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From the Academy Standards of Practice & Professional Performance| Volume 115, ISSUE 10, P1699-1709.e39, October 01, 2015

Academy of Nutrition and Dietetics: Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Public Health and Community Nutrition

Published:August 11, 2015DOI:https://doi.org/10.1016/j.jand.2015.06.374

      Abstract

      The need and demand for population-level disease prevention has increased, especially with the passage of the Affordable Care Act, a worldwide increase in obesity and chronic disease, and a global emphasis on preventative health care that includes behavioral, environmental, and policy interventions. In response to these evolving needs, the Public Health and Community Nutrition Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has developed Standards of Practice and Standards of Professional Performance as tools for registered dietitian nutritionists (RDNs) currently in practice or interested in working in public health and community nutrition, to assess their current skill levels and to identify areas for professional development. The Standards of Practice address the four steps of the Nutrition Care Process for community and public health RDNs, which are assessment, diagnosis, intervention, and evaluation/monitoring. The Standards of Professional Performance consist of the following six domains of professional performance for community and public health RDNs: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, specific indicators provide measurable action statements that illustrate the ways in which RDNs can address client and population nutrition and health. The indicators describe three skill levels (competent, proficient, and expert) for RDNs. These tools highlight the unique scope of expertise that RDNs provide to the field of public health and community nutrition.
      Editor’s note: Figures 1 and 2 that accompany this article are available online at www.andjrnl.org.
      The Public Health and Community Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics (Academy), under the guidance of the Academy Quality Management Committee, has developed Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) in Public Health and Community Nutrition. These documents build on the Academy of Nutrition and Dietetics Revised 2012 SOP in Nutrition Care and SOPP 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.
      The Academy of Nutrition and Dietetics/Commission on Dietetic Registration’s (CDR) Code of Ethics
      American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics and process for consideration of ethics issues.
      and the Academy of Nutrition and Dietetics Revised 2012 SOP in Nutrition Care and SOPP 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.
      are tools within the Scope of Practice in Nutrition and Dietetics
      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 in Nutrition and Dietetics.
      and 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.
      that guide the practice and performance of RDNs in all settings.
      All registered dietitians are nutritionists—but not all nutritionists are registered dietitians. The Academy's Board of Directors and Commission on Dietetic Registration have determined that those who hold the credential Registered Dietitian (RD) may optionally use “Registered Dietitian Nutritionist” (RDN) instead. The two credentials have identical meanings. In this document, the expert working group has chosen to use the term RDN to refer to both registered dietitians and registered dietitian nutritionists.
      Approved May 2015 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the Executive Committee of the Public Health and Community Dietetic Practice Group of the Academy.Scheduled review date: October 2019.Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Public Health and Community Nutrition may be addressed to Academy quality management staff: Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, director, Quality Management, at[email protected].
      The scope of practice in nutrition and dietetics is composed of statutory and individual components, includes the Code of Ethics, and encompasses the range of roles, activities, and regulations within which RDNs 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.
      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 in Nutrition and Dietetics.
      An RDN’s statutory scope of practice may delineate the services an RDN is authorized to perform in a state where a practice act or certification exists.
      The RDN’s individual scope of practice is determined by education, training, credentialing, and demonstrated and documented competence to practice. Individual scope of practice in nutrition and dietetics has flexible boundaries to capture the breadth of the individual’s professional practice. The Scope of Practice Decision Tool, which is an online, interactive tool, permits an RDN 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 assist an RDN in critically evaluating personal knowledge, skill, and demonstrated competence with criteria resources.
      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 Decision Tool: A self-assessment guide.
      With the passage of the Affordable Care Act, a worldwide increase in obesity and chronic disease, and a global emphasis on preventative health care that includes behavioral, environmental, and policy interventions, the demand for registered dietitian nutritionists (RDNs) with unique expertise in public health and community nutrition (PHCN) is increasing.
      • Koh H.K.
      • Sebelius K.G.
      Promoting prevention through the affordable care act.
      • Rosen B.S.
      • Maddox P.J.
      • Ray N.
      A position paper on how cost and quality reforms are changing healthcare in America focus on nutrition.
      • Cogan J.A.
      The Affordable Care Act's preventive services mandate: Breaking down the barriers to nationwide access to preventive services.
      • Swinburn B.
      • Egger G.
      • Raza F.
      Dissecting obesogenic environments: The development and application of a framework for identifying and prioritizing environmental interventions for obesity.
      • Roberto C.A.
      • Swinburn B.
      • Hawkes C.
      • et al.
      Patchy progress on obesity prevention: Emerging examples, entrenched barriers, and new thinking.
      Public health and community RDNs work collaboratively across all sectors, including health, education, government, nonprofits, and industry, to understand the complex factors that impact population and individual health and to promote health equity and disease prevention for the populations with whom they work. They work in a variety of interdisciplinary settings to provide essential public health services,

      Centers for Disease Control and Prevention. The public health system and the 10 essential public health services. 2014. http://www.cdc.gov/nphpsp/essentialServices.html. Accessed April 20, 2015.

      such as assessment and diagnosis of population health problems, grant writing, creation, management and evaluation of intervention programs, generation of policy and research, and administration of nutrition education, counseling, and training to groups and individuals at all stages of prevention and across all stages of the life course.
      About 11% of RDNs currently report that their primary practice area is community nutrition, but the demand for RDNs with expertise in PHCN is expected to dramatically increase in the near future.
      • Rogers D.
      Report on the American Dietetic Association/Commission on Dietetic Registration 2008 needs assessment.
      • Haughton B.
      • Stang J.
      Population risk factors and trends in health care and public policy.
      To meet the recommended staffing ratio of one public health nutritionist per 50,000 people, there is an immediate need for a 113% increase in the workforce.

      George AM. Public health nutrition: A workforce in transition. Doctoral dissertation, University of Tennessee, 2008. http://trace.tennessee.edu/utk_graddiss/403. Accessed June 27, 2015.

      • Dodds J.
      • Kaufman M.
      Personnel in Public Health Nutrition for the 1990s.
      Academy of Nutrition and Dietetics House of Delegates
      HOD Backgrounder: Public Health Nutrition: It’s Every Member’s Business.
      RDNs who focus on prevention and wellness are able to reduce health care expenditures, as prevention is often significantly less costly than treatment.
      • Maciosek M.V.
      • Coffield A.B.
      • Flottemesch T.J.
      • Edwards N.M.
      • Solberg L.I.
      Greater use of preventive services in US health care could save lives at little or no cost.

      Overview of Academy Quality and Practice Resources

      The Academy’s Revised 2012 SOP in Nutrition Care and SOPP 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.
      reflect the minimum competent level of nutrition and dietetics practice and professional performance for RDNs. These standards serve as blueprints for the development of focus area SOP and SOPP for RDNs in competent, proficient, and expert levels of practice. The SOP in Nutrition Care is composed of four standards representing the four steps of the Nutrition Care Process (NCP) as applied to the care of patients/clients.
      Nutrition Care Process/Standardized Language Committee
      Nutrition care process and model part I: The 2008 update.
      In PHCN, the NCP is used for interventions targeted to individual clients as well as to population groups. The SOPP consist of standards representing six domains of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. The SOP and SOPP for RDNs are designed to promote the provision of safe, effective, and efficient food and nutrition services; facilitate evidence-based practice; and serve as a professional evaluation resource.
      These focus area standards for RDNs in PHCN provide a guide for self-evaluation and expanding practice, a means of identifying areas for professional development, and a tool for demonstrating competence in delivering PHCN and dietetics services. They are used by RDNs to assess their current level of practice and to determine the education and training required to maintain currency in their focus area and advancement to a higher level of practice. In addition, the standards can be used to assist RDNs in transitioning their knowledge and skills to a new focus area of practice. Like the SOP in Nutrition Care and SOPP 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.
      the indicators (ie, measureable action statements that illustrate how each standard can be applied in practice) (see Figures 1 and 2; available online at www.andjrnl.org) for the SOP and SOPP for RDNs in PHCN were developed with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDNs in PHCN were reviewed and approved by the Executive Committee of the PHCN Dietetic Practice Group and the Academy Quality Management Committee.

      Three Levels of Practice

      The Dreyfus model
      • Dreyfus H.L.
      • Dreyfus S.E.
      Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer.
      identifies levels of proficiency (novice, advanced beginner, competent, proficient, and expert) (refer to Figure 3) during the acquisition and development of knowledge and skills. The first two levels are components of the required didactic education (novice) and supervised practice experience (advanced beginner) that precede credentialing for nutrition and dietetics practitioners. Upon successfully attaining the RDN, a practitioner enters professional practice at the competent level and manages his or her professional development to obtain individual professional goals. This model is helpful in understanding the levels of practice described in the SOP and SOPP for RDNs in Public Health and Community Nutrition. In Academy focus areas, the levels are represented as competent, proficient, and expert practice levels.
      Figure 3Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Public Health and Community Nutrition.
      Table thumbnail gr3

      Competent Practitioner

      In nutrition and dietetics, a competent practitioner is an RDN who is either just starting practice after having obtained RDN registration by CDR or an experienced RDN who has recently assumed responsibility to provide nutrition and dietetics services in a new focus area. A focus area is defined as an area of nutrition and dietetics practice that requires focused knowledge, skills, and experience.

      Academy of Nutrition and Dietetics. Definition of Terms. http://www.eatrightpro.org/resources/practice/patient-care/scope-of-practice. Accessed February 22, 2015.

      A competent practitioner who has obtained RDN status and is starting in professional employment acquires additional on-the-job skills and engages in tailored continuing education to further enhance knowledge and skills obtained with formal education. An RDN starts with technical training and professional interaction for advancement and expanding breadth of competence. A general practice RDN can include responsibilities across several areas of practice, including, but not limited to, community, clinical, consultation and business, research, education, and food and nutrition management.

      Academy of Nutrition and Dietetics. Definition of Terms. http://www.eatrightpro.org/resources/practice/patient-care/scope-of-practice. Accessed February 22, 2015.

      Proficient Practitioner

      A proficient practitioner is an RDN who is generally 3 or more years beyond entry into the profession, who has obtained operational job performance skills, and is successful in the RDN’s chosen focus area of practice.

      Academy of Nutrition and Dietetics. Definition of Terms. http://www.eatrightpro.org/resources/practice/patient-care/scope-of-practice. Accessed February 22, 2015.

      The proficient practitioner demonstrates additional knowledge, skills, and experience in a focus area of nutrition and dietetics practice. An RDN may acquire specialist credentials, if available, to demonstrate proficiency in a focus area of practice.

      Expert Practitioner

      An expert practitioner is an RDN who is recognized within the profession and has mastered the highest degree of skill in, or knowledge of, a certain focus or generalized area of nutrition and dietetics through additional knowledge, experience, or training.

      Academy of Nutrition and Dietetics. Definition of Terms. http://www.eatrightpro.org/resources/practice/patient-care/scope-of-practice. Accessed February 22, 2015.

      An expert practitioner exhibits a set of characteristics that include leadership and vision and demonstrates effectiveness in planning, achieving, evaluating, and communicating targeted outcomes. An expert practitioner may have an expanded or specialist role or both, and may possess an advanced credential, if available, in a focus area of practice. Generally, the practice is more complex and the practitioner has a high degree of professional autonomy and responsibility. The expert practitioner in PHCN tends to target population-level health.
      These Standards, along with the Academy/CDR Code of Ethics,
      American Dietetic Association/Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics and process for consideration of ethics issues.
      answer the following questions: Why is an RDN uniquely qualified to provide PHCN services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, and quality PHCN care and service at the competent, proficient, and expert levels?

      Overview

      PHCN is a diverse area of practice. Both public health and community RDNs improve nutritional health through culturally sensitive applications of health behavior theory across the lifespan, with a focus on reducing the prevalence of nutrition-related diseases and their complications through primary, secondary, and tertiary prevention interventions. As highlighted in the 2012 Academy House of Delegates Backgrounder,
      Academy of Nutrition and Dietetics House of Delegates
      HOD Backgrounder: Public Health Nutrition: It’s Every Member’s Business.
      public health RDNs combine expertise in nutrition and public health to focus on population assessment, program development and evaluation, policy generation, and systems and environmental change. Public health RDNs often need skills in biostatistics, epidemiology, program management, and policy development, in addition to classic nutrition expertise. Community RDNs provide counseling, education, and training to enhance the nutritional knowledge, attitudes, behaviors, and skills of individuals and groups in community-based settings.
      Foundational models and health behavior theories for PHCN practice include the Socio-ecological Model, the Social Determinants of Health, Life Course Theory, and Community-Based Participatory Research approaches (Figure 4).
      Figure 4Foundational models and theories for public health and community nutrition.
      Model/theoryBrief descriptionResources
      Socio-ecological ModelDeveloped by McLeroy and colleagues, the Socio-ecological Model posits that there are interacting spheres of influence that impact a person’s health behaviors and health. Those spheres include individual factors (eg, knowledge, beliefs, attitudes, skills, preferences); intrapersonal factors (eg, family and friends); institutional factors (eg, schools, churches workplaces); community/environmental factors (eg, neighborhoods); and societal factors (eg, laws, policy, social norms).
      • Roberto C.A.
      • Swinburn B.
      • Hawkes C.
      • et al.
      Patchy progress on obesity prevention: Emerging examples, entrenched barriers, and new thinking.
      • Mcleroy K.R.
      • Bibeau D.
      • Steckler A.
      • Glanz K.
      An ecological perspective on health promotion programs.
      Addressing Obesity Disparities: Social Ecological Model: http://www.cdc.gov/obesity/health_equity/addressingtheissue.html
      Social Determinants of HealthAn explanation of the social conditions (ie, economic stability, education, neighborhood, and built environment, health and health care, social and community context) and related underlying factors that influence people’s disease.Healthy People 2020: http://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health

      World Health Organization: http://www.who.int/social_determinants/en/

      Centers for Disease Control and Prevention: http://www.cdc.gov/socialdeterminants/
      Life Course TheoryA framework that describes how health outcomes in each life stage are influenced by the long-term effects of exposures during critical periods (eg, pregnancy, infancy), by long-term health habits across the life course, and through the interaction of biological, behavioral, psychological, social, economic, environmental, and equity factors.Maternal Child Health Bureau: Life Course Resource Guide http://mchb.hrsa.gov/lifecourse/

