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Academy of Nutrition and Dietetics: Scope of Practice in Nutrition and Dietetics

  • The Academy Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
Published:February 28, 2013DOI:https://doi.org/10.1016/j.jand.2012.12.009
      The Academy of Nutrition and Dietetics (Academy), the professional association for credentialed dietetics practitioners—registered dietitians (RDs) and dietetic technicians, registered (DTRs)—developed the scope of practice as a guide for nutrition and dietetics practitioners. The purpose of the Scope of Practice in Nutrition and Dietetics document is threefold:
      • 1
        Provide an overview of the components that encompass the Scope of Practice in Nutrition and Dietetics; ie, Scope of Practice for the Registered Dietitian
        Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
        Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian.
        and the Scope of Practice for the Dietetic Technician, Registered.
        Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
        Academy of Nutrition and Dietetics: Scope of Practice for the Dietetic Technician, Registered.
      • 2
        Enable RDs and DTRs to be leaders in providing safe, culturally competent, quality food and nutrition services.
      • 3
        Introduce resources for RDs and DTRs to direct scope of practice decision making.

      What Is the Rationale for a Scope of Practice in Nutrition and Dietetics?

      Scope of Practice in Nutrition and Dietetics encompasses the range of roles, activities, and regulations within which nutrition and dietetics practitioners perform. For credentialed practitioners, scope of practice is typically established within the practice act and interpreted and controlled by the agency or board that regulates the practice of the profession in a given state. In today's dynamic, diverse health care environment, demand is increasing for quality food and nutrition services that are delivered in varied settings. These new opportunities may lead credentialed dietetics practitioners to ask, “Is this activity within my scope of practice?” The Scope of Practice Decision Tool, which is an online, interactive tool, permits an RD or DTR to answer a series of questions to determine whether a particular activity is within his or her scope of practice. The tool is designed to allow for an RD or DTR to critically evaluate his or her knowledge, skill, and demonstrated competence with criteria resources.
      The Scope of Practice in Nutrition and Dietetics is built upon Academy of Nutrition and Dietetics (Academy) resources:
      • American Dietetic Association: Scope of Dietetics Practice Framework (2005)
        • O'Sullivan-Maillet J.
        • Skates J.
        • Pritchett E.
        Scope of dietetics practice framework.
        ;
      • Academy of Nutrition and Dietetics (Academy)/Commission on Dietetic Registration (CDR) Code of Ethics
        American Dietetic Association/Commission on Dietetic Registration
        Code of ethics for the profession of dietetics and process for consideration of ethical issues.
        ;
      • Academy of Nutrition and Dietetics: Standards of Practice in Nutrition Care and Standards of Professional Performance for RDs
        Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
        Academy of Nutrition and Dietetics: Revised 2012 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitians.
        ;
      • Academy of Nutrition and Dietetics: Standards of Practice in Nutrition Care and Standards of Professional Performance for DTRs
        Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
        Academy of Nutrition and Dietetics: Revised 2012 Standards of Practice in Nutrition Care and Standards of Professional Performance for Dietetic Technicians, Registered.
        ; and
      • American Dietetic Association Nutrition Care Process and Model Part I: The 2008 Update.
        Writing Group of the Nutrition Care Process/Standardized Language Committee
        Nutrition Care Process and Model Part I: The 2008 Update.
      In the 2005 Scope of Dietetics Practice Framework
      • O'Sullivan-Maillet J.
      • Skates J.
      • Pritchett E.
      Scope of dietetics practice framework.
      article, the Academy utilized the concept of a framework to describe the full range of roles, responsibilities, and activities that credentialed dietetic practitioners are educated and authorized to perform. The Scope of Practice in Nutrition and Dietetics embodies the framework components and includes practice standards, practice management materials, and other resources to assist credentialed dietetics practitioners in sound decision making that supports quality practice in traditional, emerging, and expanded roles. In addition, the Scope of Practice in Nutrition and Dietetics can serve as a resource for organizations seeking an authoritative description of the elements of competent, safe, and quality nutrition and dietetics practice.
      Approved November 2012 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the Academy House of Delegates. Scheduled review date: November 2017.
      Questions regarding the Scope of Practice in Nutrition and Dietetics may be addressed to the Academy Quality Management Staff: Karen Hui, RD, LDN, manager, Practice Standards; and Sharon M. McCauley, MS, MBA, RD, LDN, FADA, director, Quality Management at [email protected]

