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American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Behavioral Health Care

  • Author Footnotes
    a M. Emerson is a clinical dietitian at Spring Harbor Hospital, Westbrook, ME
    Mary Emerson
    Footnotes
    a M. Emerson is a clinical dietitian at Spring Harbor Hospital, Westbrook, ME
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  • Author Footnotes
    b P. Kerr is a clinical dietitian at North Central Health Care, Wausau, WI
    Paula Kerr
    Footnotes
    b P. Kerr is a clinical dietitian at North Central Health Care, Wausau, WI
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  • Author Footnotes
    c M. Del Carmen Soler is a registered dietitian for Meridian Behavioral Healthcare, Inc, Gainesville, FL, USA
    Maria Del Carmen Soler
    Footnotes
    c M. Del Carmen Soler is a registered dietitian for Meridian Behavioral Healthcare, Inc, Gainesville, FL, USA
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  • Author Footnotes
    d T. Anderson Girard is owner and nutrition consultant at Anderson Nutrition Services, Quincy, MA
    Terry Anderson Girard
    Footnotes
    d T. Anderson Girard is owner and nutrition consultant at Anderson Nutrition Services, Quincy, MA
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  • Author Footnotes
    e R. Hoffinger is an outpatient dietitian at North Florida/South Georgia Veterans Health System, Gainesville, FL, FL, USA
    Renee Hoffinger
    Footnotes
    e R. Hoffinger is an outpatient dietitian at North Florida/South Georgia Veterans Health System, Gainesville, FL, FL, USA
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  • Author Footnotes
    f E. Pritchett is past director of Quality and Outcomes and M. Otto is director of Quality Management at American Dietetic Association headquarters in Chicago, IL
    Ellen Pritchett
    Footnotes
    f E. Pritchett is past director of Quality and Outcomes and M. Otto is director of Quality Management at American Dietetic Association headquarters in Chicago, IL
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  • Author Footnotes
    f E. Pritchett is past director of Quality and Outcomes and M. Otto is director of Quality Management at American Dietetic Association headquarters in Chicago, IL
    Maureen Otto
    Footnotes
    f E. Pritchett is past director of Quality and Outcomes and M. Otto is director of Quality Management at American Dietetic Association headquarters in Chicago, IL
    Search for articles by this author
  • Author Footnotes
    a M. Emerson is a clinical dietitian at Spring Harbor Hospital, Westbrook, ME
    b P. Kerr is a clinical dietitian at North Central Health Care, Wausau, WI
    c M. Del Carmen Soler is a registered dietitian for Meridian Behavioral Healthcare, Inc, Gainesville, FL, USA
    d T. Anderson Girard is owner and nutrition consultant at Anderson Nutrition Services, Quincy, MA
    e R. Hoffinger is an outpatient dietitian at North Florida/South Georgia Veterans Health System, Gainesville, FL, FL, USA
    f E. Pritchett is past director of Quality and Outcomes and M. Otto is director of Quality Management at American Dietetic Association headquarters in Chicago, IL