      World Health Organization: A Life Course Approach to Health http://www.who.int/ageing/publications/lifecourse/alc_lifecourse_training_en.pdf

      Life Course Nutrition-Maternal and Child Health Strategies in Public Health: http://www.mchnutritionpartners.ucla.edu/life-course/module-life-course-nutrition-maternal-and-child-health-strategies-public-health
      Community-Based Participatory Research and

      Participatory Action Research
      Community-based participatory research involves long-term, equitable, co-learning relationships between academic institutions and community partners that focus on community-selected issues and aim to improve community health and eliminate health disparities by generating action for social change.
      • Wallerstein N.B.
      • Duran B.
      Using community-based participatory research to address health disparities.
      National Institutes of Health:

      http://obssr.od.nih.gov/scientific_areas/methodology/community_based_participatory_research/

      University of Washington:

      https://depts.washington.edu/ccph/cbpr/index.php

      Association of Asian Pacific Community Health Organizations/National Association of Community Health Centers:

      CBPR toolkit http://www.aapcho.org/resources_db/cbpr-toolkit/
      Public health RDNs work with partners across all sectors to accomplish identified priorities, as this is an important strategy to ensure that programs are effective and sustained when priorities shift or resources become more limited. They use participatory models, such as Community-Based Participatory Research (Figure 4), to engage stakeholders in making a sustainable and meaningful nutrition and health impact at every step of the NCP and across multiple socio-ecological levels as well as stages of the life course. It would not be unusual for a public health RDN to attend a city council meeting to provide nutrition and health justification for code improvements to create community gardens or for the strategic placement of grocery stores to improve food access. For example, public health RDNs and countless other stakeholders worked with Blue Cross Blue Shield, the Centers for Disease Control and Prevention, and the Minnesota Department of Health to create the Minnesota Food Charter (http://mnfoodcharter.com/), a statewide roadmap to provide access to safe, affordable, and healthy food.
      Public health RDNs are also adept evaluators, as there is a constant need to demonstrate impact and outcomes in order to justify funding for the programs that they administer. Working at the population level is inherently different from individual-based programming. To illustrate how a public health RDN might adapt classic individual-based strategies for assessment, a sample Problem (P), Etiology (E), Signs/Symptoms (S) statement can be found in Figure 5.
      Figure 5Example Problem (P), Etiology (E), Signs/Symptoms (S) statement for public health registered dietitian nutritionists.
      P-Problem: Excessive energy intake in a population of pregnant women

      related to:

      E-Etiology/Determinants of problem: Food- and nutrition-related knowledge/skill deficit, undesirable food choices, and physical inactivity,

      as evidenced by:

      S-Signs/Symptoms: Population-level data reports indicating an increase in prevalence of excessive gestational weight gain among US pregnant women from 35% in 2005 to 45% in 2012.
      Often, population-level public health nutrition programs are funded by the federal government and administered through state agencies, such as universities and departments of health, education, and/or aging. Descriptions of key federally funded programs can be found elsewhere, such as in Mapping the World of Nutrition: An Overview of Federal Funding for Nutrition Programs.

      Academy of Nutrition and Dietetics. Mapping the World of Nutrition: An Overview of Federal Funding for Nutrition Programs. Chicago, IL: Academy of Nutrition and Dietetics; May 2015. http://www.eatrightpro.org/∼/media/eatrightpro%20files/advocacy/take%20action/bills%20and%20laws/mappingtheworld.ashx. Accessed July 23, 2015.

      In addition, public health RDNs may receive funding support from, and work with, chronic disease prevention associations (eg, American Diabetes Association, American Heart Association, and American Cancer Society), insurance companies, private businesses, and nonprofit foundations to implement programs and interventions.
      Community nutrition RDN practice involves working directly with individuals and families, while contributing to larger public health efforts to prevent and intervene upon nutrition-related problems. Community-based RDNs often use individual participant-centered counseling methods (eg, motivational interviewing) or broad approaches, such as social marketing, to promote and enhance changes in knowledge, attitudes, behavior, and health outcomes, while being sensitive to the systems and environments in which clients live. Community nutrition RDNs work with populations across the lifespan and have expertise in counseling, nutrition education, program development and administration, and management. Much like public health RDNs, community nutrition RDNs work across sectors to ensure care for their clients, often working closely with social service agencies and community health workers (promotoras) to support the delivery of services. For example, a community RDN may provide cooking classes in a senior center, or may train community health workers to implement the classes.

      Academy Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Public Health and Community Nutrition

      An RDN can use the Academy SOP and SOPP for RDNs (Competent, Proficient, and Expert) in PHCN (see the website-exclusive Figures 1 and 2; available online at www.andjrnl.org, and Figure 3) to:
      • identify the competencies needed to provide PHCN care and services;
      • self-assess whether he or she has the appropriate knowledge base and skills to provide safe and effective PHCN care and service for their level of practice;
      • identify the areas in which additional knowledge and skills are needed to practice at the competent, proficient, or expert level of PHCN practice;
      • provide a foundation for public and professional accountability in PHCN care and service;
      • support efforts for strategic planning and assist management in the planning of PHCN services and resources;
      • enhance professional identity and communicate the nature of PHCN care and services;
      • guide the development of PHCN and dietetics-related education and continuing education programs, job descriptions, and career pathways; and
      • assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in PHCN and dietetics, and the understanding of the full scope of this focus area of practice.

      Application to Practice

      All RDNs, even those with significant experience in other practice areas, must begin at the competent level when practicing in a new setting or new focus area of practice. At the competent level, an RDN in public health and community nutrition is learning the principles that underpin this focus area and is developing skills for safe and effective public health and community nutrition practice. This RDN, who may be an experienced RDN or may be new to the profession, has a breadth of knowledge in nutrition and dietetics and may have proficient or expert knowledge/practice in another focus area. However, the RDN new to the focus area of public health and community nutrition may experience a steep learning curve while becoming familiar with the body of knowledge and available resources to support public health and community-related nutrition and dietetics practice. RDNs at the competent level tend to focus more on community nutrition as compared to public health nutrition practice.
      At the proficient level, an RDN has developed a deeper understanding of PHCN practice and is better equipped to adapt and apply evidence-based guidelines and best practices than at the competent level. This RDN is able to modify practice according to unique situations (eg, develop policies enhancing safe and affordable access to healthy foods and creating national or state surveillance systems to monitor population-level nutritional health).
      At the expert level, the RDN thinks critically about PHCN and dietetics; demonstrates a more intuitive understanding of PHCN and dietetics care and service; displays a range of highly developed skills; and formulates judgments acquired through a combination of education, experience, and critical thinking. Essentially, practice at the expert level requires the application of composite nutrition, dietetics, and public health knowledge, with practitioners drawing on not only their practical experience, but also the experience of the public health and community RDNs in various disciplines and practice settings. Expert RDNs, with their extensive experience and ability to see the significance and meaning of PHCN and dietetics within a contextual whole, are fluid and flexible and have considerable autonomy in practice. They not only implement PHCN and dietetics services, they also manage, drive, and direct programs and policies; conduct and collaborate in research and advocacy; accept organization leadership roles; engage in scholarly work; guide interdisciplinary teams; and lead the advancement of PHCN and dietetics practice.
      Indicators for the SOP (Figure 1; available online at www.andjrnl.org) and SOPP (Figure 2; available online at www.andjrnl.org) for RDNs in PHCN are measurable action statements that illustrate how each standard can be applied in practice. Within the SOP and SOPP for RDNs in PHCN, an “X” in the competent column indicates that an RDN who is working with clients/populations is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. A competent RDN in PHCN could be an RDN starting practice after registration or an experienced RDN who has recently assumed responsibility to provide PHCN services and programs for clients/populations (eg, Special Supplemental Nutrition Program for Women, Infants, and Children participants, Supplemental Nutrition Assistance Program Education recipients, and Meals on Wheels recipients).
      An “X” in the proficient column indicates that an RDN who performs at this level has a deeper understanding of PHCN and dietetics and has the ability to shape programs and interventions to meet the needs of clients/populations in various situations (eg, creating statewide programs and policies to promote healthy eating and physical activity in early child care settings). An “X” in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of PHCN and dietetics and a highly developed range of skills and judgments acquired through a combination of experience and education. The expert RDN builds and maintains the highest level of knowledge, skills, and behaviors including leadership, vision, and credentials.
      Standards and indicators presented in Figures 1 and Figure 2 (available online at www.andjrnl.org) in boldface type originate from the Academy’s Revised 2012 SOP in Nutrition Care and SOPP 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 should apply to RDNs in all three levels. Several indicators developed for this focus area not in boldface type are identified as applicable to all levels of practice. Where an “X” is placed in all three levels of practice, it is understood that all RDNs in PHCN are accountable for practice within each of these indicators. However, the depth with which an RDN performs each activity will increase as the individual moves beyond the competent level. Several levels of practice are considered in this document; thus, taking a holistic view of the SOP and SOPP for RDNs in PHCN is warranted. It is the totality of individual practice that defines the level of practice and not any one indicator or standard.
      RDNs should review the SOP and SOPP in PHCN at regular intervals to evaluate their individual focus area knowledge, skill, and competence. Regular self-evaluation is important because it helps identify opportunities to improve and/or enhance practice and professional performance. This self-appraisal also enables public health and community RDNs to better utilize these Standards in CDR’s Professional Development Portfolio process and each of its five steps for reflection, self-assessment, planning, improvement, and commitment to lifelong learning
      • Weddle D.O.
      • Himburg S.P.
      • Collins N.
      • Lewis R.
      The professional development portfolio process: Setting goals for credentialing.
      (see Figure 6). RDNs are encouraged to pursue additional training, regardless of practice setting, to maintain currency and to expand individual scope of practice within the limitations of the legal scope of practice, as defined by State law. RDNs 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.E.
      • Amaya L.
      Ethics opinion: Registered dietitian nutritionists and nutrition and dietetics technicians, registered are ethically obligated to maintain personal competence in practice.
      RDNs are encouraged to pursue additional knowledge and skill training, and collaboration with other RDNs in PHCN to promote consistency in practice and performance and continuous quality improvement. See Figure 7 for case examples of how RDNs in different roles, at different levels of practice, may use the SOP and SOPP for RDNs in Public Health and Community Nutrition.
      Figure 6Application of the Commission on Dietetic Registration Professional Development Portfolio Process.
      How to Use the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Public Health and Community Nutrition as part of the Professional Development Portfolio Process
      The 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.
      1. ReflectAssess your current level of practice and whether your goals are to expand your practice or maintain your current level of practice. Review the SOP and SOPP for RDNs in Public Health and Community Nutrition document to determine what you want your future practice to be, and assess your strengths and areas for improvement. These documents can help you set short- and long-term professional goals.
      2. Conduct learning needs assessmentOnce you have identified your future practice goals, you can review the SOP and SOPP for RDNs in Public Health and Community Nutrition document to assess your current knowledge, skills, behaviors, and define what continuing professional education is required to achieve the desired level of practice.
      3. Develop learning planBased on your review of the SOP and SOPP for RDNs in Public Health and Community Nutrition, you can develop a plan to address your learning needs as they relate to your desired level of practice.
      4. Implement learning planAs you implement your learning plan, keep reviewing the SOP and SOPP for RDNs in Public Health and Community Nutrition document to reassess knowledge, skills, and behaviors and your desired level of practice.
      5. Evaluate learning plan processOnce you achieve your goals and reach or maintain your desired level of practice, it is important to continue to review the SOP and SOPP for RDNs in Public Health and Community Nutrition document to reassess knowledge, skills, and behaviors and your desired level of practice.
      a The 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 7Case examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Public Health and Community Nutrition.
      RoleExamples of use of the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) documents by registered dietitian nutritionists (RDNs) in different practice roles
      Clinical practitionerAn RDN with responsibility for the nutrition component of the hospital’s community education program uses the SOP and SOPP for RDNs in Public Health and Community Nutrition (PHCN) as a resource for personal development to improve competence in providing services to individuals participating in classes for the community and outreach activities. This RDN networks with a community and public health RDN for mentoring on preventative program content, leads to continuing education programs, and resources.
      Clinical nutrition managerA hospital’s clinical nutrition manager (CNM) represents the hospital on a community coalition workgroup addressing access to healthy food. The CNM meets with public health RDNs to increase knowledge in PHCN, nutrition surveillance for the community, food assistance programs, food access, and best practices in policies, systems, and environmental change interventions. In reviewing the PHCN SOP SOPP, the CNM notes the use of logic models to plan nutrition programs and interventions that may have application in the hospital and seeks additional training.
      Food and nutrition services managerA food and nutrition manager obtains a contract to provide congregate and home delivered meals to a local senior center. The contract includes having staff RDNs oversee menu planning, complying with regulations, and providing nutrition education at the meal site. The PHCN SOP SOPP were reviewed to evaluate competency level on topics, such as cultural competency, senior feeding programs, engagement of the target population in the planning and delivery of services, and additional funding for programming.
      Retail RDNAn RDN working for a grocery chain in the community reports receiving more requests to participate in community initiatives to increase healthy food access, such as working with sustainable, local agriculture,
      • Tagtow A.
      • Robien K.
      • Bergquist E.
      • et al.
      Academy of Nutrition and Dietetics: Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Sustainable, Resilient, and Healthy Food and Water Systems.
      in community gardens, and improving the healthfulness of foods donated to food banks. The RDN reviews the SOP and SOPP to identify ways to gain more knowledge and skills to increase effectiveness in responding to these requests. The retail RDN partners with PHCN RDNs to identify sources of continuing education and resources to help with addressing needs of target populations.
      Public health practitioner, community nutrition practitionerAn RDN working in public health and community nutrition programs or in policy, system, and environmental approaches develops and designs population approaches in alignment with the SOP and SOPP to standardize quality improvement methods and maximize public health and community nutrition program and policy outcomes. The RDN wants to become more active in advocating for changes in regulations related to nutrition and uses the SOP and SOPP to create a professional development plan to address gaps in competencies.
      ResearcherA research RDN works with a state education department to assess changes in student food intake as a result of new federal meal guidelines. The RDN uses the SOP and SOPP as a resource in designing the research protocol and evaluation methodology using current evidence-based knowledge tools as it relates to school foodservice and disparities in food intake across grade and free/reduced-price lunch status. The SOP and SOPP may also be used for identifying the need for staff development and/or collaboration with a colleague more experienced in public health and community nutrition school nutrition research.
      Nutrition educatorAn RDN working in nutrition education with a food bank reviews the SOP and SOPP for ideas on expanding knowledge and skills to qualify for leadership roles with nonprofit organizations serving individuals with food insecurity. Using the indicators in the SOP SOPP, the RDN identifies knowledge and skills to develop, revises professional development plan, and seeks mentorship to advance his or her career.
      In some instances, components of the SOP and SOPP for RDNs in PHCN do not specifically differentiate between proficient-level and expert-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 expert level, which combines 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 knowledge is embedded in the experience, discernment, and practice of expert-level RDN practitioners. The knowledge and skills acquired through practice will continually expand and mature. The indicators will be refined as expert-level RDNs systematically record and document their experience using the concept of exemplars. Exemplars include a brief description of the need for action and the process used to change the outcome. The experienced practitioner observes events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. Exemplars provide outstanding models of the actions of individual public health and community RDNs in public health settings and the professional activities that have enhanced client and community/population health.
      • Marcason W.
      What are the new national school lunch and breakfast program nutrition standards?.
      The SOP/SOPP indicators for each practice level should be considered in conjunction with other Academy publications that support the work of public health and community nutrition RDNs (Figure 8).
      Figure 8Additional Public Health and Community Nutrition (PHCN) practitioner resources.
      Academy Public Health and Community Nutrition Resources
      • 1.
        House of Delegates Fall 2012 Backgrounder: Public health nutrition: It’s every member’s business: Provides in-depth overview of public health and community registered dietitian nutritionists (RDNs), including educational requirements, examples of practice areas, scope of activities, and data demonstrating increasing need for more RDNs in this area of practice.
        Academy of Nutrition and Dietetics House of Delegates
        HOD Backgrounder: Public Health Nutrition: It’s Every Member’s Business.
        http://www.eatrightpro.org/∼/media/eatrightpro%20files/leadership/hod/mega%20issues/backgrounders/09%20public%20health%20nutrition%20backgrounder.ashx
      • 2.
        Guidelines for Community Nutrition Supervised Experiences: Provides guidelines for supervised experiences in community nutrition programs that promote the health and well-being of individuals, families, and communities. These guidelines are the essential starting point for personnel working in community nutrition programs who seek to enhance their level of practice. The 3rd edition, “Guidelines for Public Health and Community Nutrition Practice,” expected to be published fall 2015. http://www.phcnpg.org/docs/Resources/GuideCommunityNutrSuperExp.pdf (2nd edition)
      • 3.
        Public Health/Community Nutrition – Nutrition Care Process Toolkit: Provides a guide for practitioners working in public health and community nutrition to utilize the NCP and adapt it as needed whether they are working directly with individuals, populations, families, caregivers, programs, and grants or at the administration level with regulations, policies, or performance/quality improvement measures. Available for purchase at: http://www.eatrightstore.org/products/practitioner-tools/toolkits?p=3
      Competency Assessment Tools for Public Health and Community Nutrition Practitioners

