American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and American Dietetic Association (ADA): Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Nutrition SupportA.S.P.E.N. Board of Directors and ADA Quality Management Committee
A task force composed of members of the Dietetics Practice Section of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the Dietitians in Nutrition Support Dietetic Practice Group (DNS DPG) of the American Dietetic Association (ADA) under the guidance of the A.S.P.E.N. Clinical Practice Committee and the ADA Quality Management (QM) Committee has developed Standards of Practice and Standards of Professional Performance for Registered Dietitians (RDs) in Nutrition Support (Figures 1, 2, 3). These documents are built upon ADA's Standards of Practice in Nutrition Care and Standards of Professional Performance1 found in ADA's Scope of Dietetics Practice Framework.2 The standards build upon and update the 2000 A.S.P.E.N. Standards of Practice for Nutrition Support Dietitians (approved by the A.S.P.E.N. Standards Committee and Board of Directors, and published in Nutrition in Clinical Practice in February 2000).3 The 2000 standards, based upon a role delineation study conducted by the National Board of Nutrition Support Certification,4 were reviewed by a wide variety of members and leaders within ADA and A.S.P.E.N., and were approved by the ADA QM Committee for approval and adoption by ADA.5 A.S.P.E.N. and ADA have demonstrated a more than ten-year commitment to collaboration on standards. Both organizations remain committed to a robust standards development and review process; A.S.P.E.N. has recently published results of a survey designed to make the standards and guidelines process even more effective.6
The indicators for the 2007 standards were developed by the consensus of content experts representing diverse practice and geographic perspectives and have not been validated by a practice audit (role delineation study). The National Board of Nutrition Support Certification (NBNSC) job analysis study, conducted in 2005, provided information to support these standards. These standards were developed by representatives of the A.S.P.E.N. Dietetics Practice Section and DNS DPG of ADA incorporating, as noted above, information from the A.S.P.E.N. Standards of Practice for Nutrition Support Dietitians,3 and were reviewed and approved by additional representatives of the A.S.P.E.N. Clinical Practice Committee, the A.S.P.E.N. Board of Directors, the DNS DPG of ADA, and the QM Committee of ADA. The Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians in Nutrition Support are a means for describing competencies in the assessment, selection, delivery and monitoring, of nutrition support therapy, which includes oral diets, enteral tube feeding and parenteral nutrition. The Standards of Practice and Standards of Professional Performance for Registered Dietitians in Nutrition Support should be used in conjunction with A.S.P.E.N. standards for other professionals, and for a variety of practice settings.7–16 The new standards describe three levels of practice in nutrition support therapy: Generalist, Specialty, and Advanced. However, it is acknowledged that nutrition support therapy, and its integral interventions, are most effectively undertaken with an interdisciplinary focus and at a level beyond that usually practiced by the entry-level RD. As stated in the Scope of Practice of the Standards of Practice for Nutrition Support Dietitians, the role of the RD in nutrition support "has clearly emerged as a specialty practice within professional dietetics."3 These standards, along with ADA's Code of Ethics, answer the questions: "Why is an RD uniquely qualified to provide nutrition support services?" and "What knowledge, skills, and competencies will an RD demonstrate to provide safe, effective, and quality nutrition support care at the generalist, specialty, and advanced levels?" These standards incorporate the principles of ADA's Nutrition Care Process and Model17 and apply to the continuum of nutrition support therapy (ie, acute care, extended care, home, and community settings).10–13
The Dreyfus model18 identifies levels of proficiency (Novice, Proficient, and Expert) during the acquisition and development of knowledge and skills. This model is helpful for understanding the levels of practice described in the Standards of Practice and Standards of Professional Performance for RDs in Nutrition Support. In ADA Standards of Practice and Standards of Professional Performance, the stages described by Dreyfus are represented as generalist, specialty, and advanced practice levels (Figure 4).
