The proportion of type 2 diabetes patients referred for at least one education session decreased by 10%.¹³ The authors of these studies suggest that there should be an effort to increase education, but with a focused approach. In other words, individuals who develop health education programs need to be skilled in the area of providing a needs assessment and targeting interventions when developing educational programs.

What Is Health Education?
In order to dispel these misconceptions, those providing and supporting health education efforts need to understand the broad definition of health education and the responsibilities assigned to this process. Health education is any combination of learning experiences designed to facilitate voluntary adaptations of behavior or sustain behavior conducive to health.¹⁴ Health educators are the individuals who facilitate the learning experiences that are designed to enable and reinforce the behavior conducive to health in individuals, groups, or communities.

Learning is a change in behavior and involves a process of transforming new knowledge, insights, skills, and values into new behavior. Teaching is the system of actions that includes the provision of experiences and guidance to facilitate learning. Facilitation of these actions involves a major process--the teaching-learning process.¹⁵ Effective health education efforts require incorporation of the teaching-learning process and behavioral strategies to encourage individuals to make voluntary adaptations conducive to health. The responsibilities of health educators include understanding and incorporating the teaching-learning process and behavioral techniques into the education process.

Who Are Health Educators?
A role is defined by the specific responsibilities assigned to it. For a number of years, the American School Health Association (ASHA), the Society of Public Health Educators (SOPHE), and the Association for the Advancement of Health Education (AAHE) have developed official documents concerning health educational preparation. These documents have been carefully studied as background information and have been incorporated into the Role Delineation Project for Health Education.¹⁶ Based on the Role Delineation Project, a curriculum, which includes a framework of seven responsibilities and competencies for entry-level health educators, has been developed. This curriculum is based on the steps of the traditional teaching-learning process.

The responsibilities and competencies that define the role of entry-level health educator are listed in Table 1. Since health educators assume a wide variety of responsibilities that encompass education for both individual education and community programming, the responsibilities and competencies listed in Table 1 can be applied to both of these areas.

Diabetes Education
Diabetes education, dating back to the 1930s, is acknowledged as the most fully developed of all of the fields of patient education.⁴ There are nationally and internationally adopted standards and processes for recognizing quality diabetes education programs.^17,18 The first diabetes education programs accredited by the American Diabetes Association (ADA) were recognized in 1987. Since then, 600 programs have been awarded recognition. In addition, several states have developed standards and recognition processes.

It is apparent that educational resources and standards are better developed for diabetes education than for any other area of patient education. In the United States, these efforts are paying off in reimbursement practices. In 1997, the federal Balanced Budget Act Section 4105 was passed supporting Medicare payment for diabetes self-management education.

In addition to recognition of diabetes education programs, diabetes educators have been recognized as essential providers of diabetes care in the United States. A diabetes educator is defined as a health care professional who has mastered a core of knowledge and skill in the biological and social sciences, communication and counseling, and education, and who has experience in the care of patients with diabetes.¹⁹ The role of 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 patients competencies and quality in practice, the American Association of Diabetes Educators (AADE) established the Scope of Practice for Diabetes Educators and the Standards of Practice for Diabetes Educators. The Standards of Practice for Diabetes Educators are presented in Table 2.

The scope of practice provides definitions of diabetes education and diabetes educators while providing statements of beliefs regarding the educational process. The primary area of responsibility for diabetes educators is the education of patients and their families. The content of the educational experience should include the following topics:

• Pathophysiology of diabetes
• Nutrition
• Pharmacological interventions
• Exercise
• Self-monitoring of blood glucose
• Prevention and management of acute and chronic complications
• Psychosocial adjustment
• Problem-solving skills
• Stress management
• Use of the health care delivery system

Diabetes educators should provide this information with an individualized plan and perform the following:

• Assessment
• Planning
• Implementation of the plan
• Documentation of the process
• Evaluation based on outcome criteria

The Scope of Practice and Standards documents 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 a 1992 survey of diabetes educators, at least 20% performed roles considered to be in the medical domain.²⁰

The Diabetes Control and Compli-cations Trial (DCCT) substantiated the commitment to education, the value of a multidisciplinary team, and the expanded role of the nurses and dietitians. Since the DCCT report in 1993,²¹ roles and responsibilities of diabetes educators have greatly changed. The study substantiated the need for dietitians and nurses to increase their involvement in management in order to achieve optimal diabetes control.^22,23

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 with each other.

Future Directions
Health educators have encountered frustration centered around a lack of clear professional identity. As a result, credentialing processes have been established. The benefits of credentialing for practitioners are listed in Table 3. Along with enhancing and clarifying the role of health educator, credentialing has potential benefits for society. Credentialing heightens awareness in the general public and offers some degree of safety by ensuring the competence of those providing health education.