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      Editor’s note: Figure 1, Figure 2, Figure 3 that accompany this article are available online at www.adajournal.org.
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      Figure 1Standards of practice and standards of professional performance for registered dietitians (generalist, specialty, and advanced) in behavioral health care. aRD=registered dietitian.
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      Figure 2Standards of practice for registered dietitians in behavioral health care.
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      Figure 2Standards of practice for registered dietitians in behavioral health care.
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      Figure 2Standards of practice for registered dietitians in behavioral health care.
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      Figure 2Standards of practice for registered dietitians in behavioral health care.
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      Figure 2Standards of practice for registered dietitians in behavioral health care.
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      Figure 2Standards of practice for registered dietitians in behavioral health care.
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      Figure 2Standards of practice for registered dietitians in behavioral health care.
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      Figure 2Standards of practice for registered dietitians in behavioral health care.
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      Figure 2Standards of practice for registered dietitians in behavioral health care.
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      Figure 2Standards of practice for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
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      Figure 3Standards of professional performance for registered dietitians in behavioral health care.
      The Dietetics in Developmental and Psychiatric Disorders Dietetic Practice Group (DDPD DPG) of the American Dietetic Association (ADA), under the guidance of the ADA Quality Management Committee, has developed the Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Behavioral Health Care (Figure 1, Figure 2, Figure 3, available online at www.adajournal.org). These documents are built on the Standards of Practice in Nutrition Care and Standards of Professional Performance found in the ADA’s Scope of Dietetics Practice Framework (
      • O’Sullivan-Maillet J.
      • Skates J.
      • Pritchett E.
      Scope of dietetics practice framework.
      ). The Standards of Practice and Standards of Professional Performance for Registered Dietitians (RDs) in Behavioral Health Care are a guide for evaluating and improving practice and a tool for demonstrating competence in behavioral health care. Three levels of practice in behavioral health care are defined: generalist, specialty, and advanced. These standards, along with the ADA’s Code of Ethics, answer the following questions: “Why is an RD uniquely qualified to provide nutrition services in behavioral health care?” and, “What knowledge, skills, and competencies must an RD demonstrate to provide safe, effective, and quality nutrition care in a behavioral health care setting at the generalist, specialty, and advanced levels?” These standards incorporate the principles of the Nutrition Care Process and Model (
      • Lacey K.
      • Pritchett E.
      Nutrition care process and model ADA adopts road map to quality care and outcomes management.
      ), and apply to the continuum of behavioral health care (ie, in-patient, out-patient, and community settings).

      Overview

      Behavioral health care services encompass treatments for mental illnesses, chemical dependencies, developmental disorders, and eating disorders. One in five Americans will experience a mental illness, and it is estimated that 5% to 7% of American adults will experience a serious mental illness in any given year. Approximately 5% to 9% of American children have a serious emotional disturbance. Millions of American adults and children are disabled by mental illnesses every year (
      United States Public Health Service Office of the Surgeon General
      ,
      Department of Health and Human Services
      ,
      • Kessler R.C.
      • Berglund P.A.
      • Bruce M.L.
      • Koch J.R.
      • Laska E.M.
      • Leaf P.
      • Manderscheid R.W.
      • Rosenheck R.A.
      • Walters E.E.
      • Wang P.S.
      The prevalence and correlates of untreated serious mental illness.
      ). The direct costs of mental health services in the United States in 1996 totaled $69 billion. This figure represents 7.3% of total US health spending. An additional $17.7 billion was spent on Alzheimer’s disease and $12.6 billion on substance abuse treatment (

      Mental Health: A Report of the Surgeon General. December 13, 1999. Available at: http://www.surgeongeneral.gov/library/reports.htm. Accessed February 27, 2006.

      ).
      There are also the indirect costs of behavioral health disorders, such as lost productivity in the workplace, at school, and in the home because of premature death or disability. In 1990, the indirect costs of mental illness were estimated to be $78.6 billion (
      • Rice D.P.
      • Miller L.S.
      The economic burden of schizophrenia Conceptual and methodological issues, and cost estimates.
      ). More than 80% of these costs stemmed from disability rather than death (
      • Rice D.P.
      • Miller L.S.
      The economic burden of schizophrenia Conceptual and methodological issues, and cost estimates.
      ).
      Providing nutrition services to people who have behavioral health care conditions is a complex task. Clients have more than one condition. For instance, a person who has a major mental illness may also have a substance abuse disorder, an eating disorder, or a developmental disability.
      RDs practicing in behavioral health care must use skills unique to the needs of the populations they serve. They have an understanding of the nutritional needs of and nutritional treatments available to people with altered thought processes, unstable moods, developmental and learning disabilities, addictions, and dangerous food habits, many of whom are at risk of injuring themselves or others. Assessing nutritional status, diagnosing nutritional problems, planning and implementing nutritional care for such people, and doing so safely and effectively, requires that the RD receive specialized training, education, and experience in the field of behavioral health care (
      ADA Position Paper Nutrition intervention in the treatment of anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (EDNOS).
      ).
      According to the ADA, the definition of dietetics as a profession is, “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.” (
      • O’Sullivan-Maillet J.
      • Skates J.
      • Pritchett E.
      Scope of dietetics practice framework.
      ). The Scope of Dietetics Practice Framework has been developed as a cornerstone for all members of the dietetics profession, and was published in the April 2005 issue of the Journal of the American Dietetic Association (
      • O’Sullivan-Maillet J.
      • Skates J.
      • Pritchett E.
      Scope of dietetics practice framework.
      ): “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 can evaluate their performance.”
      The core Standards of Practice and Standards of Professional Performance were also published in the April 2005 issue of the Journal. Within this framework, the Standards of Practice in Nutrition Care and Standards of Professional Performance are designed as blueprints to accommodate the development of specialty and advanced level practice standards for registered dietitians in specific areas (
      • Kieselhorst K.
      • Skates J.
      • Pritchett E.
      American Dietetic Association’s Standards of Practice in Nutrition Care and the Updated Standards of Professional Performance.
      ,
      • Kulkarni K.
      • Boucher J.L.
      • Daly A.
      • Shwide-Slavin C.
      • Silvers B.T.
      • O’Sullivan-Maillet J.O.
      • Pritchett E.
      American Dietetic Association
      Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialist, and Advanced) in Diabetes Care.
      ). Figure 4 presents the basic definitions for specialty and advanced level dietetics practice.
      Figure thumbnail gr4
      Figure 4American Dietetic Association (ADA) definitions from the ADA Scope of Dietetics Practice Framework. aRD=registered dietitian. bCDR=Commission on Dietetic Registration.