All RDs, even those with significant work experience, begin at the Novice stage when practicing in a new setting. At the Novice stage (Generalist level) the RD in nutrition support is learning the principles that underpin its practice, and developing skills that enable effective entry level practice in nutrition support. This RD, who may be an experienced RD or may be new to the profession, has a breadth of knowledge in nutrition overall, and may have specialty or advanced knowledge/practice in another area. However, the RD will experience a steep learning curve in the practices and principles of nutrition support therapy. At the Proficient stage (Specialty level), the RD has developed a deeper understanding of nutrition support therapy and is much better equipped to apply best practice and evidence-based principles. This RD is also able to modify practice according to unique situations. At the Expert stage (Advanced level), the RD thinks critically about nutrition support therapy, exhibits a range of highly developed clinical and technical skills (which may include but are not limited to performing comprehensive nutrition-focused physical assessment, placement of enteral feeding tubes, and management of high acuity patients requiring enteral and/or parenteral nutrition including formulation of components, initiation of monitoring indices [weight, laboratory and radiology tests, formula infusion rate, etc]) and formulating judgments based on a combination of experience and education. Practice at the advanced level requires the application of composite nutrition knowledge, with practitioners drawing not only on their clinical experience, but also on the experience of other nutrition support practitioners in various disciplines and practice settings. Expert practice in nutrition support therapy is often evidenced by competency-based actions authorized by physician-approved protocols. Experts, with their extensive experience and ability to see the significance and meaning of nutrition support therapy within a contextual whole, are fluid, flexible, and to some degree, autonomous, in practice. Several models for advanced practice in nutrition support are described in the literature. Davis et al describe a model for advancing clinical privileges for RDs in nutrition support therapy.19 The model includes a highly specific competency assessment tool and a credentialing flow chart specific to the organization involved. Moreland et al described the process by which RDs obtained privileges for nutrition order writing in a long-term, acute-care hospital.20 The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) defines clinical privileges as "authorization granted by the appropriate authority (for example, the governing body) to a practitioner to provide specific care, treatment, and services in an organization within well-defined limits, based on the following factors, as applicable: license, education, training, experience, competence, health status, and judgement."21 Clinical privileges must be determined to be within the RD's professional, institutional, individual and state-specific scopes of practice. Depending on the organization, specific clinical privileges may not be required if the RD is making decisions in accordance with an approved algorithm or protocol and physician oversight.22 Organizations may require institutional credentialing/privileging for complex roles and responsibilities such as those suggested for an RD practicing in nutrition support therapy at the advanced level.
Quantifying the exact number of registered dietitians who practice in nutrition support is difficult. As of October 2006, 3,463 RDs were members of the DNS DPG of ADA, and 3,456 RDs were members of A.S.P.E.N. Approximately 1,275, or 37%, of the RDs belong to both organizations. RDs who specialize in nutrition support may practice in a variety of patient care settings, such as short- and long-term acute care, extended care facilities, ambulatory/outpatient clinics, and in home care.3 In addition, RDs practicing in nutrition support may (solely, or in combination with a clinical practice) conduct research, teach, consult, and write for peer-reviewed professional publications. Nutrition support therapy encompasses provision of nutrients orally, enterally, or parenterally with therapeutic intent. This includes, but is not limited to, provision of enteral or parenteral nutrition to maintain and/or restore optimal nutrition status and health. The RD practicing in nutrition support collaborates with other healthcare professionals such as speech pathologists, respiratory therapists, pharmacists, nurses, and physicians to support, restore, and maintain optimal nutrition health in individuals with known or potential compromise in nutrition status.3 This interdisciplinary team approach has been shown to reduce cost and improve patient outcomes, and the RD is a key resource in various aspects of nutrition support therapy, including determinations of route and timing.23 Skipper24 suggests that the dietetics profession consider the model of the profession of advanced practice nursing, which is a definitive model for progressive clinical practice. For the advanced level practice RD in nutrition support, this model could include activities such as management of insulin therapy, catheter and device care, etc.24 The ADA defines dietetics as "the integration and application of principles derived from the sciences of food, nutrition, management, communication, and biological, physiological, behavioral, and social sciences to achieve and maintain optimal human health with flexible scope of practice boundaries to capture the breadth of the profession."2 ADA's Scope of Dietetics Practice Framework, developed as a cornerstone for all members of the dietetics profession, was published in the April 2005 Journal of the American Dietetic Association.2 "This framework defines core evaluation resources, Standards of Practice in Nutrition Care, Standards of Professional Performance, and a Code of Ethics to be used by individual practitioners in conjunction with relevant state, federal, and licensure laws so that practitioners can determine whether a particular activity falls within their own legitimate scope of practice and evaluate their performance."2 The core Standards of Practice in Nutrition Care and Standards of Professional Performance were also published in the April 2005 issue of the Journal of the American Dietetic Association.1 The Standards of Practice in Nutrition Care and Standards of Professional Performance were designed as blueprints to accommodate the development of specialty and advanced level practice standards for RDs in specific areas of practice.1 Figure 4 presents the ADA's definitions for specialty and advanced level dietetics practice. The Standards of Practice and Standards of Professional Performance for RDs in Nutrition Support is the fourth set of practice-specific standards to be developed under the Scope of Dietetics Practice Framework, building on the core RD Standards of Practice for Nutrition Care and the Standards of Professional Performance. Others, also published by ADA, describe standards in the areas of diabetes, behavioral health, and oncology.25–27