      Future Directions

      There is a need for expertise in preventive and public health nutrition; RDNs in this area of practice would benefit from specialist or advanced practice certification. The SOP and SOPP for RDNs in PHCN are innovative and dynamic documents. Future revisions will reflect changes and advances in practice, dietetics education programs, and outcomes of practice audits and coordination with the Academy resources in Figure 8. The authors acknowledge that the three practice levels may require more clarity and differentiation in content and role delineation, and that competency statements that better characterize differences among the practice levels are needed. Creation of this clarity, differentiation, and definition are the challenges of today's public health and community RDNs to better serve tomorrow's practitioners and their patients, clients, and communities/populations.

      Conclusions

      RDNs face complex situations every day. Addressing the unique needs of each situation and applying standards appropriately are essential to providing safe, timely, population- or person-centered quality care and service. All RDNs are advised to conduct their practice based on the most recent edition of the Code of Ethics, the Scope of Practice in Nutrition and Dietetics, the Scope of Practice for RDs, and the SOP in Nutrition Care and SOPP for RDs. The SOP and SOPP for RDNs in PHCN are complementary documents and are key resources for RDNs at all knowledge and performance levels. These standards can and should be used by public health and community RDNs in daily practice to consistently improve and appropriately demonstrate competency and value as providers of safe and effective nutrition and dietetics care and services. These standards also serve as a professional resource for self-evaluation and professional development for RDNs specializing in PHCN practice. Just as a professional’s self-evaluation and continuing education process is an ongoing cycle, these standards are also a work in progress, and will be reviewed and updated every 5 years. Current and future initiatives of the Academy as well as advances in PHCN care and services will provide information to use in these updates and in further clarifying and documenting the specific roles and responsibilities of RDNs at each level of practice. As a quality initiative of the Academy and the PHCN Dietetic Practice Group, these standards are an application of continuous quality improvement and represent an important collaborative endeavor.
      These standards have been formulated to be used for individual self-evaluation and the development of practice guidelines and specialist credentials, but not for 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 health care professional. The use of the standards for any other purpose than that for which they were formulated must be undertaken within the sole authority and discretion of the user.

      Acknowledgements

      We would like to acknowledge the input and efforts by Margaret Tate, MS, RD, and Jamie Stang, PhD, MPH, RD, to the indicators. We would also like to thank the following people for their careful review and suggestions to the document: Jamie Stang, PhD, MPH, RD; Marsha Spence, PhD, MS-MPH, RD; Marion Taylor Baer, PhD, RD; Samia Hayden, MPH, RD; and Kay Sisk, MS, RD, LD. Finally, we would like to thank the Academy staff, in particular, Carol Gilmore, MS, RD, LD, FADA, FAND, and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, who supported and facilitated the development of these SOP and SOPPs.

      Supplementary Materials

      Figure 1Standards of Practice for Registered Dietitian Nutritionists (RDNs) in Public Health and Community Nutrition.
      Standard 1: Nutrition Assessment

      The registered dietitian nutritionist (RDN) uses accurate and relevant data and information to identify nutrition-related problems.

      Rationale:

      Nutrition assessment is the first of four steps of the Nutrition Care Process. Nutrition assessment is a systematic process of obtaining, verifying, and interpreting data in order to make decisions about the nature and cause of nutrition-related problems. It is initiated by referral and screening of individuals or groups for nutrition risk factors.

      Nutrition assessment is conducted using validated tools, the five domains of nutrition assessment and comparative standards as documented in the Nutrition Care Process Terminology (eNCPT). eNCPT is available as an online resource (formerly the International Dietetics & Nutrition Terminology Reference Manual [IDNT]). Nutrition assessment is an ongoing, dynamic process that involves not only initial data collection, but also reassessment and analysis of client or community needs. In public health and community nutrition, assessments are completed with clients and other stakeholders, including community members and health practitioners. Process assessments are also involved. Assessments provide the foundation for nutrition diagnosis, the second step of the Nutrition Care Process.

      Refer to eNCPT online.
      Indicators for Standard 1: Nutrition Assessment
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Anthropometric assessment:

      Assesses anthropometric measures that may include: height, weight, body mass index (BMI), waist circumference, growth pattern indices/percentile ranks/z scores and weight history
      XXX
      1.1AUtilizes culturally appropriate methods for anthropometric assessmentsXXX
      1.1BMonitors individual and population-based measuresXXX
      1.1CParticipates in collecting measures for population-based programs (eg, WIC
      WIC=Special Supplemental Nutrition Program for Women Infants and Children (United States) (http://www.fns.usda.gov/wic/women-infants-and-children-wic).
      database, BRFSS
      BRFSS=Behavioral Risk Factor Surveillance System (http://www.cdc.gov/brfss/index.htm).
      )
      XXX
      1.1DInitiates collecting measures for population-based programs (eg, SNAP-Ed
      SNAP-Ed=Supplemental Nutrition Assistance Program Education (http://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program-education-snap-ed).
      )
      XX
      1.1EManages systems for anthropometric assessment (ie, provides training, quality assessment, updating, monitoring)XX
      1.1FDesigns and contributes to improvements of systems for anthropometric data collection across populationsX
      1.2Biochemical data, medical tests, and procedure assessment:

      Assesses laboratory profiles, medical tests, and procedures, which may include: acid−base balance, electrolyte, renal, essential fatty acid, gastrointestinal, glucose/endocrine, inflammatory, lipid, metabolic rate, mineral, nutritional anemia, protein, urine, and vitamin/mineral profiles
      XXX
      1.2AInterprets and applies diagnosis-related data from medical providers (eg, anemia, cancer, diabetes) in assessmentsXXX
      1.2BInitiates and participates in collection of biochemical data (eg, nutritional anemia profile, oral glucose tolerance test to screen for gestational diabetes, elevated blood lead or mercury levels, population-based laboratory data from health surveillance systems, electronic health record data)XXX
      1.2CDesigns protocols and systems for nutritional biochemical assessment at population levelsXX
      1.2DApplies quantitative skills to evaluate diet and disease relationships in epidemiologic studiesXX
      1.3Nutrition-focused physical findings assessment (often referred to as clinical assessment): Assesses findings from evaluation of body systems, muscle and subcutaneous fat wasting, oral health, hair, skin and nails, signs of edema, suck/swallow/breathe ability, appetite, and affectXXX
      1.3AParticipates in collection of self-reported and other sources of dataXXX
      1.3BTrains staff on applying physical findings into health care (including direct client care and with other health care providers)XXX
      1.4Food and nutrition-related history assessment (often referred to as dietary assessment): AssessesXXX
      1.4AFood and nutrient intake including the composition and adequacy of food and nutrient intake, meal and snack patterns, and food allergies and intolerancesXXX
      1.4A1Applies and participates in multiple individual and population group assessment methods (eg, interviews, surveys, nutrient analysis software, nutrition surveillance systems)XXX
      1.4A2Initiates data collection using multiple individual and population group assessment methods (eg, interviews, surveys, nutrient analysis software, meal patterns in food programs, nutrition surveillance systems)XX
      1.4A3Designs systems and tools for multiple individual and population group assessment methods (eg, interviews, surveys, questionnaires, nutrient analysis, meal patterns in food programs, nutrition surveillance systems)X
      1.4BFood and nutrient administration, including current and previous diets and diet prescriptions and food modifications, eating environment, and enteral and parenteral nutrition administrationXXX
      1.4B1Accommodates and tailors approach for participants with special needs participating in federal nutrition assistance programs (eg, NSLP
      NSLP=National School Lunch Program (http://www.fns.usda.gov/nslp/national-school-lunch-program-nslp).
      , WIC, special formulas, congregate and home delivered meals)
      XXX
      1.4CMedication and dietary and herbal supplement use, including prescription and over-the-counter medications, herbal preparations, and complementary medicine products usedXXX
      1.4C1Considers potential diet interactions with medications, as well as dietary and herbal supplement use across the life course on individual and population levels (eg, interactions with human milk)XXX
      1.4C2Addresses any potential toxicities on individual and population levels (eg, human milk fortifier)XXX
      1.4C3Assesses illegal substance effects on individual and population levelsXXX
      1.4C4Considers client/population use of and need for dietary and herbal supplementationXXX
      1.4DKnowledge, beliefs, and attitudes including understanding of nutrition-related concepts, conviction of the truth and feelings/emotions toward some nutrition-related statement or phenomenon, body image and preoccupation with food and weight, and readiness to change nutrition-related behaviorsXXX
      1.4EBehavior including client/population activities and actions, which influence achievement of nutrition-related goalsXXX
      1.4E1Assesses behavioral and environmental influences using the socio-ecological approach or other health behavior theoryXXX
      1.4FFactors affecting access to food that influences intake and availability of a sufficient quantity of safe, healthful food and water, as well as food/nutrition-related suppliesXXX
      1.4F1Evaluates access to food at individual and population level (eg, availability and use of federal feeding programs such as NSLP, congregate and home-delivered meals, and presence of food deserts)XXX
      1.4F1iDetermines influence of policy/systems and other environmental factors on food accessXX
      1.4GPhysical activity, cognitive and physical ability to engage in specific tasks such as self-feeding, activities of daily living (ADLs), instrumental activities of daily living (IADLs), and breastfeedingXXX
      1.4HNutrition-related client/population-centered measures, including nutrition quality of life, and client/population perception of nutrition intervention, cultural, ethnic, religious, and lifestyle factors and their impact on lifeXXX
      1.4H1Collaborates with promotoras/peer/community health workers in assisting with assessmentsXXX
      1.4H2Trains and mentors promotoras/peer/community health workers on proper assessment techniquesXX
      1.5Client/population history: Assesses current and past information related to personal, medical, family, and social historyXXX
      1.5AAssesses target population health status in relation to community healthXXX
      1.5BUses population-based data to inform history and assessmentXXX
      1.5CTracks changes in personal history (community RDNs) and population-based health (public health RDNs)XXX
      1.5DLeads interdisciplinary team in identifying plan and tools for assessing target populations initially and over timeXX
      1.6Comparative standards:

      Identifies and uses comparative standards to estimate energy, fat, protein, carbohydrate, fiber, fluid, vitamin, and mineral needs, as well as recommended body weight, BMI, and desired growth patterns
      XXX
      1.6AIdentifies the most appropriate reference standards (ie, national, state, institutional, and regulatory) based on practice setting, client age, and disease/injury state and compares nutrition assessment data to appropriate criteria, relevant norms, population-based surveys, and standardsXXX
      1.6BUtilizes reference standards for guidance (eg, food safety, IOM
      IOM=Institute of Medicine (United States) (http://www.iom.edu/).
      and US Preventative Services Taskforce recommendations, DGA
      DGA=Dietary Guidelines for Americans (http://www.cnpp.usda.gov/dietaryguidelines).
      , CDC
      CDC=Centers for Disease Control and Prevention (United States) (http://www.cdc.gov).
      , and WHO
      WHO=World Health Organization (http://www.who.int/en/).
      [infant growth charts] guidelines)
      XXX
      1.7Physical activity habits and restrictions:

      Assesses physical activity, history of physical activity and exercise training
      XXX
      1.7AAnalyzes factors of accessibility, adequacy, and safety of the physical environment for both individuals and populationsXXX
      1.7BApplies Physical Activity Guidelines for Americans, NASPE
      NASPE=National Standards for Physical Education (http://www.shapeamerica.org/standards/pe/).
      , and CDC guidelines in assessments
      XXX
      1.7CConsults with exercise scientists, kinesiologists, and physical therapists as appropriateXXX
      1.8Reviews collected data for factors that affect nutrition and health statusXXX
      1.8AUtilizes nutrition assessment data documented by the nutrition and dietetics technician, registered (NDTR) or dietetic technician, registered (DTR) or other health care practitionerXXX
      1.8BUtilizes nationally available nutrition assessment data (eg, NHANES
      NHANES=National Health and Nutrition Examination Survey (United States) (http://www.cdc.gov/nchs/nhanes.htm).
      , BRFSS/YRBSS
      YRBSS=Youth Risk Behavior Surveillance System (http://www.cdc.gov/HealthyYouth/yrbs/index.htm).
      , Profiles, SHIPs
      SHIPs=State Health Improvement Plans (http://www.astho.org/WorkArea/DownloadAsset.aspx?id=6597).
      , Safety Performance Standards)
      XXX
      1.8CIntegrates knowledge of human nutrition with principles of epidemiologyXX
      1.8DUses biostatistical skills to assess relationships between nutrition-related factors and behaviors/outcomesXX
      1.8EOversees methods and instruments to ensure ongoing collection of valid and reliable quantitative and qualitative assessment data which may include electronic devices or web-based toolsX
      1.9Organizes and clusters nutrition risk factors, complications, and assessment data to identify possible problem areas for determining nutrition diagnosesXXX
      1.9AUses health theories to cluster nutrition risk factorsXXX
      1.9BGains deep understanding of epidemiological principles to interpret the magnitude and directionality of nutrition-related risk factorsXX
      1.10Documents and communicates:XXX
      1.10ADate and time of assessmentXXX
      1.10BPertinent data (eg, medical, social, behavioral)XXX
      1.10CComparison to appropriate standardsXXX
      1.10DClient/population perceptions, values, and motivation related to presenting problemsXXX
      1.10EChanges in client/population perceptions, values, and motivation related to presenting problemsXXX
      1.10FReason for discharge/discontinuation or referral if appropriateXXX
      1.10GCommunicates and disseminates assessment findings via a brief or report with the community and stakeholdersXXX
      1.10HIntegrates feedback from stakeholders in documenting program justifications and in planning program designXX
      Examples of Outcomes for Standard 1: Nutrition Assessment
      • Appropriate assessment tools and procedures (matching assessment method to situation) are implemented (eg, focus groups to assess population-level barriers to accessing early prenatal care or federal nutrition programs).
      • Appropriate and pertinent data are collected (eg, demographic data such as age, sex, race, ethnicity, income, migrant status, or health indicator data such as low birth weight, prematurity, anemia, overweight, obesity, special needs, and food security).
      • Effective interviewing methods are utilized (eg, USDA
        USDA=US Department of Agriculture (http://www.usda.gov/wps/portal/usda/usdahome).
        Participant Centered Value Enhanced Nutrition Assessment [VENA]).
      • Use of population-level assessment data leads to the determination that a nutrition diagnosis/problem does or does not exist (eg, prenatal weight gain data from a subpopulation of Hispanic women of child-bearing age, indicates a risk factor of excessive maternal weight gain due to cultural norms with food intake).
      • Consultation with or refer to another health practitioner (eg, assessment of prenatal smoking in a maternal population requiring referral to community smoking cessation programs).
      • Documentation and communication of assessments are complete, relevant, accurate, and timely (eg, individual care plans and/or population-level executive summary reports).
      Standard 2: Nutrition Diagnosis

      The registered dietitian nutritionist (RDN) identifies and labels specific nutrition problem(s)/diagnosis(es) that the RDN is responsible for treating.

      Rationale:

      Nutrition diagnosis is the second of four steps of the Nutrition Care Process. At the end of the nutrition assessment step, data are clustered, analyzed, and synthesized. This will reveal a nutrition diagnosis category from which to formulate a specific nutrition diagnosis statement.

      The nutrition diagnosis demonstrates a link to determining goals for outcomes, selecting appropriate interventions, and tracking progress in attaining expected outcomes. Diagnosing nutrition problems is the responsibility of the RDN in collaboration with the client (community nutrition) and community (public health nutrition).

      Refer to the eNCPT online.
      Indicators for Standard 2: Nutrition Diagnosis
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Derives the nutrition diagnosis(es) from the assessment dataXXX
      2.1AIdentifies and labels the problemXXX
      2.1A1Relates problems/diagnoses to demographics and characteristics of targeted population groups; consults with more experienced practitioners as neededXXX
      2.1BDetermines etiology (cause/contributing risk factors)XXX
      2.1B1Identifies and labels individual, social, environmental, community or policy conditions that are influencing the problem(s) using health behavior theory, such as the Socio-ecological Model; consults with more experienced practitioners as neededXXX
      2.1B2Relates risk factors to broad community health indicators (eg, cultural child feeding practices in relation to nutrition/health risk factors)XXX
      2.1B3Uses epidemiological data to evaluate the personal and social determinants that impact the nutrition diagnosis(es)XX
      2.1CClusters signs and symptoms (defining characteristics)XXX
      2.1C1Applies epidemiological methodologies (ie, surveys) and other qualitative methods (ie, focus groups and interviews) to determine the incidence and prevalence of common signs, symptoms, and risk factors among population groups, including trends in chronic disease risk and health disparitiesXX
      2.1C2Designs nutrition epidemiology studies to understand clustering of signs and symptomsX
      2.2Prioritizes and classifies the nutrition diagnosis(es)XXX
      2.2ARelates the client’s/population’s diagnosis(es) to food and environmental problems in the communityXXX
      2.2BPrioritizes individual, social, environmental, community, or policy conditions that can be addressed to mitigate the nutrition diagnosis(es)XX
      2.3Validates the nutrition diagnosis(es) with clients/community, family members or other health care professionals when possible and appropriate; corroborates right client/population to right diagnosisXXX
      2.3AConsults with other community and public health practitioners and community leadersXXX
      2.3BValidates nutrition diagnosis(es) with nutrition surveillance data, population-based research, and community feedbackXX
      2.4Documents the nutrition diagnosis(es) using standardized language and written statement(s) that include Problem (P), Etiology (E), and Signs and Symptoms (S) (PES statement[s])XXX
      2.4AAssesses prevalence and incidence of nutrition diagnoses at a population levelXX
      2.4BFrames and communicates diagnoses within the context of logic models, health behavior theories, and/or population outcomes dataXX
      2.5Re-evaluates and revises nutrition diagnosis(es) when additional assessment data become availableXXX
      2.5AApplies timely and relevant standards, program evaluation, and research-based evidence to population groupsXXX
      2.5BTracks changes and trends in diagnosesXXX
      2.5CConfers with biostatisticians to discuss methodologiesXX
      Examples of Outcomes for Standard 2: Nutrition Diagnosis
      • Nutrition Diagnostic Statements are: 1) clear and concise; 2) specific client or community-centered; 3) science-based; 4) based on reliable and accurate assessment data; and 5) includes date and time. Examples:
        • Inadequate physical activity related to limited outside recess after school lunch as evidenced by children returning immediately to class after school lunch.
        • Percent of low-income schools implementing policies for recess before lunch or at least 30 minutes of daily outside recess.
        • Increase in community breastfeeding initiation rates with implementation of social media texting program targeting prenatal women who are in the third trimester.
      • Documentation of nutrition diagnosis(es) is relevant, accurate, and timely (eg, applicable population-level data reports on public health problems [obesity, anemia, neural tube defects] are generated and retained within a standardized computer database system using a consistent procedure at regular intervals).
      • Documentation of nutrition diagnosis(es) is revised and updated as additional assessment data become available (eg, as maternal weight gain data become available for a population of pregnant women, the data are entered into a computer database system and analyzed on a periodic basis. The determination of prevalence will occur at regular intervals with documentation of any increase or decrease in excessive maternal weight gain over time).
      Standard 3: Nutrition Intervention

      The registered dietitian nutritionist (RDN) identifies and implements appropriate, purposefully planned interventions designed with the intent of changing a nutrition-related behavior, risk factor, environmental condition or aspect of health status for an individual, target group, or the community at large.

      Rationale:

      Nutrition intervention is the third of four steps of the Nutrition Care Process. It consists of two interrelated components—planning and implementation. Planning involves prioritizing the nutrition diagnoses, conferring with the client and others, reviewing practice guidelines and policies, and setting goals and defining the specific nutrition intervention strategy.

      Implementation of the nutrition intervention/plan of care is the action phase that includes carrying out and communicating the intervention/plan of care, continuing data collection, and revising the nutrition intervention/plan of care strategy, as warranted, based on the client/population response. An RDN implements the interventions or assigns components of nutrition intervention/plan of care to support staff in accordance with applicable laws and regulations. Nutrition intervention/plan of care is ultimately the responsibility of the RDN.

      Refer to the eNCPT online.
      Indicators for Standard 3: Nutrition Intervention
      Bold Font Indicators are Academy Core RDN Standards of