In 1988, the National Commission for Health Education Credentialing, Inc., established its certification process for health educators.²⁴ Al-though there remains controversy, credentialing for health educators is still in process.

In 1986, certification of diabetes educators was initiated. Certification by the National Certification Board of Diabetes Educators (NCBDE) indicates that an individual possesses a basic level of knowledge in the field of diabetes.²⁵ The certified diabetes educator (CDE) credential does not confer any permission to manage diabetes beyond the limitations of the individual's professional practice. Job descriptions and functions are determined by the licensing board and employing agency, not by the CDE test.

As a result of the rapidly changing health care system and implementation of the results of the DCCT, health care providers are now assuming roles that have traditionally been outside of their typical practices in order to provide the necessary care for the millions of people with diabetes. For example, nurse educators are managing insulin regimens, dietitians are teaching blood glucose monitoring, and physicians are reviewing food diaries. With a heightened interest in reimbursement issues and an increase in liability concerns, questions regarding these responsibilities have arisen.

In response, the American Diabetes Association formed a task force, with representation from all of the diabetes-related disciplines, to define the roles of professionals involved in diabetes education, explore the training and background of these individuals, and explore the legal and reimbursement practices related to these issues. A report from the Task Force on the Clarification of the Roles and Responsibilities in Providing Diabetes Self-Management Education was issued in April 1996.²⁶ The task force determined that health professionals involved in diabetes education should be capable of implementing the process standards of the National Standards for Diabetes Self-Manage-ment Education.¹⁷ These standards include the traditional steps in the teaching-learning process, e.g., assessment, implementation of a plan, documentation, and follow-up.

The task force researched the educational and/or training background of a variety of professions involved in diabetes education, e.g., pharmacists, nurses, and dietitians, and realized that the educational preparation of the professionals varied with the institutions they had attended. Although an appropriate guideline could be the CDE certification, the task force recommended that the next group that reviews and revises the National Standards for Diabetes Self-Manage-ment Education consider that the standards addressing staff qualifications be based on the ability of staff to perform certain tasks adequately to address all 15 content areas based on their educational background and professional licensure, rather than identifying specific disciplines as required staff.

The task force reiterated that the CDE exam verifies a basic level of knowledge and does not confer any permission to manage diabetes beyond the limits of licensure and scope of practice. The group recommended that the scopes of practice as recommended by the professional organizations serve as guidelines.

Conclusions
Health education and diabetes education are expanding and evolving fields. Although health education is now recognized in the United States as key to achieving outcomes of health care, many questions remain unanswered. For example, reimbursement and liability issues cannot be addressed because of the constantly changing health care systems.

In response to these questions, credentialing examinations, standards, and scopes of practice for health educators have been implemented. However, these efforts still need to be thoroughly evaluated. In order to substantiate the role of the health educator in practice and obtain reimbursement for services, acceptance of clearly defined responsibilities and outcome data are imperative.

In order to meet the needs of all individuals who require health education in the prevention and treatment of disease, health educators need to be recognized and accepted from a variety of disciplines. However, in order to assure that the health education process is effective, those providing this service need to be trained in the proper steps of delivery.

References

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⁴Redman B: The Practice of Patient Education. 8th edition. St. Louis, Mo., CV Mosby, 1997.

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¹⁸International Diabetes Federation Consultative Section on Education: International Consensus Standards of Practice for Diabetes Education. United Kingdom, Bakersville Press, 1997.

¹⁹American Association of Diabetes Educators: The scope of practice for diabetes educators and the standards of practice for diabetes educators. Diabetes Educ 18:52-59, 1992.

²⁰Cypress M, Wylie-Rosett J, Engel S, Stager T: The scope of practice of diabetes educators in a metropolitan area. Diabetes Educ 18:111-14, 1992.

²¹The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977-86, 1993.

²²The DCCT Research Group: Expanded role of the dietitian in the Diabetes Control and Complications Trial: implications for clinical practice. J Amer Dietetic Assoc 93:758-67, 1993.

²³The DCCT Research Group: The Diabetes Control and Complications Trial: the trial coordinator perspective. Diabetes Educ 13:236-41, 1993.

²⁴National Commission for Health Education Credentialing, Inc.: Application Handbook for Certification of Health Education Specialists. New York, Professional Examination Service, 1988.

²⁵National Certification Board for Diabetes Educators: NCBDE News 5:4, 1995.

²⁶Report of the American Diabetes Association Task Force on the Clarification of the Roles and Responsibilities in Providing Diabetes Self-Management Education. Diabetes Spectrum 10:155-58, 1997.

Linda M. Siminerio, PhD, RN, CDE, is the Diabetes Program coordinator at Children's Hospital of Pittsburgh, in Pittsburgh, Pa. She is editor-in-chief of Diabetes Spectrum.

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