The RD uses the A.S.P.E.N/ADA Standards of Practice and Standards of Professional Performance for the Registered Dietitians (Generalist, Specialty and Advanced) in Nutrition Support (Figures 1, 2, 3) to:
These standards have been formulated to be used for individual self-evaluation and the development of practice guidelines, but not for institutional credentialing or for adverse or exclusionary decisions regarding privileging, employment opportunities or benefits, disciplinary actions, or determinations of negligence or misconduct. These standards do not constitute medical or other professional advice, and should not be taken as such. The information presented in these standards is not a substitute for the exercise of professional judgment by the healthcare professional. The use of these standards for any other purpose than that for which they were formulated must be undertaken within the sole authority and discretion of the user. An individual who holds the RD credential alone may be capable of performing at any of the three levels, depending on the individuals' education and work experience, competencies achieved, and professional practice. Additional credentials may be beneficial for professional recognition but not required. However, advanced training and/or further education may be needed in order to gain the knowledge and skills to progress to a higher competency level. Education, knowledge, experience, and abilities circumscribe the competency of the dietitian in nutrition support.3
Suggested minimum qualifications for RDs electing to practice in nutrition support include at least three of the following3:
Certain components of these standards reflect aspects of the knowledge and skills required for the CNSD credential, offered through the NBNSC. The specialty level of practice described in these documents is not equivalent to that implied by the CNSD certification. Rather, the specialty level described in this document encompasses the skill level of an RD who cares for patients receiving nutrition support therapy beyond the level seen in the entry level nutrition support practitioner. An RD who is also a CNSD has met recommended minimum experience requirements and has successfully completed the CNSD examination, certifying the ability to practice nutrition support therapy according to the core principles of nutrition support. While RDs who have earned the right to use the CNSD credential may practice nutrition support at the specialty or advanced level, the credential by itself does not certify this level of practice. Currently, no credential certifying specialty or advanced level practice for RDs in nutrition support therapy exists. In 2006, the NBNSC embarked on a new program of certification for nutrition support therapy professionals. Beginning in 2008, candidates who pass the nutrition support certifying examination administered by the NBNSC will earn the credential of Certified Nutrition Support Clinician (CNSC). This credential will certify knowledgeable nutrition support therapy professionals based on a common core of practice among practitioners of all disciplines.
Within the Standards of Practice (Figure 2) and Standards of Professional Performance (Figure 3), an X in the Generalist column indicates that an RD who is caring for patients requiring nutrition support therapy is expected to be able to complete the stated activity and/or take action to seek assistance in learning how to perform the activity at the level of the standard. The generalist in nutrition support could be an entry level RD or an experienced RD who has only recently assumed care of patients who require nutrition support. The generalist could also be an experienced individual who has changed the focus of his or her nutrition support practice to another age group (eg, adults to pediatrics) or to another specialty (eg, cardiology to trauma). See Figure 4. An X in the Specialty column indicates that an RD who performs at this level requires a deeper understanding of nutrition support therapy and has the ability to modify therapy to meet the needs of patients in various situations. An X in the Advanced column indicates that the RD who performs at this practice level must have a comprehensive understanding of nutrition support therapy and a highly developed range of skills and judgments acquired through a combination of experience and education. Bolded standards and indicators originate from ADA's Standards of Practice in Nutrition Care and Standards of Professional Performance1 documents, and should apply to RDs in all categories. (In some instances, Xs were not placed in all three categories within bolded standards due to the unique nature of nutrition support therapy compared with other areas of nutrition care). Where Xs are placed in all three categories of practice, it is understood that all RDs in nutrition support are accountable for practice within each of these indicators. However, the depth with which an RD performs each activity will increase as the individual moves beyond the Generalist level. Level of practice considerations warrant taking a holistic view of the Standards of Practice and Standards of Professional Performance for RDs in Nutrition Support. It is the totality of individual practice that depicts the level of practice and not any one indicator or standard. RDs should review the Standards of Practice and Standards of Professional Performance for RDs in Nutrition Support at regular intervals to evaluate their nutrition support knowledge, skill, and competence. Regular self-evaluation is important because it helps to identify opportunities to improve and/or enhance practice and professional performance. This appraisal also allows RDs to better use the Commission on Dietetic Registration Professional Development Portfolio for self-assessment, planning, improvement, and commitment to lifelong learning.28 These standards may be used in each of the five steps in the Professional Developmental Portfolio process (Figure 5). Individuals are expected to practice only at the level at which they are competent, and this will vary depending on education, training, and experience.29 RDs are encouraged to pursue additional knowledge and skill training, regardless of practice setting, to expand their scope of nutrition support therapy practice. See Figure 6 for case examples of how RDs in different roles, at different levels of practice, may use the Standards of Practice and Standards of Professional Performance for Registered Dietitians in Nutrition Support in their practice.