      Competence in Practice

      Competence is ”a principle of professional practice, identifying the ability of the provider to administer safe and reliable services on a consistent basis.”
      • Miller- Keane
      • O'Toole M.
      Miller-Keane Encyclopedia & Dictionary of Medicine, Nursing, & Allied Health.
      Competence is integral to the delivery of safe, quality health care, and other services that credentialed dietetics practitioners provide. In keeping with the Code of Ethics,
      American Dietetic Association/Commission on Dietetic Registration
      Code of ethics for the profession of dietetics and process for consideration of ethical issues.
      RDs and DTRs can only practice in areas in which they are qualified and have demonstrated competence in delivery of food and nutrition services that achieve safe, ethical, and quality outcomes. RDs and DTRs are expected to be competent in, and accept accountability and responsibility for, ensuring safety and quality in the services they provide.
      Competence to perform designated activities within defined practice settings is an essential element of the scope of practice in nutrition and dietetics, as demonstrated by the following principles:
      • 1
        level of experience, skills, and proficiency to perform designated activities varies among individuals;
      • 2
        individual practitioners might not be competent in all aspects of the field;
      • 3
        practitioners are expected to practice in the areas in which they are competent; and
      • 4
        practitioners pursue additional education and experience to expand their individual scope of practice.
        • O'Sullivan-Maillet J.
        • Skates J.
        • Pritchett E.
        Scope of dietetics practice framework.
      Competent practitioners use up-to-date knowledge and skills; make sound decisions based on appropriate data; communicate effectively with patients, customers, and other professionals; critically evaluate their own practice; and improve their performance based on self-awareness, applied practice, continued education, and feedback from others.
      • Gates G.
      Ethics opinion: Dietetics professionals are ethically obligated to maintain personal competence in practice.
      Furthermore, according to the Centers for Medicare and Medicaid Services' Interpretive Guidelines for Hospitals §482.28(a)(3), “Administrative and technical personnel must be competent in their assigned duties. This competence is demonstrated through education, experience and specialized training appropriate to the task(s) assigned. Personnel files should include documentation that the staff member(s) is competent in their respective duties.”
      Centers for Medicare and Medicaid Services State Operations Manual Appendix A-Survey, Protocol, Regulations and Interpretive Guidelines for Hospitals (p 291).
      RDs and DTRs and the RD/DTR team operate within the directives of applicable federal and state laws and regulations, as well as policies and procedures established by the organization in which they are employed. To determine whether an activity is within the scope of practice of the RD or DTR, the practitioner critically evaluates his or her knowledge, skill, and demonstrated competence with criteria resources. The Academy's Scope of Practice Decision Tool, which is an online, interactive tool, is specifically designed to assist with this exercise in evaluation by the individual practitioner and his or her organization.

      Components of Scope of Practice in Nutrition and Dietetics

      The Figure displays the scope of practice components that RDs and DTRs utilize in nutrition and dietetics. Component descriptions and location of the documents and resources are provided. Components are Education Preparation and Credentialing, Practice Standards, Practice Management and Advancement, and Practice Resources.
      Figure thumbnail gr1
      FigureScope of practice components that registered dietitians (RDs) and dietetic technicians, registered (DTRs) utilize in nutrition and dietetics. ACEND=Accreditation Council for Education in Nutrition and Dietetics; CDR=Commission on Dietetic Registration.

      Education Preparation and Credentialing

      RD

      The Commission on Dietetic Registration (CDR), the credentialing agency for the Academy, defines the RD as an individual who has met current minimum (Baccalaureate) academic requirements with successful completion of both specified didactic education and supervised practice experiences through programs accredited by the Accreditation Council for Education in Nutrition and Dietetics (ACEND) of the Academy of Nutrition and Dietetics and who has successfully completed the Registration Examination for Dietitians. To maintain the RD credential, the RD must comply with the CDR Professional Development Portfolio recertification requirements (accrue 75 units of approved continuing professional education every 5 years).
      Commission on Dietetic Registration. Who is a registered dietitian (RD)?.

