Abstract
Eating disorders (ED) are complex mental illnesses and are not a result of personal choice. Full recovery from an ED is possible. The severity and inherent lethality of an ED is undisputed, and the role of the registered dietitian nutritionist (RDN) is essential. Clinical symptomology presents at varying developmental milestones and is perpetuated through a sociocultural evaluation of beauty and drive for ascetic idealism. ED are globally prevalent in 4.4% of the population aged 5 to 17 years, yet affect individuals across the entire lifespan, including all cultures and genders. The Behavioral Health Nutrition Dietetic Practice Group, along with the Academy of Nutrition and Dietetics Quality Management Committee, revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs in Eating Disorders. Including the RDN in ED treatment is vital for all levels of care. The RDN must be perceptive to negative symptoms indicative of psychological triggers when exploring food belief systems, patterns of disinhibition, and nutrition misinformation with clients. Through a conscious awareness of medical, psychological, and behavioral strategies, the implementation of the SOP and SOPP supports a dynamic and holistic view of ED treatment by the RDN. The SOP and SOPP are complementary resources for RDNs and are intended to be used as self-evaluation tools for assuring competent practice in ED and for determining potential education, training, supervision, and mentorship needs for advancement to a higher practice level in a variety of settings.
Editor’s note: Figures 1 and 2 that accompany this article are available online at www.jandonling.org.
The Behavioral Health Nutrition Dietetic Practice Group of the Academy of Nutrition and Dietetics (Academy), under the guidance of the Academy Quality Management Committee, has revised the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians in Disordered Eating and Eating Disorders originally published in 2011.
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The revised document, Academy of Nutrition and Dietetics: Revised 2020 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Eating Disorders, reflects advances in practice during the past 9 years and replaces the 2011 Standards. This document builds on the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs.- Tholking M.M.
- Mellowspring A.C.
- Eberle S.G.
- et al.
American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Disordered Eating and Eating Disorders (DE and ED).
J Am Diet Assoc. 2011; 111: 1242-1249e37
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The Academy of Nutrition and Dietetics/Commission on Dietetic Registration’s (CDR) Code of Ethics for the Nutrition and Dietetics Profession,3
along with the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs2
and Revised 2017 Scope of Practice for the RDN,4
guide the practice and performance of RDNs in all settings.Scope of practice in nutrition and dietetics is composed of statutory and individual components, includes the code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employers code of ethics), and encompasses the range of roles, activities, practice guidelines, 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.
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An RDN’s statutory scope of practice can delineate the services an RDN is authorized to perform in a state where a practice act or certification exists. For more information, see www.eatrightpro.org/advocacy/licensure/licensure-map.The RDN’s individual scope of practice is determined by education, training, credentialing, experience, and demonstrating and documenting competence to practice. Individual scope of practice in nutrition and dietetics has flexible boundaries to capture the breadth of the individual’s professional practice. Professional advancement beyond the core education and supervised practice to qualify for the RDN credential provides RDNs practice opportunities, such as expanded roles within an organization based on training and certifications, if required, or additional credentials (eg, Certified Eating Disorders Registered Dietitian [CEDRD] or CEDRD-supervisor [CEDRD-S], Certified Nutrition Support Clinician [CNSC], or focus area CDR specialist certification, eg, Certified Specialist in Sports Dietetics [CSSD] or Certified Specialist in Pediatric Nutrition [CSP]). The Scope of Practice Decision Algorithm (www.eatrightpro.org/scope) guides an RDN through a series of questions to determine whether a particular activity is within their scope of practice. The algorithm is designed to assist an RDN to critically evaluate their personal knowledge, skill, experience, judgment, and demonstrated competence using criteria resources.
Approved June 2020 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the Executive Committee of the Behavioral Health Nutrition Dietetic Practice Group of the Academy. Scheduled review date: June 2026. Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Eating Disorders may be addressed to Academy Quality Management Staff: Dana Buelsing, MS, manager, Quality Standards Operations; and Carol J Gilmore, MS, RDN, LD, FADA, FAND scope/standards of practice specialist, Quality Management at [email protected].
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). The two credentials have identical meanings. In this document, the authors have chosen to use the term RDN to refer to both registered dietitians and registered dietitian nutritionists.
The Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services, Hospital
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and Critical Access HospitalAppendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual.