In some instances, components of the Standards of Practice for Registered Dietitians in Nutrition Support do not specifically differentiate between specialty and advanced level practice. In these areas, it was the consensus of the content experts that the distinctions are subtle, captured in the knowledge, experience, and intuition demonstrated in the context of practice at the advanced level, which combines dimensions of understanding, performance, and value as an integrated whole.30 A wealth of untapped knowledge is embedded in the experience, discernment, and practice of advanced level nutrition support therapy practitioners. The knowledge and skills acquired with it will continually expand and mature. It will be captured in refined indicators as advanced level RDs systematically record their experiences using the concept of clinical exemplars. The exemplar observes clinical events and analyzes them for connections between events and ideas producing a synthesized whole. Clinical exemplars describe outstanding examples of the actions of individuals in clinical settings or professional activities that have changed and enhanced patient care. They include a brief description of the need for action and the process used to change the outcome.31–34 The Standards of Professional Performance for RDs in Nutrition Support address the differentiation in practice level. For example, in Figure 3, Standard 1: "Provision of Services," includes an indicator that states the following:
The Standards of Practice and Standards of Professional Performance for Registered Dietitians in Nutrition Support are evolutionary and dynamic documents. Their creation is a beginning and their future revisions will reflect changes in dietetics education programs and outcomes of planned practice audits. The authors acknowledge that the three practice levels require more clarity and differentiation in content and role delineation, as well as more clearly defined competency statements that readily characterize the practice level differences. Creation of this clarity, differentiation, and definition are the challenges for today's nutrition support RDs, to better serve tomorrow's practitioners and their patients/clients/customers.
The Standards of Practice for the Registered Dietitian in Nutrition Support therapy and the Standards of Professional Performance for the Registered Dietitian in Nutrition Support therapy are key resources for RDs at all knowledge and performance levels. These standards can and should be used by RDs in daily practice to consistently improve and appropriately demonstrate competency and value as providers of safe and effective nutrition support therapy. The standards development and evaluation process is dynamic. These standards will be reviewed at least every 5 years for applicability to practice. Current and future initiatives of A.S.P.E.N. and ADA will provide information that will be used in these updates and in further clarifying and documenting the specific roles and responsibilities of practitioners at each level. As a quality initiative of A.S.P.E.N., its Dietetics Practice Section, ADA and its DNS DPG, the standards themselves are an application of continuous quality improvement concepts and represent another, very important, collaborative endeavor.
Approved June 2007 by the Clinical Practice Committee and the Board of Directors of the American Society for Parenteral and Enteral Nutrition, and the Quality Management Committee of the American Dietetic Association House of Delegates and the Executive Committee of the Dietitians in Nutrition Support Dietetic Practice Group of the American Dietetic Association. Expiration date: June 2012 © The American Society for Parenteral and Enteral Nutrition and the American Dietetic Association 2007. The American Society for Parenteral and Enteral Nutrition and the American Dietetic Association authorize republications of this paper, in its entirety, provided full and proper credit is given. Requests to use portions of this paper and questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitians in Nutrition Support may be directed to Sharon McCauley, MS, MBA, RD, LDN, FADA, Director of Quality Management at ADA, at smccauley{at}eatright.org or Peggi Guenter, PhD, RN, CNSN, Program Director for Clinical Practice at A.S.P.E.N., at peggig{at}aspen.nutr.org. This article will also be published in the Journal of the American Dietetic Association. The article is substantively identical in both journals and may include only minor stylistic differences.
Nutrition in Clinical Practice, Vol. 22, No. 5,
558-586 (2007)
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Practice Levels
Overview