      ADA Standards of Practice and Standards of Professional Performance for RDs (Generalist, Specialty, and Advanced) in Behavioral Health Care

      The RD will use the American Dietetic Association Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Behavioral Health Care (Figure 1, Figure 2, Figure 3, available online at www.adajournal.org) to:
      • identify the competencies needed to provide nutritional care in the behavioral health setting;
      • self-assess whether they have the appropriate skill and knowledge base to provide safe and effective nutrition care for their level of practice in behavioral health care;
      • identify the areas in which additional knowledge and skills are needed to practice at the generalist, specialty, or advanced level of behavioral heath care;
      • provide a foundation for public accountability;
      • assist management in the planning of services and resources;
      • enhance professional identity and communicate the nature of dietetics; and
      • guide the development of behavioral health-related dietetics education programs, job descriptions, and career pathways.

      Application to Practice

      The Dreyfus model identifies levels of proficiency from novice to expert during the acquisition and development of knowledge and skills and is a helpful model for viewing the level of practice context for the Standards of Practice and Standards of Professional Performance in behavioral health care (
      • Dreyfus H.L.
      • Dreyfus S.E.
      ). RDs new to the specialty of behavioral health care experience a steep learning curve. Three stages of proficiency, novice, proficient, and expert, reflect this development process. In the Standards of Practice and Standards of Professional Performance, these three stages are represented as the generalist, specialty, and advanced practice levels (Figure 4).
      In applying this concept to behavioral health care, it is recognized that even experienced RDs start at the novice stage when practicing in a new setting. At the novice stage (generalist level), the RD is new to behavioral health care and is learning the principles that underpin practice. At the proficient stage (specialty level), the RD has developed a deeper understanding of behavioral health care and is able to apply these principles and modify practice according to the situation. At the expert stage (advanced practice level), the RD has developed a more intuitive understanding of behavioral health care and practice reflects a range of highly developed clinical skills and judgments acquired through a combination of experience and education. Essentially, advanced practice level requires the application of advanced dietetics knowledge, with practitioners drawing not only on their clinical experience, but also on the experience of the behavioral health care profession as a whole. Experts, with their extensive experience and ability to see the significance and meaning within a contextual whole, are fluid and flexible in practice.
      Level of practice considerations support taking a holistic view of the Standards of Practice and Standards of Professional Performance in Behavioral Health Care. It is the totality of 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 in Behavioral Health Care at regular intervals to evaluate their competency. Regular evaluation is important because it helps to identify opportunities to improve and/or enhance practice and professional performance. It also helps RDs as they utilize the Commission on Dietetic Registration Professional Development Portfolio to demonstrate the process of self-assessment, planning, improvement, and commitment to lifelong learning (
      • Weddle D.O.
      The professional development portfolio process Setting goals for credentialing.
      ). The Standards of Practice and Standards of Professional Performance in Behavioral Health Care can be used at each of the five steps in the Professional Developmental Portfolio process (Figure 5). RDs are encouraged to pursue additional training, regardless of practice setting, to expand their personal scope of behavioral health care practice. Individuals are expected to practice only at the level at which they are competent, and this will vary depending on education, training, and experience (
      • Gates G.
      Ethics opinion Dietetics professionals are ethically obligated to maintain personal competence in 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 in Behavioral Health Care to guide their practice.
      Figure thumbnail gr5
      Figure 5Application of the Commission on Dietetic Registration Professional Development Portfolio Process. aThe Commission on Dietetic Registration Professional Development Portfolio process is divided into five interdependent steps that build sequentially upon the previous step during each 5-year recertification cycle and succeeding cycles.
