Enhancing the capacity of the health workforce to deliver best practice diabetes care
Giuliana Murfet
A J * , Ashley H Ng B , Virginia Hagger C D , Susan Davidson E , Grace Ward F , Brett Fenton G and Bodil Rasmussen D H I
A School of Public Health, University of Technology Sydney, Ultimo, NSW, Australia.
B Department of Dietetics, Human Nutrition and Sport, La Trobe University, Bundoora, Vic., Australia.
C School of Nursing and Midwifery, Deakin University, Burwood, Vic., Australia.
D Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Vic., Australia.
E Australian Diabetes Educators Association, Chifley, ACT, Australia.
F Aboriginal and Torres Strait Islander Engagement, Diabetes Australia, Canberra, ACT, Australia.
G Diabetes Services, Central Coast Local Health District, Gosford, NSW, Australia.
H Department of Public Health, University of Copenhagen, Nørregade 10, DK-1017 Copenhagen, Denmark.
I Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, DK-5230 Odense, Denmark.
J Present address: Diabetes Centre, Tasmanian Health Service, Burnie, Tas. 7250, Australia.
Australian Health Review 46(4) 496-500 https://doi.org/10.1071/AH22040
Submitted: 25 February 2022 Accepted: 15 June 2022 Published: 19 July 2022
© 2022 The Author(s) (or their employer(s)). Published by CSIRO Publishing on behalf of AHHA. This is an open access article distributed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND)
Abstract
Diabetes prevalence is increasing; the technologies and medicines used to manage diabetes have become more complex, and the specialist health workforce with qualifications in diabetes is insufficient. Generalist health professionals have limited diabetes knowledge, despite engaging with people with diabetes in healthcare daily. An innovative framework is needed to align with the Australian National Diabetes Strategy to build a competent, flexible and adaptive workforce to promote excellence in diabetes care. A three-staged modified Delphi technique was used to identify a consensus Capability Framework for Diabetes Care (the ‘Framework’). An implementation phase followed, involving representation from people with diabetes and key health professional organisations to co-design and implement the ‘Framework’. The ‘Framework’ can guide curricula at universities and TAFE institutes, and the professional development and practice of Australian nurses, allied health professionals, First Nations Australians health workers and practitioners, pharmacists, midwives and health assistants when delivering care to people living with diabetes. The ‘Framework’ defines nine core capabilities that healthcare providers require to deliver diabetes care effectively, underpinned by three sets of attributes for seven practice levels to enable the workforce. Information within the practice levels provides a nationally consistent approach to learning and training different healthcare providers in the essential elements of diabetes care. A ‘living’ evidence-based national ‘Framework’ for the whole health workforce and associated online resources will help promote a more responsive health workforce delivering better and more equitable diabetes care.
Keywords: capability framework, capacity-building, credentialled diabetes educators, diabetes, diabetes capabilities, diabetes educator, diabetes policy, diabetes strategy, health workforce, university curriculum.
Introduction
More than a quarter of Australians accessing healthcare services live with diabetes.1,2 Over 1.4 million Australians have diabetes, which is three times more prevalent among First Nations Australians.3,4 To advance diabetes management, the number and complexity of medicines and technologies used have increased exponentially.5,6 Simultaneously, medical shortfalls in areas of geographical remoteness and populations of extreme disadvantage persist.7–9
Australia has 1700 full-time equivalents (FTE) of diabetes-qualified healthcare professionals (HCPs), 1589 Credentialled Diabetes Educators and 736 diabetes educators; half work part-time or are aged over 50 years, and less than 20 are Indigenous HCPs.10,11 An ideal ratio is 2.75 FTE/1000 people with diabetes based on an Australian workforce model, calculating consultation time against diabetes clinical guidelines for 20 competencies.12 Double the current diabetes-specialist workforce (3850 FTEs) is necessary to meet the needs of people with diabetes, many of whom do not have access to diabetes-competent staff.13
Primary HCPs report inadequate skills, confidence, time or access to resources as common barriers to delivering person-centred diabetes care, often due to lack of preparedness from undergraduate degrees.13–16 An inadequately diabetes-trained health workforce can lead to improper clinical care, longer hospitalisation, re-admission, and conflicting advice, leading to disengagement with health services, low health literacy and reduced self-care practices.17–20 These consequences increase personal and financial burdens on people with diabetes and the health system.21,22
Standard approach to training the workforce in diabetes
Competency frameworks are task-focused tools to guide, assess and standardise HCPs’ practice in stable and predictable situations.23,24 Currently, national and international diabetes competency frameworks focus on separate health topic areas and individual health disciplines, leading to inconsistent training across professions and risk of reduced currency because of organisations’ diverse priorities in determining framework updates.13,25–30
Competency frameworks are tied to one-dimensional views of learning, healthcare roles, and discipline requirements and do not recognise the benefits of autonomous practice that enable innovation, hindering expertise.16,24,31 In Australia, there is no diabetes framework to inform the entire workforce, nor are any frameworks, internationally or nationally, capability-based to accommodate dynamic healthcare changes.13 The lack of these frameworks compromises consistency in advice and clinical care delivered, limiting sustainable health workforce development.16,24
A capability approach to training the whole health workforce
An accessible and sustainable framework that evolved expediently with the evidence-base was needed to inform and train the whole health workforce in managing diabetes consistently, promoting engagement with health services, guiding clinical practice referral pathways, and accommodating the dynamic nature of healthcare.13,19,20,32,33 Importantly, it needed to increase equitable, safe diabetes healthcare to reduce the burden of diabetes and address health system challenges.32,34