      DTR

      The Commission on Dietetic Registration (CDR) defines the DTR as an individual who has met current minimum requirements through one of three routes:
      • successful completion of a minimum of an Associate degree and a Dietetic Technician Program as accredited by the Accreditation Council for Education in Nutrition and Dietetics (ACEND) of the Academy of Nutrition and Dietetics (Academy) that includes 450 hours of supervised practice experience;
      • successful completion of a minimum of a Baccalaureate degree, met current academic requirements (Didactic Program in Dietetics) as accredited by ACEND of the Academy, successfully completed a supervised practice program under the auspices of a Dietetic Technician Program as accredited by ACEND; or
      • completed a minimum of a Baccalaureate degree; successfully completed a Didactic Program in Dietetics as accredited by ACEND.
      In all three routes, the individual must successfully complete the Registration Examination for Dietetic Technicians. To maintain the DTR credential, the DTR must comply with the CDR Professional Development Portfolio recertification requirements (accrue 50 hours of approved continuing professional education every 5 years).
      Who is a dietetic technician, registered (DTR)?
      Commission on Dietetic Registration.
      Registration eligibility requirements for dietetic technicians
      Commission on Dietetic Registration.

      Practice Standards

      Practice standards are core documents of the Academy that lay the foundation for the profession of nutrition and dietetics. Included are the following:
      • Code of Ethics
        American Dietetic Association/Commission on Dietetic Registration
        Code of ethics for the profession of dietetics and process for consideration of ethical issues.
        ;
      • Scope of Practice for the RD
        Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
        Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian.
        ;
      • Scope of Practice for the DTR
        Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
        Academy of Nutrition and Dietetics: Scope of Practice for the Dietetic Technician, Registered.
        ;
      • Standards of Practice in Nutrition Care and Standards of Professional Performance for RDs
        Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
        Academy of Nutrition and Dietetics: Revised 2012 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitians.
        ; and
      • Standards of Practice in Nutrition Care and Standards of Professional Performance for DTRs.
        Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
        Academy of Nutrition and Dietetics: Revised 2012 Standards of Practice in Nutrition Care and Standards of Professional Performance for Dietetic Technicians, Registered.
      These resources, along with applicable state and federal regulations, state practice acts, and organizational standards and program policies, serve as guides for ensuring safe, person-centered, culturally competent, quality nutrition and dietetics practice. Additional uses can include any of the following: evaluate performance, develop position descriptions, contribute to hiring decisions, initiate regulatory reform, or determine whether a specific activity aligns with a practitioner's individual scope of practice, such as clinical privileges.

      Practice Management and Advancement

      The Scope of Practice Decision Tool is a resource that assists RDs and DTRs in determining whether a new activity is within their individual scope of practice and, if applicable, statutory scope of practice. State and federal regulations, standards of patient/client safety, ethical practice, organizational policies and procedures, and education, training, and competence of the practitioner form the basis for determining whether an activity falls within a practitioner's scope of practice. The tool can also aid RDs and DTRs in expanding their practice in response to changing roles, new opportunities, and demands for food and nutrition services. The Scope of Practice Decision Tool, which is an online, interactive tool, is available on the Academy's website (http://www.eatright.org/SHOP).
      The Academy's Dietetics Career Development Guide forms the cornerstone for practice management and advancement in nutrition and dietetics. The Guide uses the Dreyfus model of skill acquisition
      • Dreyfus H.L.
      • Dreyfus S.E.
      Mind over Machine: The Power of Human Intuitive Expertise in the Era of the Computer.
      to illustrate how a practitioner attains increasing levels of knowledge and skill throughout a career. Through life-long learning and professional development, practitioners acquire and develop skills that lead to increased competence and higher levels of practice. The Academy's website features a graphic representation and explanation of the guide (http://www.eatright.org/futurepractice/).
      Maintenance of the RD and DTR credentials requires documentation of continuing education via the Professional Development Portfolio. Participating in certificate programs as well as acquiring advanced degrees and certifications are additional ways in which RDs and DTRs gain new skills and advance their practice. An option available is CDR's Board Certification Specialist for RDs in focus areas of practice in recognition of an applicant's documented practice experience and successful completion of an examination.
      CDR certifications
      Commission on Dietetic Registration.