      Practice Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      Plans the Nutrition Intervention/Plan of Care:
      3.1Prioritizes the nutrition diagnosis(es) based on problem severity, safety, client/population needs, likelihood that nutrition intervention/plan of care will influence problem and client/population perception of importance which involves community input and includes policy initiatives and the community environmentXXX
      3.2Bases intervention/plan of care on best available research/evidence, evidence-based guidelines, and best practicesXXX
      3.2ACreates interventions based on funding requirements, including as appropriate state and federal guidelinesXXX
      3.2BConsiders health behavior theory (eg, Socio-ecological Model) in developing interventionsXXX
      3.2CCollaborates with epidemiologists and/or biostatisticians to refine project goals, available resources, and measuresXX
      3.2DLeads the development of intervention guidelines and outcome measures for local, state, and/or national nutrition servicesX
      3.3Refers to policies and program standardsXXX
      3.3AUses community/population-based national standards and guidelines/standards such as DGA, MyPlate, community health indicators, in planning the interventionXXX
      3.3BDevelops policy and environmental change/systems approaches, aligning messages across programs, collaborating with partners in order to strengthen messaging and leverage funding, and maximize reach to target populationsX
      3.4Confers with client, caregivers, interdisciplinary team, community stakeholders, other health care and community professionals (eg, city planners, educators, and policy makers)XXX
      3.4ACommunicates priorities and community needs to policy and other decision makers to support nutritional health of the populationXXX
      3.4BRaises awareness on policy-related issues with stakeholders and policy makers that can impact environmental conditions contributing to problems (eg, federal nutrition programs and food regulations)XX
      3.4CConvenes and collaborates with multisector public and private community coalitions and partners (eg, urban planners, NGOs
      NGOs=nongovernmental organizations.
      , nonprofits, breastfeeding coalitions, advocacy organizations) to develop and implement policy and environmental changes
      X
      3.5Determines client/population-centered plan, goals, and expected outcomesXXX
      3.5AUses logic model for planning and implementation of interventions, considering target population, as well as the broader community according to assessment of needsXXX
      3.5BCreates goals that are inclusive of cultural sensitivity, geographic diversity, socioeconomic diversity, practical implementationXXX
      3.5CIncorporates the concepts of the social determinants of health into programs and services that promote health equity and minimize/eliminate health disparitiesXXX
      3.5C1Focuses interventions on prevention approachesXXX
      3.6Develops the nutrition prescriptionXXX
      3.6AIdentifies, selects, and/or develops evidence-based or evidence-informed practices, programs, and science-based nutrition education materials based on nutritional needs of the target population; consults with more experienced practitioners as neededXXX
      3.6BImplements health promotion and disease prevention activities that are based on population’s nutritional statusXXX
      3.6CIntervenes and coordinates on all levels of the Socio-ecological Model to promote population healthXX
      3.7Defines time and frequency of care including intensity, duration, and follow-upXXX
      3.7ADevelops short-, intermediate-, and long-term interventions using logic models and needs assessment dataXXX
      3.7BUtilizes realistic and appropriate time frames to measure outcomes, with the understanding that some interventions can take many years to see changeXXX
      3.7B1Describes specific time frames for each level of intervention, with intrapersonal and interpersonal components generally taking shorter periods of time, and community, systems interventions taking yearsXXX
      3.7B2Defines measures specific to intervention outcomes, which could take months, years, or decades for each measureXX
      3.7B3Develops guidelines for timing of interventions and follow-up based on research and best practicesX
      3.8Utilizes standardized terminology for describing interventionsXXX
      3.8AIncorporates standard terminology from the fields of nutrition and public health, systems/environmental approaches, including the Public Health Community Nutrition Care Process ToolkitXXX
      3.8BFrames intervention-related communication to targeted stakeholders (eg, community partners, policy makers, businesses)XX
      3.9Identifies resources and referrals neededXXX
      3.9AApplies factors that impact accessibility, adequacy, and safety of food supply to community healthXXX
      3.9A1Connects population groups to services for food/water supplies and systems (via agriculture, business, retail, safety net programs, public institutions, hospitals)XXX
      3.9A2Uses information about nutrients and contaminants in the food and water supply in planning the interventionXX
      3.9BLinks individuals/populations to food and nutrition services to assure optimal nutritional status (eg, food pantries, home delivered meals programs, SNAP-Ed, free and reduced-price school meals, Summer Food Service Program, Child and Adult Care Food Program, WIC) and assists them with determining program eligibility and enrollment optionsXXX
      3.9CUtilizes an interdisciplinary approach to leverage resources across systemsXX
      3.9DEstablishes and maintains interagency networks based on client/population intervention needs; links nutrition and other servicesX
      Implements the Nutrition Intervention/Plan of Care:
      3.10Collaborates with colleagues, interdisciplinary team, and other health and community professionalsXXX
      3.10AIdentifies key stakeholders and collaboratorsXXX
      3.10BCollaborates within and across agencies and organizations, including other governmental sectors, nonprofits, community partners, business/insurance companies, industry and coalitions that work on addressing population health issues (eg, disparities in access to food, nutritional intake)XX
      3.10CAdvocates for evidence-based approaches to addressing nutrition-related population health issues with policy makers, elected officials, and other influential leadersXX
      3.10DMobilizes stakeholders, including food policy councils while building community leadership capacity for change to create health promoting environments and practicesXX
      3.11Communicates and coordinates the nutrition intervention/plan of careXXX
      3.11APartners with primary health care providers to ensure community nutrition services complies with clients’ plans of careXXX
      3.11BParticipates in boards, organizations, task forces, committees, coalitions, and partnerships to support nutrition interventionsXX
      3.11CDisseminates intervention plans and outcomes with key community partners and stakeholders in a transparent mannerXX
      3.11DConvenes boards, organizations, task forces, committees, coalitions, and partnerships to support nutrition interventionsX
      3.12Initiates and individualizes the nutrition intervention/plan of careXXX
      3.12AUtilizes physician/referring practitioner-driven protocols or other facility-specific processes to implement, initiate, or modify orders for diet or nutrition-related services (eg, nutrition supplements, dietary supplements, food-texture modifications for dentition or individual preferences, enteral and parenteral nutrition, nutrition-related laboratory tests and medications, and nutrition education and counseling); services are consistent with specialized training where required, competence, approved clinical privileges for order writing and organization policyXXX
      3.12BUtilizes physician/referring practitioner-driven protocols or other facility-specific processes to manage nutrition support therapies (eg, formula selection, rate adjustments based on energy needs or laboratory results, addition of designated medications and vitamin/mineral supplements to parenteral nutrition solutions or supplemental water for enteral nutrition); services are consistent with specialized training where required, competence, approved clinical privileges for order writing, and organization policyXXX
      3.12CEnsures availability of quality nutrition services to target populations, including screening, assessment, education, counseling, and referral to food assistance programsXXX
      3.12DConsiders social/ethnic disparities, culture, food access, and socioeconomic status in developing the nutrition interventionXXX
      3.12EEmploys a variety of strategies (eg, social media, billboards, flyers, public service announcements, radio ads) to reach/educate target populationXX
      3.13Assigns activities to NDTR or DTR and other administrative support and technical personnel in accordance with qualifications, organization policies, and applicable laws and regulationsXXX
      3.13ASupervises support personnelXXX
      3.13A1Engages community volunteersXX
      3.13A2Collaborates with and oversees community health workers (ie, paraprofessionals, lay health workers, promotoras)XX
      3.13A3Mobilizes cross-disciplinary staff in program interventions (eg, school and school foodservice staff, government professionals, public university employees, city planners, and community advocates)X
      3.14Continues data collectionXXX
      3.14ATracks progress toward achieving short-, intermediate-, and long-term outcomes according to intervention plans often using logic modelsXXX
      3.14BObtains and utilizes client and community input and feedback in asset mapping, needs assessment, gap analysis, program outputs, and outcomesXX
      3.14CTrains staff on data collection protocols and methodsXX
      3.15Follows up and verifies that nutrition intervention/plan of care is occurringXXX
      3.15AMonitors intervention for achievement of expected outcomesXXX
      3.15BConducts process evaluations and fidelity assessments to ensure that programs are being implemented according to standards/plans and for potential efficienciesXX
      3.16Adjusts nutrition intervention/plan of care strategies, if needed, as response occursXXX
      3.16AUses population-level data to inform and adjust program and objectivesXX
      3.16BUses formative research and focus group testing for ongoing program/intervention planning and adjustments for optimal outcomesXX
      3.16CMentors and guides process and planning in unpredictable and dynamic situations (eg, emergency preparedness and response)X
      3.17Documents:
      3.17ADate and timeXXX
      3.17BSpecific intervention goals and expected outcomesXXX
      3.17CRecommended interventionsXXX
      3.17DAdjustments to the plan and justificationXXX
      3.17EClient/community receptivityXXX
      3.17FReferrals made and resources usedXXX
      3.17GClient/population comprehensionXXX
      3.17HKnowledge, skill, and behavior change of client/populationsXXX
      3.17IBarriers to changeXXX
      3.17JOther information relevant to intervention and monitoring progress over timeXXX
      3.17KPlans for follow up and frequency of careXXX
      3.17LRationale for discharge or referral, if applicableXXX
      3.17MReports to funders, policy makers, and other stakeholdersXXX
      Examples of Outcomes for Standard 3: Nutrition Intervention
      • Documentation of nutrition intervention/plan of care is: 1) comprehensive (eg, revisions and updates to WIC and hospital lactation policies, education and practices); 2) specific (eg, no artificial nipples or ABM
        ABM=artificial breast milk.
        provided to WIC mothers in the hospital after delivery); 3) accurate (eg, correctly identifies factors, eg, artificial nipples and ABM, that are barriers to breastfeeding initiation and success); 4) relevant (eg, eliminate nipple confusion and ABM administration leading to breastfeeding preference); 5) timely (eg, early preference for breastfeeding success = increase in imitation rate in population); and 6) dated and timed (eg, documentation in hospital medical records and WIC records).
      • Documentation of nutrition intervention/plan of care is revised and updated as needed and determined by epidemiological/tracking data.
      • Food insecurity is considered as a nutrition diagnosis and refers clients to nutritional services and food assistance programs.
      • Convening of stakeholders (school officials, teachers, foodservice directors, elected officials) to present plan for increasing school breakfast program offering within a county school system to address high levels of childhood food insecurity.
      • Appropriate prioritizing and setting of goals/expected outcomes.
      • Client/population, caregivers, and interdisciplinary team, as appropriate, are involved in developing nutrition intervention/plan of care.
      • Appropriate individualized client/population-centered nutrition intervention/plan of care, including nutrition prescription, is developed (eg, schedule intervention team meeting to plan intervention, including review of policies and practices, setting goals to increase participation in congregate meals).
      • Interdisciplinary collaborations are utilized (eg, food bank RDNs collaborate with business owners and farmers to increase availability of fresh produce to clients/populations).
      • Logic model as a dynamic tool is used to document intervention/plan of care.
      Standard 4: Nutrition Monitoring and Evaluation

      The registered dietitian nutritionist (RDN) monitors and evaluates indicators and outcomes data directly related to the nutrition diagnosis, goals, and intervention strategies to determine the progress made in achieving desired outcomes of nutrition care and whether planned interventions should be continued or revised.

      Rationale:

      Nutrition monitoring and evaluation is the fourth step in the Nutrition Care Process. Through monitoring and evaluation, the RDN identifies important measures of change or client/population outcomes relevant to the nutrition diagnosis and nutrition intervention/plan of care and describes how best to measure these outcomes.

      Nutrition monitoring and evaluation are essential components of an outcomes management system. The aim is to promote uniformity within the profession in evaluating the efficacy of nutrition interventions/plans of care.

      Refer to the eNCPT online.
      Indicators for Standard 4: Nutrition Monitoring and Evaluation
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Monitors progress:XXX
      4.1AAssesses client/population understanding and compliance with nutrition intervention/plan of careXXX
      4.1A1Tracks nutrition-related trends at a population levelXXX
      4.1A1iUses principles of epidemiology and basic biostatistics to track trendsXX
      4.1A2Applies a range of evaluative measures (eg, qualitative, quantitative, impact, and process information)XX
      4.1A3Determines evaluation measures and systems for use with client/population interventionsX
      4.1BDetermines whether the nutrition intervention/plan of care is being implemented as prescribedXXX
      4.1B1Adjusts intervention based on evaluation dataXX
      4.1B2Determines if measures are capturing desired outcomes (ie, reliability and validity of measures)XX
      4.1CEvaluates progress or reasons for lack of progress related to problems and interventionsXXX
      4.1C1Assesses program/intervention assessment tools for reliability and validityXX
      4.1C2Engages target population and other stakeholders to understand evaluation outcomes (eg, satisfaction surveys, focus groups)XX
      4.1C3Communicates barriers and progress to stakeholdersXX
      4.1C4Mobilizes stakeholders in analysis and troubleshootingXX
      4.1DEvaluates evidence that the nutrition intervention/plan of care is influencing a desirable change in the client/population behavior or statusXXX
      4.1D1Evaluates behavior change through knowledge, application of social, behavioral, and educational theoriesXXX
      4.1D2Evaluates impact of health status of populations receiving public health nutrition servicesXX
      4.1D3Identifies complex underlying problems beyond the scope of nutrition that are interfering with the intervention and recommends appropriate intervention, partnering with stakeholdersX
      4.1EIdentifies positive or negative outcomesXXX
      4.1E1Documents effectiveness, accessibility, and quality of population-based servicesXX
      4.1E2Identifies unintended consequences and outcomes, adjusts intervention based on findings (especially at policy and system level)X
      4.1FSupports conclusions with evidenceXXX
      4.1GEvaluates impact of policy on health status of a population group.X
      4.2Measures outcomes:XXX
      4.2ASelects the nutrition care/intervention outcome indicator(s) to measureXXX
      4.2BUses standardized nutrition care outcome indicator(s)XXX
      4.3Evaluates outcomes:XXX
      4.3ACompares monitoring data with nutrition goals/prescription or reference standardXXX
      4.3A1Benchmarks datasets from program participants to national, state, and local public health datasets (eg, Healthy People National Health Objectives, Healthcare Effectiveness Data and Information Set)X
      4.3BEvaluates impact of the sum of all interventions on overall client/population health outcomesXXX
      4.3B1Participates in the evaluation of interventionsXXX
      4.3B2Leads evaluation of the efficacy and effectiveness of interventions on overall client/population health outcomes in partnership with stakeholders and the communityXX
      4.3B3Analyzes legislative impact on health programs, federal food assistance programs, policies, and interventionsX
      4.3CApplies surveillance systems to monitor population health over timeXX
      4.4DocumentsXXX
      4.4ADate and timeXXX
      4.4BIndicators measured, results, and the method for obtaining measurementXXX
      4.4CCriteria to which the indicator is compared (eg, nutrition goal/prescription or a reference standard)XXX
      4.4DFactors facilitating or hampering progressXXX
      4.4EOther positive or negative outcomesXXX
      4.4FFuture plans for nutrition care, nutrition monitoring, and evaluation, follow up, referral or dischargeXXX
      4.4GUses the logic model as a dynamic tool to document revisions/updates to the plan of care, especially in population-based interventionsXXX
      Examples of Outcomes for Standard 4: Nutrition Monitoring and Evaluation
      • The client/population outcome(s) directly relate to the nutrition diagnosis and the goals established in the nutrition intervention/plan of care. Examples include, but are not limited to:
        • Nutrition outcomes (eg, change in knowledge, behavior, food, or nutrient intake)
        • Clinical and health status outcomes (eg, change in laboratory values, body weight, blood pressure, risk factors, signs and symptoms, clinical status, infections, complications, morbidity, and mortality)
        • Client-centered outcomes (eg, quality of life, satisfaction, self-efficacy, self-management, functional ability)
        • Community-centered outcomes (eg, access to fruits/vegetables, changes in prevalence of overweight/obesity, increase in rate of breastfeeding duration, consumption of fruits and vegetables, increased access to federal nutrition programs and improved food systems)
        • Health care utilization and cost effectiveness outcomes (eg, special procedures, decreased admissions for preventable nutrition-related problems, prevented or delayed morbidity and mortality)
      • Documentation of nutrition monitoring and evaluation is comprehensive, specific, accurate, relevant, timely, dated, and timed
      a WIC=Special Supplemental Nutrition Program for Women Infants and Children (United States) (http://www.fns.usda.gov/wic/women-infants-and-children-wic).
      b BRFSS=Behavioral Risk Factor Surveillance System (http://www.cdc.gov/brfss/index.htm).
      c SNAP-Ed=Supplemental Nutrition Assistance Program Education (http://www.fns.usda.gov/snap/supplemental-nutrition-assistance-program-education-snap-ed).
      e IOM=Institute of Medicine (United States) (http://www.iom.edu/).
      f DGA=Dietary Guidelines for Americans (http://www.cnpp.usda.gov/dietaryguidelines).
      g CDC=Centers for Disease Control and Prevention (United States) (http://www.cdc.gov).
      h WHO=World Health Organization (http://www.who.int/en/).
      i NASPE=National Standards for Physical Education (http://www.shapeamerica.org/standards/pe/).
      j NHANES=National Health and Nutrition Examination Survey (United States) (http://www.cdc.gov/nchs/nhanes.htm).
      k YRBSS=Youth Risk Behavior Surveillance System (http://www.cdc.gov/HealthyYouth/yrbs/index.htm).
      l SHIPs=State Health Improvement Plans (http://www.astho.org/WorkArea/DownloadAsset.aspx?id=6597).
      m USDA=US Department of Agriculture (http://www.usda.gov/wps/portal/usda/usdahome).
      n NGOs=nongovernmental organizations.
      o ABM=artificial breast milk.
      Figure 2Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Public Health and Community Nutrition. Note: The term client/population is used in this evaluation resource as a universal term. Client/population could also mean client/patient, resident, participant, consumer, student, or any individual, group, organization or stakeholder to which the RDN provides services.
      Standard 1: Quality in Practice

      The registered dietitian nutritionist (RDN) provides quality services using a systematic process with identified leadership, accountability, and dedicated resources.