      Figure thumbnail gr6
      Figure 6Case examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians (RDs) (Generalist, Specialty, and Advanced) in Behavioral Health Care. aWIC=Special Supplemental Nutrition Program for Women, Infants, and Children.
      When the Standards of Practice in Behavioral Health Care do not have defined advanced level indicators that depict a differentiation in the level between specialty and advanced level practice, it is because this distinction between specialty and advanced level is captured in the knowledge, experience, and intuition that is demonstrated in the context of actual practice at the advanced level, combining dimensions of understanding, performance, and value as an integrated whole (
      • Chambers D.W.
      • Gilmore C.J.
      • Maillet J.O.
      • Mitchell B.E.
      Another look at competency-based education in dietetics.
      ). A wealth of untapped knowledge is embedded in the practice and the know-how of advanced level dietetics practitioners. This knowledge will expand and fully develop to be captured in refined indicators as advanced practice RDs systematically record what they learn from their own experience of advanced level practice using clinical exemplars. Clinical events are observed by the experienced clinician and analyzed to make new connections between events and ideas, thus producing a synthesized whole. As does any scholar, the clinical scholar seeks truths, explanations, and ever-increasing information about the phenomena of the discipline. The scholarliness of the clinical work is produced by the constant analysis of the work and the interpretation of the events to others. Clinical scholarship has its basis in the application of theory and research to practice. Knowledge is gained not just through theory and principles, but also through the embodiment of those principles in daily practice. 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 (
      • Boyer E.
      ,
      • Glassick C.
      • Huber M.
      • Maeroff G.
      ,
      • Parks S.C.
      • Schiller M.R.
      • Bryk J.
      President’s page Investigate in our future—The role of science and scholarship in developing knowledge for dietetics practice.
      ).
      The Standards of Professional Performance in Behavioral Health Care account for this expectation. For example, in Figure 3, Standard 6: “Continued Competence and Professional Accountability” has an indicator that states: “Supports the application of research findings and best available evidence to professional practice.” This indicator has these sub-indicators for specialty and advanced practice:
      • 6.6A Familiarizes self with major behavioral health care and education publications;
      • 6.6B Serves as an author of behavioral health–related publications and as a behavioral health presenter for consumer and health care provider audiences on behavioral health topics; and
      • 6.6C Develops skill in accessing and critically analyzing research.
      This final sub-indicator is reserved for advanced practice only:
      • 6.6D Uses planned change principles at the advanced level of practice to integrate research and practice.

      Summary

      The Standards of Practice and Standards of Professional Performance for RDs in Behavioral Health Care are key resources for RDs at all levels of practice. In daily practice, dietetics professionals can consistently show their competency and value as providers of safe and effective behavioral health care services. These standards are very much works in progress, and will be reviewed periodically. As a quality initiative of the ADA and the Dietetics in Developmental and Psychiatric Disorders Dietetic Practice Group, the standards themselves are an application of continuous quality improvement concepts, reflecting a commitment to ongoing improvement. Behavioral health services provided by RDs will continue to be dynamic elements within the health care delivery process as the number of RDs in behavioral health care increases and their levels of knowledge, experience, and expertise advance.
      Approved November 2005 by the Quality Management Committee of the American Dietetic Association House of Delegates and the Executive Committee of the Dietetics in Developmental and Psychiatric Disorders Dietetic Practice Group (DDPD DPG) of the American Dietetic Association. Scheduled review date: November 2008. The American Dietetic Association authorizes 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 Behavioral Health Care may be addressed to Maureen Otto, MS, RD, director of Quality Management at ADA, at [email protected]

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