      Practice Resources

      The Academy's practice resources aid RDs and DTRs in providing safe, quality food and nutrition services. A brief description of each resource category is provided:
      • The Definition of Terms is a cumulative anthology of definitions developed by the Academy. The definitions are broad-based, have implications for use across the nutrition and dietetics profession, and are consistent with the regulatory and legal needs of the profession. The terms are a resource for RDs, DTRs, and other food and nutrition practitioners. As a reference document, the definitions serve as standardized language and standardized application in various practice settings (http://www.eatright.org/scope/).
      • The Evidence Analysis Library is a synthesis of nutritional research on important dietetics practice questions and is housed within an accessible online library. The Evidence Analysis Library is designed to guide RDs and DTRs in making evidence-based decisions
        • Myers E.F.
        ADA Evidence Analysis Library.
        (http://www.adaevidencelibrary.com/).
      • Evidence-Based Nutrition Practice Guidelines and Toolkits aid RDs in implementing evidence-based practice in specific practice areas. Evidence-based nutrition practice guidelines are a series of guiding statements and treatment algorithms that are developed using a systematic process for identifying, analyzing, and synthesizing scientific evidence. They are designed to assist the RD and patient/client in making decisions about appropriate nutrition care for specific disease states or conditions in typical settings. Evidence-based toolkits are a set of companion documents that are disease or condition specific and detail how the practitioner applies the evidence-based nutrition practice guidelines in practice. Evidence-based nutrition practice guidelines and toolkits incorporate the Academy's Nutrition Care Process and Model as the standard process for patient/client care (http://www.adaevidencelibrary.com/) and are submitted to the National Guideline Clearinghouse.
      • The National Guideline Clearinghouse is an initiative of the Agency for Healthcare Research and Quality (http://www.ahrq.gov/), US Department of Health and Human Services. The National Guideline Clearinghouse was originally created by the Agency for Healthcare Research and Quality in partnership with the American Medical Association and the American Association of Health Plans (now America's Health Insurance Plans). The mission of the National Guideline Clearinghouse is to provide physicians and other health professionals, health care providers, health plans, integrated delivery systems, and purchasers with an accessible mechanism for obtaining objective, detailed information to further the dissemination, implementation, and use of clinical practice guidelines (http://www.guideline.gov/about/index.aspx).
      • The Nutrition Care Manual products are therapeutic diet and professional practice manuals for RDs, DTRs, and allied health professionals that are housed on the Internet through the Academy website. Three versions are available: The Adult Nutrition Care Manual, the Pediatric Nutrition Care Manual, and the Sports Nutrition Care Manual. Manuals are based on the Nutrition Care Process (NCP) and provide online access to evidence- and knowledge-based nutrition information for safe, quality practice. All manuals are continuously updated and purchased annually by subscription.
        Academy of Nutrition and Dietetics. Nutrition Care Manual
      • The NCP is a systematic problem-solving method that credentialed dietetics practitioners use to think critically and make decisions that address practice-related problems. The NCP contains four distinct, inter-related steps: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation. The NCP is a standardized model that guides RDs and DTRs in providing safe, quality nutrition care.
        Writing Group of the Nutrition Care Process/Standardized Language Committee
        Nutrition Care Process and Model Part I: The 2008 Update.
      • Standardized Language for the NCP, published by the Academy as the International Dietetics and Nutrition Terminology (IDNT), includes commonly used terms by credentialed dietetics practitioners. The IDNT is one of many standardized terminologies that are used by health professions. A primary function of the IDNT is to describe, document, and record dietetics practice and nutrition care in the medical record. The NCP and IDNT demonstrate the unique functions of credentialed dietetics practitioners, facilitate clear and consistent descriptions of the services they provide, and supply the framework and data terms for research that assists with measurement of nutrition practice and outcomes.
        Writing Group of the Nutrition Care Process/Standardized Language Committee
        Nutrition Care Process Part II: Using the International Dietetics and Nutrition Terminology to Document the Nutrition Care Process.
        Academy of Nutrition and Dietetics
        International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process.
      • Nutrition Services Coverage Coding and Billing provides practice management information and best practices regarding coverage and reimbursement for medical nutrition therapy (MNT) services (http://www.eatright.org/coverage/). MNT is an essential component of comprehensive health care. Individuals with a variety of conditions and illnesses can improve their health and quality of life by receiving MNT. During an MNT intervention, RDs counsel clients on behavioral and lifestyle changes that impact long-term eating habits and health
        Medical nutrition therapy (MNT)
        Academy of Nutrition and Dietetics.
        (http://www.eatright.org/coverage/).
      • Position Papers are germane to the vision, mission, values, goals, and strategies of the Academy. A position paper consists of an abstract, a position statement, and a support paper. The position statement is the Academy's stance on an issue, which is derived from pertinent facts, data, and the research literature. Although a position paper is not a comprehensive literature review of the topic, it presents current facts, data, and research. Position papers may be developed using the Evidence Analysis Process (http://www.eatright.org/positions/).
      • Practice Papers provide key opportunities for critical reasoning and quality improvement in nutrition and dietetics practice. Depending on the topic, practice papers may be developed using the Evidence Analysis Process. Other practice paper topics may include peer-reviewed perspectives from content experts, employers, and alliance groups of the Academy (http://www.eatright.org/members/practicepapers/).
      • Quality Management Resources are designed to promote and support RDs and DTRs in meeting or exceeding established practice and professional standards in all employment settings. The resources advance quality nutrition and dietetics practice, as it is paramount to our nation's health care and to the marketplace, with the expectation of public reporting at national, state, regional, and organizational levels. Tools are used to measure quality assurance and performance improvement of health care being provided, to report outcomes of food and nutrition services, and to ensure the organization is accountable to their patients/clients. Clinical Quality Measures being utilized in health care organizations and practice settings address one or more quality elements: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity
        National Research Council
        Crossing the Quality Chasm: A New Health System for the 21st Century.
        (http://www.eatright.org/quality/).