      Rationale:

      Quality practice in nutrition and dietetics is built on a solid foundation of education, credentialing, evidence-based practice, demonstrated competence, and adherence to established professional standards. Quality practice requires systematic measurement of outcomes, regular performance evaluations, and continuous improvement.
      Indicators for Standard 1: Quality in Practice
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Complies with applicable laws and regulations as related to his/her area(s) of practiceXXX
      1.1AComplies with local, regional, state, and federal government regulations and guidance (eg, nutrition education should be based off of MyPlate and/or DGA
      DGA=Dietary Guidelines for Americans (http://www.cnpp.usda.gov/dietaryguidelines).
      , ethics boards) and/or funders
      XXX
      1.2Performs within individual and statutory scope of practiceXXX
      1.2AIncorporates the Public Health Core Functions and 10 Essential Services (http://www.cdc.gov/nphpsp/essentialservices.html) in practiceXXX
      1.2BFollows any additional scope of practice requirements related to additional credentialing or position (eg, Certified Health Education Specialist, Certified Diabetes Educator)XXX
      1.3Adheres to sound business and ethical billing practices applicable to the settingXXX
      1.3AProvides accurate and timely financial reports to funders (eg, government grants and contracts, foundations, and nonprofits)XX
      1.4Utilizes national and global quality and safety data (eg, Institute of Medicine, National Quality Forum, Institute for Healthcare Improvement, Healthy People 2020, Millennium Development Goals, NGO
      NGO=nongovernmental organization.
      /foundation benchmarks [eg, Kids Count, US Preventive Task Force]) to improve the quality of services provided and to enhance client/population-centered service
      XXX
      1.4AContributes to interdisciplinary team to promote understanding an adoption of recommended evidence-based practicesXX
      1.4BLeads local, state, national, and/or international quality initiative efforts to support public health and community nutrition goals and best practicesX
      1.5Utilizes a systematic performance improvement model (eg, community health improvement plans) that is based on practice knowledge, evidence, research, and science for delivery of the highest quality servicesXXX
      1.5AIncorporates health behavior theory, logic models, and/or other appropriate models to plan and implement programs and services; consults with more experienced practitioners as neededXXX
      1.6Participates in or designs an outcomes-based management system to evaluate safety, effectiveness, and efficiency of practiceXXX
      1.6AInvolves colleagues and others, as applicable, in systematic outcomes managementXXX
      1.6A1Engages community members, funders, and multidisciplinary stakeholders in developing and monitoring outcomes-based management systemsXX
      1.6BUtilizes indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)XXX
      1.6CDefines expected outcomesXXX
      1.6C1Includes process, impact, and outcome indicatorsXXX
      1.6C2Relates program outcomes to multilevel outcomes (eg, agency, program, individual outcomes/needs)XX
      1.6DMeasures quality of services in terms of process and outcomeXXX
      1.6D1Considers short-, medium-, and long-term outcomes, collaborating across agencies and partners, including cost-effectivenessXX
      1.6EDocuments outcomesXXX
      1.6E1Engages multidisciplinary partners, including the community, in documenting outcomes and impactXX
      1.7Identifies and addresses potential and actual errors and hazards in provision of servicesXXX
      1.7AApplies food safety and sanitation protocols within food distribution programsXXX
      1.7BRefers clients to appropriate services when hazard is outside of practitioner’s scope of practiceXX
      1.7CWorks closely with federal, state, and local regulatory bodies to inform the public on food recalls and environmental hazards based on epidemiological surveillance dataXX
      1.7DApplies Health Impact Assessments and/or biostatistical assessments to address unintended consequencesXX
      1.7ELeads in collaboration with stakeholders development of processes to identify, addresses, and prevent errors or hazards (eg, state food safety protocols)X
      1.8Compares actual performance to performance goals (eg, Gap Analysis, SWOT Analysis [Strengths, Weaknesses, Opportunities, and Threats], PDCA Cycle [Plan-Do-Check-Act], Logic Models)XXX
      1.8AReports and documents action plan to address identified gaps in performanceXXX
      1.9Evaluates interventions to improve processes and servicesXXX
      1.9AParticipates in dissemination and collection of intervention evaluationsXXX
      1.9BEngages community members and stakeholders in intervention evaluations (eg, satisfaction surveys, alignment with cultural norms, process and outcome evaluations)XX
      1.9CDesigns systems and processes for obtaining community and stakeholder participation in intervention evaluationsX
      1.10Improves or enhances services based on measured outcomesXXX
      1.10AUses culturally competent group engagement processes to improve and enhance servicesXXX
      1.10BOversees, monitors, ensures consistency, and revises process and outcome evaluation efforts to improve servicesXX
      1.10CLeads the development of performance improvement activities; designs and implements evaluation protocols, analyzes data, and implements improvementsX
      Examples of Outcomes for Standard 1: Quality in Practice
      • Actions are within scope of practice and applicable laws and regulations (eg, in providing MNT
        MNT=medical nutrition therapy.
        ; counsels, refers, and guides clients based on state rules around WIC-approved foods and current food package rules).
      • National quality standards and best practices are evident in client/population-centered services (eg, organizes, participates in training on, and demonstrates effective application of Value Enhanced Nutrition Assessment).
      • Performance indicators are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.) (eg, ensures program objectives align with and evaluation tools are valid and reliable in measuring intended outcomes).
      • Aggregate outcomes meet pre-established criteria (eg, application of safe food-handling guidelines results in lowered risk/incidence of foodborne illness in food rescue program).
      • Results of quality-improvement activities direct refinement and advancement of practice (eg, focus groups and client feedback forms are used to measure satisfaction with program participation and areas for improved delivery).
      Standard 2: Competence and Accountability

      The registered dietitian nutritionist (RDN) demonstrates competence in and accepts accountability and responsibility for ensuring safety and quality in the services provided.

      Rationale:

      Competence and accountability in practice includes continuous acquisition of knowledge, skills, and experience in the provision of safe, quality, client/population-centered service.
      Indicators for Standard 2: Competence and Accountability
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Adheres to the Academy Code of Ethics and Code of Ethics for Public HealthXXX
      2.1AApplies Public Health Code of Ethics (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447186/pdf/0921057.pdf) and the principal of interdependence of people and the health of the communityXXX
      2.1BApplies Academy and Public Health Codes of Ethics within the context of federal, state, local, and agency guidelines (eg, advocacy guidelines)XXX
      2.2Integrates the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) into practice, self-assessment, and professional developmentXXX
      2.2AIntegrates applicable focus area SOPs and SOPPs into practice according to populations served (eg, Sustainable, Resilient, and Healthy Food and Water Systems, Diabetes Care, Pediatric Nutrition)XXX
      2.2BIncorporates the Public Health and Community Nutrition SOP and SOPP into human resources systems (eg, job descriptions and performance plans)XX
      2.3Demonstrates and documents competence in practice and delivery of client/population-centered serviceXXX
      2.3ADocuments the engagement of the community and stakeholders in the delivery of servicesXXX
      2.4Assumes accountability and responsibility for actions and behaviorsXXX
      2.4AAcknowledges and corrects errorsXXX
      2.4A1Reports errors and problems to funding agencies and ethical review boardsXX
      2.4BUtilizes lessons learned from previous projectsXX
      2.4CEnsures that all staff (including paraprofessionals or colleagues in other disciplines) have adequate training to deliver appropriate services; seeks consultation if neededXX
      2.4DDirects and develops policies that assure accountability as applicable to a management roleX
      2.5Conducts self-assessment at regular intervalsXXX
      2.5AIdentifies needs for professional developmentXXX
      2.5BUses self-assessment tools, such as those incorporated in the Guidelines for Community Nutrition Supervised Experiences (self-assessment tool for public health nutritionists to be republished in 2015/2016 as Guidelines for Public Health and Community Nutrition Practice, 3rd ed)XXX
      2.6Designs and implements plans for professional developmentXXX
      2.6ADocuments professional development activities in career portfolioXXX
      2.6A1Includes professional development goals around key dimensions of public health practice (Analytical/Assessment, Policy Development/Program Planning, Communication, Cultural Competency, Community Dimensions of Practice, Public Health Sciences, Financial Planning and Management, Leadership, and Systems Thinking)XXX
      2.6BDocuments professional development activities as per organization guidelinesXXX
      2.7Engages in evidence-based practice and utilizes best practicesXXX
      2.7AIncorporates best practices for addressing the health needs of clients and population groupsXXX
      2.7BCollaborates with key partners and allied professionals (eg, urban planners, social workers) to ensure incorporation of evidence-based and best practices from their field in program planning and implementationXXX
      2.7CUtilizes health behavior theories as the framework for best practicesXXX
      2.7DParticipates in councils, committees, and taskforces that shape evidence-based guidelines and practices supported by policyXX
      2.7EIntegrates research findings and evidence into peer-reviewed publications and recommendations for practiceX
      2.8Participates in peer review of self and othersXXX
      2.8AAddresses public health domains in evaluation of self-performance and peer or employee evaluationsXXX
      2.9Mentors othersXXX
      2.9AGuides the professional development and training of paraprofessionals, volunteers, community health workers, and promotoras working in the communityXXX
      2.9BParticipates in mentoring entry-level RDNs and RDNs interested in public health and community nutritionXX
      2.9CProvides expertise and council to educational institutions related to mentoring and training of community and public health nutrition professionalsX
      2.10Pursues opportunities (education, training, credentials) to advance practice in accordance with laws and regulations and requirements of practice settingXXX
      2.10ARemains informed on nutrition practice-related laws and public policyXXX
      2.10BParticipates in training to ensure that programs are fair and equitableXXX
      2.10CProvides leadership to colleagues (RDNs, community members, and other public health professionals) on nutrition and public policyXX
      2.10DMonitors public health nutrition program integrity and gains professional development as it relates to program regulations and nutrition standards (eg, FNS
      FNS=US Department of Agriculture Food and Nutrition Service (http://www.fns.usda.gov/).
      programming: WIC
      WIC=Special Supplemental Nutrition Program for Women Infants and Children (United States) (http://www.fns.usda.gov/wic/women-infants-and-children-wic).
      , CACFP
      CACFP=Child and Adult Care Food Program (United States) (http://www.fns.usda.gov/cacfp/child-and-adult-care-food-program).
      , NSLP
      NSLP=National School Lunch Program (http://www.fns.usda.gov/nslp/national-school-lunch-program-nslp).
      )
      XX
      2.10ETakes leadership roles in local, state and national advisory groups related to public health nutrition laws and regulationsX
      Examples of Outcomes for Standard 2: Competence and Accountability
      • Practice reflects the code of ethics and adheres to ethical principles relevant to public health issues (eg, Skills for the Ethical Practice of Public Health, James Thomas, PhD, MPH, University of North Carolina−Public Health Leadership Society, 2004)
      • Practice reflects the SOP/SOPP as a basis for all interactions with organizations, communities, populations, and individuals
      • Competence is demonstrated and documented (Core Competencies for Public Health Professionals, Council on Linkages between Academia and Public Health Practice, 2010: http://www.phf.org/programs/corecompetencies)
      • Safe, quality client/population service is provided, which is client/population-centered recognizing community linkages and relationships among multiple factors/determinants (eg, uses the Socio-ecological Model)
      • Practice incorporates successful strategies for interactions with individuals/groups from diverse backgrounds (cultural, socioeconomic, educational, racial, sex, age, ethnic, sexual orientation, religious, mental/physical capabilities)
      • Self-assessments are conducted regularly using this SOP/SOPP or the University of Minnesota’s Self-Assessment Tool for Public Health/Community Nutritionists (http://www.epi.umn.edu/let/assessment/index.shtm)
      • Professional Development needs are identified and incorporate assessment of skills for Public Health Professionals (eg, Competency Assessment, Public Health Foundation)
      • Practice reflects evidenced-based practice and best practices
      • Partnerships are developed with other public health and community professionals to build the scientific base
      • Commission on Dietetic Registration recertification requirements are met
      Standard 3: Provision of Services

      The registered dietitian nutritionist (RDN) provides safe, quality service based on client/population expectations and needs, and the mission and vision of the organization/business.

      Rationale:

      Quality programs and services are designed, executed, and promoted based on the RDN’s knowledge, experience, and competence in addressing the needs and expectations of the organization/business and its clients/populations.
      Indicators for Standard 3: Provision of Services
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      3.1Contributes to or leads the development and maintenance of programs/services that address needs of the clients/target population(s)XXX
      3.1AAligns program/service development with the mission, vision, and service expectations and outputs of the organization/businessXXX
      3.1A1Utilizes the logic model in order to meet the health outcomes of clients/populationsXXX
      3.1A2Develops programs with short-, medium- and long-term goals with a shared vision of health across all levels of the Socio-ecological Model in order to maximize the reach and effectiveness of programsX
      3.1BUtilizes the needs, expectations, and desired outcomes of the client/population (eg, administrator, client organization[s]) in program/service developmentXXX
      3.1B1Includes the community, policy makers, and other stakeholders in the development of programsXXX
      3.1B2Integrates population-based/formative assessments findings into service deliveryXX
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environmentXXX
      3.1C1Shapes, modifies, and adapts program and service delivery in alignment with funding requirements and prioritiesXX
      3.1C2Emphasizes the transformation of community environments through population-level programsX
      3.1DProposes programs and services that are client/population-centered, culturally appropriate, and minimize health disparitiesXXX
      3.1D1Follows federal guidance (eg, USDA
      USDA=US Department of Agriculture (http://www.usda.gov/wps/portal/usda/usdahome).
      , FNS, and CDC
      CDC=Centers for Disease Control and Prevention (United States) (http://www.cdc.gov).
      ) to ensure that programming incorporates inclusivity, equality and equity
      XXX
      3.1D2Engages community stakeholders in the development, adaptation, and sustainability of programsXXX
      3.1D3Uses and collects data to track changes in health disparities and ensure inclusivity, equality, and equityXX
      3.1D4Creates messages and opportunities to address social justice and social equityXX
      3.1D5Develops recommendations related to policy, systems, and environmental supportX
      3.2Promotes public access and referral to credentialed nutrition and dietetics practitioners for quality food and nutrition programs and servicesXXX
      3.2AContributes to or designs referral systems that promote access to qualified, credentialed nutrition and dietetics practitionersXXX
      3.2A1Ensures that RDNs are part of a multidisciplinary approach across collaborative programs and effortsXXX
      3.2BRefers clients/populations to appropriate providers when requested services or identified needs exceed the RDN’s individual scope of practiceXXX
      3.2B1Implements established agreements and referral systems for social and health-related services (eg, dental, family planning, community action agencies)XXX
      3.2B2Creates policies and practices that support a strong safety net for clients and populationsXX
      3.2B3Establishes agreements and referral systems with health and community partnersX
      3.2B4Supports referral sources with curriculum and training regarding needs of client/populationX
      3.2CMonitors effectiveness of referral systems and modifies as needed to achieve desirable outcomesXXX
      3.2C1Collects and uses data to track effectiveness of referral systems (eg, WIC information systems) for targeted outcomesXXX
      3.2C2Shares aggregate referral data and related outcomes of the referral with external partners (eg, reports on smoking rates)XXX
      3.2C3Completes process and outcome evaluation of referral system and reports back to stakeholders and/or fundersXX
      3.2C4Modifies referral system in collaboration with external partners to improve effectivenessX
      3.3Contributes to or designs client/population-centered servicesXXX
      3.3AAssesses needs, beliefs/values, goals, and resources of the client/populationXXX
      3.3A1Conducts needs assessments (eg, community health assessments) in partnership with individuals and community stakeholders; consults with more experienced practitioners as neededXXX
      3.3A2Develops targeted, tailored, and/or personalized services based on needs assessments and cultural normsXXX
      3.3A3Conducts formative assessments/research in developing servicesX
      3.3BUtilizes knowledge of the client’s/target population’s health conditions, cultural beliefs, and business objectives/services to guide design and delivery of client/population-centered servicesXXX
      3.3B1Collaborates with community stakeholders to ensure comprehensive servicesXXX
      3.3B2Tailors interventions based on health behavior theory (eg, Stages of Change, Socio-ecological Model, Social Cognitive Theory)XXX
      3.3B3Utilizes common terminology with community stakeholders to promote community nutrition initiatives/servicesXXX
      3.3B4Creates programs tailored to populations’ needs based on nutrition-related factors identified in assessmentsXX
      3.3B5Leads in utilizing, evaluating, and communicating the effectiveness of different theoretical frameworks for interventions (eg, Health Belief Model, Social Cognitive Theory)X
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the client or target populationXXX
      3.3C1Communicates the relationships among food, environment/systems, and disease prevention as the foundation for nutrition education, programs, and prevention approachesXXX
      3.3C2Connects food and the environment/systems using the Socio-ecological Model for clients, populations, and stakeholdersXX
      3.3DCollaborates with the clients and target populations to set priorities, establish goals, and create client/population-centered action plans to achieve desirable outcomesXXX
      3.3D1Uses a participatory process to engage clients and populationsXXX
      3.3EInvolves clients and target population in decision makingXXX
      3.4Executes programs/services in an organized, collaborative, and client/population-centered mannerXXX
      3.4ACollaborates and coordinates with peers, colleagues, stakeholders, and within interdisciplinary teamsXXX
      3.4A1Consults and provides expertise with partners to ensure evidence-based nutrition servicesXXX
      3.4A2Shares initiatives and health outcomes of services with all levels of stakeholders and policy makers (eg, evaluations shared with government and legislature, policy makers, school communities); consults with more experienced practitioners as neededXX
      3.4A3Ensures that public health nutrition is integrated in multidisciplinary programs across the lifespan (eg, child care, schools, senior programs)XX
      3.4A4Leads interdisciplinary and/or interagency teams addressing community and public health nutrition prioritiesX
      3.4BParticipates in or leads in the design, execution, and evaluation of programs and services (eg, nutrition screening system, medical and retail foodservice, electronic health records, interdisciplinary programs, community education, grant management) for clients and target populationsXXX
      3.4B1Comments on state and federal rules to actively shape nutrition programs (eg, MCHB
      MCHB=Maternal and Child Health Bureau (http://mchb.hrsa.gov/).
      block grant and federal nutrition assistance programs)
      XXX
      3.4B2Incorporates social determinants of health into evaluationXX
      3.4B3Communicates feasibility and fiscal implications of services with funders, policy makers, and stakeholdersX
      3.4B4Justifies public dollars and ROI
      ROI=return on investment.
      based on services
      X
      3.4B5Writes and reviews guidelines and statutes for local, state, and federal programsX
      3.4CDevelops or contributes to design and maintenance of policies, procedures, protocols, standards of care, technology resources, and training materials that reflect evidence-based practice in accordance with applicable laws and regulationsXXX
      3.4C1Conducts reviews to ensure that policies and procedures are followedXX
      3.4C2Demonstrates effectiveness of staff training in compliance with policies and proceduresXX
      3.4C3Ensures that program staff have the appropriate technology, infrastructure, and tools to implement programs/services according to policies and proceduresXX
      3.4C4Documents that policies and practices are being implemented appropriately to provide a data-driven practiceXX
      3.4C5Interprets federal regulations for state and local policy implementationX
      3.4C6Conducts feasibility analyses to ensure alignment with expected outcomes and sustainabilityX
      3.4C7Forecasts financing and mechanisms for funding nutrition servicesX
      3.4DParticipates in or develops process for clinical privileges required for enhanced activities and expanded roles consistent with state practice acts, federal and state regulations, organization policies, and medical staff rules, regulations and bylaws; enhanced activities include but not limited to implementing physician-driven protocols or other facility-specific processes, initiating or modify orders for therapeutic diets, nutrition supplements, dietary supplements, enteral and parenteral nutrition, nutrition-related laboratory tests and medications, and adjustments to fluid therapies or electrolyte replacements; expanded roles and nutrition-related services include but not limited to initiating and performing bedside swallow screenings, insertion and monitoring of nasogastric and nasoenteric feeding tubes, and indirect calorimetry measurementsXXX
      3.4D1Complies with federal and state regulations to administer client nutrition services (eg, special WIC formulas and special diets in schools)XXX
      3.4EComplies with established billing regulations and adheres to ethical billing practicesXXX
      3.4E1Collects data to support funding and program costsXXX
      3.4E2Manages financial operations in accordance with grant/funding requirements and guidelinesXX
      3.4E3Oversees braid funding (mixing and intertwining) to ensure rules are being followed (eg, state money with foundation funds)X
      3.4E4Maximizes population impact by leveraging funding and institutes policies and practices to prevent supplanting of fundsX
      3.4FCommunicates with the interdisciplinary team and referring party consistent with the Health Insurance Portability and Accountability Act (HIPAA) rules for use and disclosure of client’s personal health informationXXX
      3.4F1Operates in accordance with state guidance on disclosure/protection of personal identifying informationXXX
      3.5Utilizes support personnel appropriately in the delivery of client/population-centered care in accordance with laws, regulations, and organization policiesXXX
      3.5AAssigns activities, including direct care to clients/populations, consistent with the qualifications, experience and competence of support personnelXXX
      3.5A1Designs procedures to appropriately assign client referrals based on nutrition risk and competence level of health professionals (eg, support personnel, such as paraprofessionals providing nutrition education in WIC)XX
      3.5A2Creates and provides continuing education for staff at all levels and partnering agenciesXX
      3.5BSupervises technical and support personnel (eg, promotoras and community health workers, volunteers, and cultural brokers)XXX
      3.6Designs and implements food delivery systems to meet the needs of clients/target populationsXXX
      3.6ACollaborates on or designs food delivery systems to address nutrition status, health care needs and outcomes, and to satisfy the cultural preferences and desires of target populations (eg, health care patients/clients, employee groups, visitors to retail venues, schools, senior centers, community clinics, farmers markets, grocery stores, community feeding sites, food banks)XXX
      3.6A1Tailors food availability within federal programs (eg, WIC food packages) to populations’ and clients’ needsXXX
      3.6A2Supports and leverages increased healthy food access across food assistance programs (eg, food banks and food assistance programs)XXX
      3.6A3Collaborates with interdisciplinary partners to create and improve access to healthy food systems (eg, farmers markets, healthy food financing, food policy councils, community supported agriculture initiatives)XXX
      3.6A4Participates in outreach and/or referrals to ensure those who are eligible participate in federal food assistance programsXXX
      3.6BParticipates in, consults with others or leads in developing menus to address health and nutritional needs of target population(s) in accordance with guidance (eg, federal food assistance programs such as CACFP, School Meal Programs)XXX
      3.6CParticipates in, consults, or leads interdisciplinary process for determining nutritional supplements, dietary supplements, enteral and parenteral nutrition formularies and delivery systems for target population(s)XXX
      3.7Maintains records of services providedXXX
      3.7ADocuments according to organization policy, standards, and system including electronic health recordsXXX
      3.7A1Creates reports as required by state and federal program regulations and/or grant requirementsXX
      3.7BImplements data management systems to support data collection, maintenance, and utilizationXXX
      3.7B1Transfers local and state data to federal agencies (eg, USDA Participant Characteristics Report)XXX
      3.7B2Participates in nutrition surveillance systemsXXX
      3.7B3Aligns measures with state and federal recommendationsXX
      3.7B4Creates data management systems for local and state nutrition surveillanceXX
      3.7CUses data to document outcomes of services (eg, health outcomes, staff productivity, cost/benefit, budget compliance, quality of services) and provide justification for maintenance or expansion of servicesXXX
      3.7C1Monitors and documents short-, medium-, and long-term outcomesXXX
      3.7C2Shares program outcomes and impact with the program participants and publicXXX
      3.7C3Provide structure and systems for staff to create reports to identify program outcomes and gapsXX
      3.7DUses data to demonstrate compliance with accreditation standards, laws, and regulationsXXX
      3.7D1Conducts (eg, through management evaluations) reviews to ensure compliance with state policies and federal regulationsXX
      3.8Advocates for provision of quality food and nutrition services as part of public policyXXX
      3.8ACommunicates with policy makers regarding the benefit/cost of quality food and nutrition servicesXXX
      3.8A1Identifies policies and proposed legislation at local, state, federal, and international levels that impact public health nutritionXXX
      3.8A2Considers organizational policies related to advocacyXXX
      3.8A3Promotes policy change in support of public health and community nutrition servicesXX
      3.8A4Collaborates with groups working on public health nutrition policies and legislation at local, state, federal, and international levelsXX
      3.8A5Organizes dynamic grassroots campaigns to educate and engage the community on benefit/cost of quality public health and community nutrition servicesXX
      3.8A6Facilitates forums about proposed legislation, rules, or codes that impact the delivery of quality public health and community nutrition servicesXX
      3.8A7Develops draft legislation or policies in cooperation with policy makers that advance public health and community nutrition servicesX
      3.8A8Performs public health and community nutrition policy analysis, identifies gaps and opportunities in current public policies and adjusts strategies as neededX
      3.8A9Develops and implements a communication plan to educate policy makers about benefit/cost of quality public health and community nutrition servicesX
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needsXXX
      3.8B1Advances access to healthy food/water and food assistance programs for underserved populations including underserved groups (eg, individuals living on reservations)XXX
      3.8CServes on local, state, federal, or international committees that support policies and initiatives that improve the delivery of public health and community nutrition as appropriate to experience and skill levelXXX
      Examples of Outcomes for Standard 3: Provision of Services
      • Program/service design and systems aligns with organization/agencies mission and is centered around client/population needs and impact.
      • Population and targeted communities participate in establishing goals and client/population-focused action plans.
      • Population/community needs are met and feel that public health and community nutrition programs are responsive to public concerns about nutrition and health.
      • The public is actively engaged in improving the health of themselves and their larger community.
      • Evaluations reflect expected outcomes, including efficiency, effectiveness, and ability to achieve equity among populations.
      • Effective screening and referral services are established.
      • Clients have access to food assistance.
      • Clients have access to food and nutrition services at the federal, state, and local levels.
      • Support personnel are supervised when applying nutrition care standards in programs and policies.
      • Ethical and transparent funding practices are utilized in all aspects of grant management.
      Public Health Nutrition Provision of Service Example: The Value Enhanced Nutrition Assessment (VENA) process in WIC includes participant-centered standards for nutrition assessment centered around personalizing WIC nutrition education, providing more relevant community referrals, and tailoring the food package based on needs and cultural preferences. This participant-centered approach in WIC has strengthened the effectiveness of nutrition services and optimized the nutrition status of the larger population as a whole.
      Standard 4: Application of Research

      The registered dietitian nutritionist (RDN) applies, participates in, or generates research to enhance practice. Evidence-based practice incorporates the best available research/evidence in the delivery of nutrition and dietetics services.

      Rationale:

      Application, participation, and generation of research promote improved safety and quality of nutrition and dietetics practice and services.
      Indicators for Standard 4: Application of Research
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Accesses and reviews best available research/evidence for application to practiceXXX
      4.1AIdentifies science-based information from multiple reputable disciplines and sources (eg, government, national/international nongovernment organization publications)XXX
      4.1BDemonstrates understanding of research design and methodology, data collection, interpretation of results, and application within client and population groupsXX
      4.1B1Critically evaluates the integrity of science-based information for limitations and potential biasXX
      4.1CDemonstrates the experience and critical thinking skills required to review original research and evidence-based guidelines relevant to public health and community nutritionXX
      4.2Utilizes best available research/evidence as the foundation for evidence-based practiceXXX
      4.2AFollows evidence-based practice guidelines and recommendations (eg, Academy EAL
      EAL=Academy of Nutrition and Dietetics Evidence Analysis Library (http://andeal.org).
      , APHA
      APHA=American Public Health Association (http://www.apha.org).
      , IOM
      IOM=Institute of Medicine (United States) (http://www.iom.edu/).
      , CDC, WHO
      WHO=World Health Organization (http://www.who.int/en/).
      , HRSA
      HRSA=Health Resources and Services Administration (http://www.hrsa.gov/index.html).
      , USDA, MCHB, USPSTF
      USPSTF=US Preventive Services Task Force (http://www.uspreventiveservicestaskforce.org/).
      , HHS
      HHS=US Department of Health and Human Services (http://www.hhs.gov/).
      , AAP
      AAP=American Academy of Pediatrics (https://www.aap.org/en-us/Pages/Default.aspx).
      ) to provide quality service for populations and communities
      XXX
      4.2BInterprets current research in public health and community nutrition and related areas and applies to professional practice as appropriateXXX
      4.2CUtilizes the Academy EAL as a resource in writing or reviewing research papersXXX
      4.2DIncorporates latest evidence to support delivery of public health programs in grant proposalsXX
      4.2EApplies an evidence-based approach to develop and/or evaluate proposals in relationship to existing public health nutrition research, laws/regulations, and recommendationsX
      4.3Integrates best available research/evidence with best practices, clinical and managerial expertise, and client/population valuesXXX
      4.3ACreates opportunities for community engagement to address target population needs in public health and community nutrition research and evaluationXXX
      4.3BEvaluates and responds to the unintended consequences and

      externalities of public health and community nutrition practice
      XX
      4.3CMentors others in identifying and applying best available research/evidence and best practices to integrate into practiceX
      4.4Contributes to the development of new knowledge and research in nutrition and dieteticsXXX
      4.4AUses evidence-based guidelines, best practices, and clinical experience to generate new knowledge and develop guidelines, programs, and policies in public health and community nutritionXXX
      4.4BParticipates in interdisciplinary research teams to address public health and community nutrition issuesXXX
      4.4CInitiates research with specific population groups to address public health and community nutrition needs in collaboration with others (eg, biostatistician, epidemiologist)XX
      4.4DEvaluates impacts of public health and community nutrition services on environmental, economic, social, and health outcomesXX
      4.4EContributes to the development of evidence-based practice guidelines and position papers related to public health and community nutritionXX
      4.4FFunctions as an author or major contributor or reviewer of research and organization position papers, and other scholarly workX
      4.4GServes as advisor, mentor, preceptor, and/or committee member for graduate-level researchX
      4.5Promotes research through alliances and collaboration with food and nutrition and other professionals and organizationsXXX
      4.5AParticipates as a member/consultant to collaborative teams addressing public health and community nutrition issues by providing science-based expertise as appropriate for skill levelXXX
      4.5BDisseminates the results and emphasizes the significance and value of public health and community nutrition research findingsXXX
      4.5CIdentifies key stakeholder groups and their public health and community nutrition priorities for further research collaborationsXX
      4.5DAdvocates to stakeholder organizations for prioritizing and funding of public health and community nutrition research projectsX
      4.5EServes as a primary or senior investigator in collaborative research and evaluation teams that examines relationships among environmental, economic, social, and health outcomesX
      Examples of Outcomes for Standard 4: Application of Research
      • Evidence-based practice, best practices, clinical and managerial expertise, client/population values, and public health and community nutrition principles are integrated in the delivery of nutrition and dietetics services
      • Innovations in nutrition services are provided based on the effective application of best available research/evidence
      • Improvements to federal and state nutrition guidelines and/or programs are made based on trends and data from public health and community nutrition programs and studies
      Standard 5: Communication and Application of Knowledge

      The registered dietitian nutritionist (RDN) effectively applies knowledge and expertise in communications.