Evidence from 64 studies indicated people with diabetes report receiving contradictory advice from HCPs and an Australian study linking Pharmaceutical Benefits Scheme and National Diabetes Services Scheme data found inequities in access to evidence-based diabetes medicines related to residing remotely.35,36 Ensuring that generalist HCPs are competent in diabetes care is crucial to maximise the health workforce’s effectiveness in meeting people’s needs and addressing remoteness-related inequities in healthcare.32,37–40
Capability-based learning offers an innovative alternative to current frameworks.13,16 It is based on Sen’s capability approach, a moral framework describing how opportunities are made feasible and are constrained by internal (personal) and external (social and environment) factors.41,42 It encompasses competency and extends beyond technical skills, promoting self-efficacy supported by emphasising adaptability and lifelong learning.23,24,41
Sen’s capability approach, used in educational theory and practice, supports increased flexibility and responsiveness, translating into increased workforce capacity.13,23,41,42 For example, survey data from 307 research and development and manufacturing organisations found ‘employee autonomy’, mediated innovative performance and increased employees’ intrinsic motivation to share knowledge. Areas such as housing, education (e.g. health professionals, teaching, eHealth), and public service leadership policy have increased capacity by better meeting adult learners’ needs through aligning learning with human motivation differences.24,31,41–45
Capable learners respond to changing clinical situations creatively and flexibly, which is essential as HCPs are likely to encounter people with diabetes at critical time-points in their life when experiencing adverse events.45–47 These are opportunities for HCPs to support engagement with people with diabetes, e.g. when disengaged, young people with type 1 diabetes have a health-related turning point.47
A framework that increases the capability of non-medical HCPs to deliver diabetes care was identified by consensus via a 3-staged modified Delphi technique from a purposefully recruited diverse panel of Australian diabetes-experts with representation from all Australian healthcare sectors (see Supplementary material).13,16
Capability framework for diabetes care (the ‘Framework’)
The ‘Framework’ promotes adequate diabetes content and consistency in curricula in all Australian HCP degrees or courses. The intended outcome is a diabetes-literate workforce and training aligned with HCPs’ scope of practice; Table 1 highlights ways the ‘Framework’ prepares the workforce. The ‘Framework’ includes nine capabilities underpinned by three overarching attributes promoting agility and seven HCP practice levels aligned to an appropriate diabetes clinical competence stage and relevant training.13,16
|
National implementation of the ‘Framework’ was imperative to improve consistency and equity in diabetes healthcare. Key stakeholders formed an Implementation Advisory Group, including people living with diabetes, and representatives from Aboriginal and Torres Strait Islander health workers and practitioners, nursing, midwifery, pharmacy and allied HCP organisations. The group advised on the ‘Framework’ implementation to embed it into professional education and practice.16 The ‘living’ (continually modified to align with emerging evidence) online ‘Framework’ will be launched in 2022: hosted on the Australian Diabetes Educators Association website. Health professionals can access evidence-based resources aligned to the ‘Framework’, mentoring and communication opportunities.16 The ‘Framework’ addresses the Australian Commission on Safety and Quality in Health Care concerns, which suggested redistributing aspects of care to different HCPs. This will promote agility and collaborative, ongoing mentorship.13,16,46
Conclusions
The Delphi technique identified a novel way to prepare the Australian health workforce to deliver quality diabetes care. By identifying capabilities required at different practice levels within the health workforce, the ‘Framework’ delivers a comprehensive evidence-informed mechanism to build diabetes capacity that supports an agile and flexible workforce. The ‘living’ online ‘Framework’ is an innovative way to support practice and education sustainably and consistently, strengthening connections and mentorship within the workforce. Ongoing evaluation of the ‘Framework’s’ implementation and impact on workforce training is planned, including identifying culturally-specific mentoring required to serve First Nations Australians best.
Ethics approval
Ethics approval gained from the Tasmania Health and Medical Human Research Ethics Committee – Ethics approval number: 24606.
Supplementary material
Supplementary material is available online.
Data availability
The data used to generate the results in the paper are available in a PhD thesis available online at Deakin University, Burwood (Australia) at https://dro.deakin.edu.au/view/DU:30159402 or by contacting the corresponding author.
Conflicts of interest
The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; or in the decision of results to publish.
Declaration of funding
The evaluation study is funded by a Australian Diabetes Educator Association – Diabetes Research Foundation Research Fellowship grant. The National Partnership Agreement on Improving Health Services in Tasmania (Tasmanian Wellness Project) funded a clinical scholarship to GM during 2019 PhD studies.
Author contributions
Conceptualisation: G. M. Methodology: G. M. Software: G. M. Validation: G. M., B. R., J. O., A. N., V. H., B. F., G. W., and S. D. Formal analysis: G. M. Secondary analysis and cross coding: B. R. and J. O. Implementation of framework: G. M., B. R., A. N., V. H., G. W., B. F., and S. D. Data curation: G. M. Writing – original draft preparation: G. M. Writing – review and editing, G. M., B. R., A. N., V. H., G. W., B. F., S. D. Supervision, B. R. and J. O. Project administration: G. M. Funding acquisition: G. M. All authors have read and agreed to the published version of the manuscript.
Acknowledgements
The authors thank the 90 dedicated and passionate diabetes health professionals who volunteered from 2017 to 2020 to identify the Capability Framework for Diabetes Care. Also, G. M. extends her gratitude to her PhD primary supervisor, the late Emeritus Professor Trisha Dunning (Deakin University, Melbourne, Australia), and associate supervisors Dr Joan Ostaszkiewicz (National Aging Research Institute, Melbourne, Australia) and Professor Bodil Rasmussen for their ongoing wisdom and guidance. Additionally, the Expert Advisory Group and the Implementation Advisory Group are acknowledged as critical to the validating, co-designing and implementing the framework into the real world, including representation from consumers and health professionals and Indigenous partner organisations.
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