      Summary

      The goal of credentialed dietetics practitioners (RDs and DTRs) is to provide safe, culturally competent, quality care. Within the flexible and broad boundaries of the profession of nutrition and dietetics, RDs and DTRs assume accountability and responsibility for safe, ethical, and competent practice that achieves desirable outcomes. RDs and DTRs engage in continuing education and training to maintain currency, demonstrate competence, and advance their careers. The Academy developed this Scope of Practice in Nutrition and Dietetics overview document, as well as other resources, such as the Scope of Practice for the Registered Dietitian
      Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
      Academy of Nutrition and Dietetics: Scope of Practice for the Registered Dietitian.
      and the Scope of Practice for the Dietetic Technician, Registered
      Academy of Nutrition and Dietetics Quality Management Committee and Scope of Practice Subcommittee of the Quality Management Committee
      Academy of Nutrition and Dietetics: Scope of Practice for the Dietetic Technician, Registered.
      to aid RDs and DTRs in assessing their individual scope of practice and, if applicable, statutory scope of practice, and to support RDs and DTRs in providing safe, quality food and nutrition services. The Scope of Practice Decision Tool, which is an online, interactive tool, assists RDs and DTRs in examining his or her individual scope of practice activities to meet the needs of quality food and nutrition services.

      Acknowledgements

      The Academy Quality Management Committee and its Scope of Practice Subcommittee thank the following Academy members for their assistance with manuscript preparation: COL George A. Dilly, PhD, RD, LD, US Army; LTC Dianne T. Helinski, MHPE, RD, LD, US Army; Martin Yadrick, MBA, MS, RD, FADA; Elaine Ayres, MS, RD, FAC-PPM; Christina Ferroli, PhD, RD; Connie Mueller, MS, RD, SNS; Diane Duncan-Goldsmith, MS, RD, LD; Angie Tagtow, MS, RD, LD; Deborah Canter, PhD, RD, LD; Glenna McCollum, DMOL, MPH, RD; and Lindsay Hoggle, MS, RD, PMP.

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        (Accessed February 13, 2013)
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