      Rationale:

      The RDN works with and through others to achieve common goals by effective sharing and application of their unique knowledge, skills and expertise in food, nutrition, dietetics, and management services.
      Indicators for Standard 5: Communication and Application of Knowledge
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      5.1Communicates current, evidence-based knowledge related to a particular aspect of the profession of nutrition and dieteticsXXX
      5.1ADisseminates nutrition recommendations and tailors communications to population groupsXXX
      5.1BIncorporates appropriate communication strategies to meet the needs of internal and external partnersXXX
      5.1CTranslates evidence-based research (eg, epidemiological trends, program outcomes) and policy to practical application in communications with diverse stakeholders and the general publicXX
      5.1DServes as an expert in public health and community nutrition with diverse stakeholdersXX
      5.2Communicates and applies best available research/evidenceXXX
      5.2ADemonstrates critical thinking and problem-solving skills when communicating with othersXXX
      5.2A1Evaluates and addresses environmental, economic, social, and health variables in communications with diverse stakeholdersXX
      5.2BAddresses potential bias (eg, funding, motivation, values) and

      the importance of transparency in public health and community nutrition-related science
      XXX
      5.2CModels critical thinking skills and provides open and inclusive

      environments for discussions
      XX
      5.3Selects appropriate information and most effective method or format when communicating information and conducting nutrition education and counselingXXX
      5.3AUtilizes communication methods (ie, oral, print, one-on-one, group, visual, electronic, and social media) targeted to the audienceXXX
      5.3A1Communicates public health and community nutrition information and trends through social media networksXXX
      5.3BUses information technology to communicate, manage knowledge, and support decision makingXXX
      5.3B1Implements systems including health/management information systems in order to facilitate, communicate and collaborate with partners to deliver services (eg, Utah WIC electronic prescription system)X
      5.3CIncorporates health literacy, cultural competence, and developmental appropriateness in communications and educational materialsXXX
      5.3C1Evaluates materials for health literacy, cultural competence, developmental appropriateness (eg, CDC’s Simply Put, Academy DANEH
      DANEH=Developing and Assessing Nutrition Education Handouts (http://healthyfoodbankhub.feedingamerica.or/wp-content/uploads/2013/12/Nutrition-Education-Handout-Checklist-rev-10-17-13.pdf).
      , HECAT
      HECAT=Health Education Curriculum Analysis Tool (http://www.cdc.gov/healthyyouth/HECAT/).
      )
      XXX
      5.3C2Advises others as a subject matter expert on health literacy, cultural competence, developmental appropriatenessX
      5.4Integrates knowledge of food and nutrition with knowledge of health, social sciences, communication, and management in new and varied contextsXXX
      5.4ANetworks with multilevel partners and stakeholders that impact federal, state, and local public health and community nutrition programsXXX
      5.4A1Addresses the environment, policy, and systems with regards to food access and community needsXX
      5.4A2Leads activities that engage multilevel partners and stakeholders in collaborations around local, state, national, and/or international public health and community nutrition programsX
      5.5Shares current, evidence-based knowledge, information with clients/populations, colleagues, and the publicXXX
      5.5AGuides clients/populations, students, and interns in the application of knowledge and skillsXXX
      5.5A1Mentors or serves as a preceptor for community nutrition students and dietetic interns, as well as novice public health students considering specialties in nutrition and food systemsXXX
      5.5A2Provides multidisciplinary education and experiential learning opportunitiesXX
      5.5A3Contributes to the education and professional development of RDNs, public health, and/or health care professionals through formal and informal mentor/teachingXX
      5.5A4Expands course curricula, site-specific learning activities and research projects to include public health and community nutrition principles and applicationX
      5.5BAssists individuals and groups to identify and secure appropriate and available resources and servicesXXX
      5.5B1Promotes and supports programs, businesses, policies, and resources that incorporate public health and community nutrition principlesXXX
      5.5CUtilizes professional writing and verbal skills in communicationsXXX
      5.5C1Sharpens written and oral communication skills with the ability to translate complex scientific and policy information to the general publicXXX
      5.5C2Disseminates public health and community nutrition lessons learned and best practicesXXX
      5.5C3Develops grants and white papers, delivers presentations, and authors books and articles that incorporate public health and community nutrition for peers, consumers, health professionals, community groups, policy makers, and food systems leadersXX
      5.5C4Functions as an expert or media spokesperson on public health and community nutrition (eg, interviews, guest commentary, editorials)X
      5.6Establishes credibility and contributes as a resource within interdisciplinary professional teams and communities to promote food and nutrition strategies that enhance health and quality of life outcomes for target populationsXXX
      5.6AConducts activities and provides resources to educate members of the interdisciplinary team about public health and community nutrition, its applications and impacts on human, environmental, economic, and social healthXXX
      5.6BParticipates in multidisciplinary or interdisciplinary collaborations at a systems level (eg, community advisory boards, food policy councils, licensure boards)XX
      5.6CContributes nutrition-related expertise to high-level national projects and professional organizations (eg, USDA food assistance programs, Let’s Move!, Healthy People, IOM)X
      5.7Communicates performance improvement and research results through publications and presentationsXXX
      5.7APresents evidence-based public health and community nutrition research and information to community groups and colleaguesXXX
      5.7BInterprets demographics, statistical, epidemiological, programmatic, and scientific informationXX
      5.7CServes in a leadership role for public health and community nutrition-related scholarly work (eg, reviewer, editor, editorial advisory board) and in program planning for conferences (eg, local, regional, national, and international)X
      5.7DDirects collation of research data (eg, position papers, practice papers, meta-analysis, review articles) into publications and presentationsX
      5.7ETranslates research findings for incorporation into development of policies, procedures, and guidelines for professional and lay audiencesX
      5.8Seeks opportunities to participate in and assume leadership roles in local, state, and national professional and community-based organizationsXXX
      5.8AFunctions as a public health and community nutrition resource as an active member of local/state/national organizationsXXX
      5.8BServes as a subject matter expert in public health and community nutrition with local, state, national, and international organizationsX
      5.8CManages and directs the integration of public health and community nutrition principles within larger systemsX
      Examples of Outcomes for Standard 5: Communication and Application of Knowledge
      • Expertise in food, nutrition, and management is demonstrated and shared (eg, document and communicate expertise through policy briefs, articles, position statements, and proposals).
      • Information technology is used to support practice (eg, support the daily practice/work, enhance efficiency, productivity, and effectiveness through the utilization of shared networks and applications, such as SharePoint).
      • Effective and efficient communications occur through appropriate and professional use of e-mail, texting, and social media tools such as Facebook and Twitter. Clients/populations and stakeholders:
        • Receive current and appropriate information and client/population-centered service;
        • Demonstrate understanding of information received; and
        • Know how to obtain additional guidance from the RDN.
      • Leadership is demonstrated through active professional and community involvement (eg, participate on committees, boards, and work groups for organizations such as March of Dimes, State Public Health Associations and Health Coalitions, American Heart Association and American Diabetes Association, Academy of Nutrition and Dietetics)
      Standard 6: Utilization and Management of Resources

      The registered dietitian nutritionist (RDN) uses resources effectively and efficiently.

      Rationale:

      The RDN demonstrates leadership through strategic management of time, finances, facilities, supplies, technology, and human resources.
      Indicators for Standard 6: Utilization and Management of Resources
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      6.1Uses a systematic approach to manage resources and improve operational outcomesXXX
      6.1AUses logic model or other appropriate models to guide the planning, implementation, and evaluation of servicesXXX
      6.1BManages and implements information management systems to disseminate resources, policies, and trainings while maximizing staff resourcesXX
      6.1CImplements programs with long-term sustainability plans, leveraging diverse resources and funding streamsXX
      6.1DOversees the responsible and accurate management of sub-grants in order to achieve comprehensive outcomesX
      6.2Quantifies management of resources in the provision of nutrition and dietetic services with the use of standardized performance measures and benchmarking as applicableXXX
      6.2AParticipates in operational planning of food and nutrition programs and services (eg, grant writing, management of deliverables, collecting program evaluation data, budgeting staff and resources in accordance with grant allocation and expected outcomes)XXX
      6.2BManages effective delivery of nutrition programs and services (eg, business and marketing planning, cost−benefit analysis, program administration, delivery of education programs, materials development, program evaluation) related to public health and community nutrition programsXX
      6.2CDirects or manages business and strategic planning for the design and delivery of nutrition services in public health and community nutrition for international, federal, state, and/or local settingsX
      6.3Evaluates safety, effectiveness, productivity, and value while planning and delivering services and productsXXX
      6.3AIncorporates formative evaluations through a participatory approach including diverse stakeholders and community membersXXX
      6.3BAssesses and communicates short-, medium-, and long-term program effectiveness given the use of public funds to deliver servicesXX
      6.3CEnsures organizational practices are in concert with changes in the public health and community nutrition system and the larger social, political, and economic environmentX
      6.4Participates in quality assurance and performance improvement and documents outcomes and best practices relative to resource managementXXX
      6.4AEngages the community and stakeholders in continuous quality-improvement processesXX
      6.4BAnticipates outcomes and consequences of different approaches and makes necessary modifications to achieve desired outcomes (eg, health impact assessment process) in context of resourcesXX
      6.4CDirects the development and management of continuous quality-improvement systems (eg, fiscal, personnel, services, materials, data)X
      6.4DReports outcomes of delivery of services against goals and performance targetsX
      6.4EPartners with health economists to assess ROI of services and programsX
      6.5Measures and tracks trends regarding patient/client/population, employee and stakeholder satisfaction in the delivery of products and servicesXXX
      6.5AConducts regular surveys with participants and stakeholders to assess client/population satisfactionXXX
      6.5BCommunicates the need for change based on collected dataXX
      6.5CResolves internal and external problems that may affect the delivery of essential public health and community nutrition servicesX
      Examples of Outcomes for Standard 6: Utilization and Management of Resources
      • Resources are effectively and efficiently managed to promote client/population health.
      • Documentation of resource use is consistent with requirements of funding and oversight agencies.
      • Data are used to promote, improve, and validate interventions, organizational practice, and public policy.
      • Desired outcomes are achieved, documented, and disseminated to stakeholders.
      a DGA=Dietary Guidelines for Americans (http://www.cnpp.usda.gov/dietaryguidelines).
      b NGO=nongovernmental organization.
      c MNT=medical nutrition therapy.
      d FNS=US Department of Agriculture Food and Nutrition Service (http://www.fns.usda.gov/).
      e WIC=Special Supplemental Nutrition Program for Women Infants and Children (United States) (http://www.fns.usda.gov/wic/women-infants-and-children-wic).
      f CACFP=Child and Adult Care Food Program (United States) (http://www.fns.usda.gov/cacfp/child-and-adult-care-food-program).
      h USDA=US Department of Agriculture (http://www.usda.gov/wps/portal/usda/usdahome).
      i CDC=Centers for Disease Control and Prevention (United States) (http://www.cdc.gov).
      j MCHB=Maternal and Child Health Bureau (http://mchb.hrsa.gov/).
      k ROI=return on investment.
      l EAL=Academy of Nutrition and Dietetics Evidence Analysis Library (http://andeal.org).
      m APHA=American Public Health Association (http://www.apha.org).
      n IOM=Institute of Medicine (United States) (http://www.iom.edu/).
      o WHO=World Health Organization (http://www.who.int/en/).
      p HRSA=Health Resources and Services Administration (http://www.hrsa.gov/index.html).
      q USPSTF=US Preventive Services Task Force (http://www.uspreventiveservicestaskforce.org/).
      r HHS=US Department of Health and Human Services (http://www.hhs.gov/).
      s AAP=American Academy of Pediatrics (https://www.aap.org/en-us/Pages/Default.aspx).
      u HECAT=Health Education Curriculum Analysis Tool (http://www.cdc.gov/healthyyouth/HECAT/).

      References

        • 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.
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      Biography

      M. Bruening is an assistant professor, Nutrition Program, School of Nutrition and Health Promotion, Arizona State University, Phoenix.
      A. Z. Udarbe is director, Pinnacle Prevention, Chandler, AZ.
      E. Yakes Jimenez is an assistant professor of nutrition and family and community medicine, Department of Individual, Family, and Community Education, Nutrition/Dietetics Program, Department of Family and Community Medicine, University of New Mexico, Albuquerque.
      P. Stell Crowley is Utah State WIC nutrition coordinator, Salt Lake City.
      D. C. Fredericks is a nutrition and wellness consultant, Morgan Hill, CA.
      L. A. Edwards Hall is director, National Partnership Operations, Share Our Strength, Charlotte, NC.