A case study in industrial instantiation
The Credentialled Diabetes Educator role provides a particularly clear example of industrial instantiation in healthcare: the way professional boundaries become embedded in jobs, classifications, career structures and employer practices.
Diabetes educators in Australia come from several primary professions, including nursing, dietetics, podiatry, pharmacy, exercise physiology, midwifery and physiotherapy. They can undertake an accredited postgraduate qualification and complete a common credentialling process to use the title Credentialled Diabetes Educator, or CDE.
The contemporary credential is therefore profession-spanning. It recognises diabetes education as a specialist field that can be entered from several professional backgrounds.
This does not mean that every CDE has an identical scope of practice. Practitioners retain the legal authorities and responsibilities of their primary profession, and their scope is also shaped by their education, experience, supervision and clinical context. But the CDE role itself is not reserved by law to nurses, nor does the credential formally establish separate nurse and allied health versions of diabetes education.
King and colleagues examined what happened when this shared credential was translated into actual employment. Their study, based on documentary analysis and interviews with nineteen stakeholders, found that formal recognition of a common role had not produced equivalent access to employment and career opportunities.
Participants reported that hospitals often established positions specifically as nurse diabetes educator roles rather than as profession-neutral diabetes educator positions. As one podiatrist observed, the roles were set up as nursing roles from the outset. Allied health practitioners who developed diabetes education expertise were more likely to incorporate it into an existing allied health position than to enter a recognised diabetes educator role.
This is industrial instantiation.
It does not necessarily make it unlawful for an allied health CDE to undertake diabetes education. Instead, it determines whether an employer creates a position through which that practitioner can be appointed, authorised, recognised and remunerated to do the work.
A practitioner may therefore hold the relevant postgraduate qualification and credential, yet remain unable to access a diabetes educator job because the position has been located within the nursing establishment. The restriction is not written into professional regulation. It is written into the position description, workforce structure, classification and career pathway.
The study also found that participants often understood the boundary as a legal one. Nurse and allied health diabetes educators alike commonly believed that nurses possessed distinctive legislative authority in relation to medication management. However, King and colleagues found no clear legislative distinction that gave nurse CDEs a general monopoly over this aspect of diabetes education.
The perceived legal boundary nevertheless had practical effects. Allied health CDEs sought approval from nurse colleagues, referred work they believed they were not permitted to undertake, or withdrew from diabetes education altogether. A boundary did not need to be legally accurate to influence workplace behaviour. It needed only to be widely accepted within the organisation.
Employment structures were reinforced by a broader professional story about the nature of the work. Some nurse participants described nursing as bringing distinctive qualities of holism, caring, commitment and broad clinical experience to diabetes education. These qualities were presented not simply as competencies that could be learned and assessed, but as attributes inherent in nursing.
This helped sustain the assumption that diabetes education properly belonged within the nursing workforce, even where practitioners from other professions held the same specialist credential.
Credentialling history also contributed to the boundary. Some allied health groups initially faced delays or barriers in becoming eligible for CDE status. These are not industrial restrictions in themselves, but they influenced who could enter the field and reinforced its historical association with nursing. The case therefore shows how employment structures can be supported by educational history, professional narratives and mistaken assumptions about regulation.
The significance of the case is not that nursing and allied health CDEs always perform identical work, or that every nurse CDE is paid more than every allied health CDE. It is that a shared specialist credential did not translate into equivalent access to recognised specialist roles.
The professional boundary was reproduced at the point where employers converted capability into jobs. The diabetes educator case therefore raises a broader question than who is eligible to apply for a particular job. It asks how health systems recognise and value work.
Where diabetes education is located within a nursing career structure, specialist capability can be recognised through a defined position, classification, title, pay scale and pathway for advancement. Where an allied health practitioner undertakes comparable work, that capability may simply be absorbed into an existing role, without equivalent recognition or progression.
The difference is not necessarily in the complexity, responsibility or value of the work being performed. It lies in the employment structure through which the work is seen.
This is an important feature of industrial instantiation. Industrial systems do not merely organise workers into jobs. They influence which forms of expertise are visible, which responsibilities count as advanced practice, and which work attracts higher status and remuneration. When classification systems are organised primarily around professional identity, the same or comparable work can be valued differently depending on who performs it.
The reform challenge is therefore not simply to create profession-neutral diabetes educator positions or allow more professions to compete for them. It is to recognise and value the work consistently.
That requires classification and remuneration systems capable of assessing the nature of the work itself: its complexity, accountability, knowledge requirements, autonomy and impact. Specialist work should not gain or lose value simply because it is performed by a nurse, podiatrist, dietitian, pharmacist or another appropriately qualified practitioner.
The diabetes educator boundary was not primarily written into statute.
It was written into jobs — and into the different value attached to the same work depending on who was employed to do it.
References
King, Olivia, et al. “Interprofessional role boundaries in diabetes education in Australia.” Health Sociology Review 28.2 (2019): 162-176.
King, Olivia, et al. “Diabetes educator role boundaries in Australia: a documentary analysis.” Journal of foot and ankle research 10.1 (2017): 28.