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Conditions of Participation now allow a hospital and its medical staff the option of including RDNs or other clinically qualified nutrition professionals within the category of “non-physician practitioners” eligible for ordering privileges for therapeutic diets and nutrition-related services if consistent with state law and health care regulations. RDNs in hospital settings interested in obtaining ordering privileges must review state laws (eg, licensure, certification, and title protection), if applicable, and health care regulations to determine whether there are any barriers or state-specific processes that must be addressed. For more information, review the Academy’s practice tips that outline the regulations and implementation steps for obtaining ordering privileges (www.eatrightpro.org/dietorders/). For assistance, refer questions to the Academy’s State Affiliate organization.Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
Medical staff oversight of an RDN(s) occurs in one of two ways. A hospital has the regulatory flexibility to appoint an RDN(s) to the medical staff and grant the RDN(s) specific nutrition ordering privileges or can authorize the ordering privileges without appointment to the medical staff. To comply with regulatory requirements, an RDN’s eligibility to be considered for ordering privileges must be through the hospital’s medical staff rules, regulations, and bylaws, or other facility-specific process.
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The actual privileges granted will be based on the RDN’s knowledge, skills, experience, and specialist certification, if required, and demonstrated and documented competence.42 CFR Parts 413, 416, 440 et al. Medicare and Medicaid Programs; Regulatory provisions to promote program efficiency, transparency, and burden reduction; Part II; Final rule (FR DOC #2014-10687; pp 27106-27157). US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
The Long-Term Care Final Rule published October 4, 2016 in the Federal Register, now “allows the attending physician to delegate to a qualified dietitian or other clinically qualified nutrition professional the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by State law” and permitted by the facility’s policies.
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The qualified professional must be acting within the scope of practice as defined by state law; and is under the supervision of the physician that may include, for example, countersigning the orders written by the qualified dietitian or clinically qualified nutrition professional. RDNs in eating disorders (ED) who work or consult in long-term care settings may have a policy in place that allows a resident’s attending physician to delegate to the RDN writing orders for the diet/meal plan and other nutrition-related services. Whether ordering or recommending a meal plan, this would facilitate the RDN addressing the resident’s ED-related needs and preferences consistent with any advanced directives that may be in place. Monitor the Academy’s updates for any CMS changes to §483.60 Food and Nutrition Services (www.eatrightpro.org/practice/quality-management/national-quality-accreditation-and-regulations/centers-for-medicare-and-medicaid-services). Review the state’s long-term care regulations to identify potential barriers to implementation; and identify considerations for developing the facility’s processes with the medical director and for orientation of attending physicians. The CMS State Operations Manual, Appendix PP-Guidance for Surveyors for Long-Term Care Facilities contains the revised regulatory language (new revisions are italicized and in red color).US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final Rule (FR DOC#2016; pp 68688-68872) – Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178).
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CMS periodically revises the State Operations Manual Conditions of Participation; obtain the current information at www.cms.gov/files/document/appendices-table-content.pdf.Academy Quality and Practice Resources
The Academy’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs
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reflect the minimum competent level of nutrition and dietetics practice and professional performance. The core 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 4 standards consistent with the Nutrition Care Process and clinical workflow elements as applied to the care of patients/clients/residents/populations in all settings.11
The SOPP consist of standards representing 6 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, efficient, and equitable quality food and nutrition care and services; facilitate evidence-based practice; and serve as a professional evaluation resource.These focus area standards for RDNs in ED 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 ED nutrition 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 general clinical practice with maintaining minimum competence in the focus area and by RDNs transitioning their knowledge and skills to a new focus area of practice. Like the Academy’s core SOP in Nutrition Care and SOPP for RDNs,
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the indicators (ie, measurable action statements that illustrate how each standard can be applied in practice) (see Figures 1 and 2, available at www.jandonline.org) for the SOP and SOPP for RDNs in Eating Disorders were revised with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDNs in Eating Disorders were reviewed and approved by the Executive Committee of the Behavioral Health Nutrition Dietetic Practice Group and the Academy Quality Management Committee.Three Levels of Practice
The Dreyfus model
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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 2 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 credential, a practitioner enters professional practice at the competent level and manages their professional development to achieve individual professional goals. This model is helpful in understanding the levels of practice described in the SOP and SOPP for RDNs in Eating Disorders. In Academy focus areas, the 3 levels of practice are represented as competent, proficient, and expert.Figure 3Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Eating Disorders.
| Standards of Practice (SOP) are authoritative statements that describe practice demonstrated through nutrition assessment, nutrition diagnosis (problem identification), nutrition intervention (planning, implementation), and outcomes monitoring and evaluation (4 separate standards) and the responsibilities for which registered dietitian nutritionists (RDNs) are accountable. The SOP for RDNs in Eating Disorders presuppose that the RDN uses critical thinking skills; analytical abilities; theories; best available research findings; current accepted nutrition, dietetics, and medical knowledge; and the systematic holistic approach of the nutrition care process as they relate to the application of the standards. Standards of Professional Performance (SOPP) for RDNs in Eating Disorders are authoritative statements that describe behavior in the professional role, including activities related to Quality in Practice; Competence and Accountability; Provision of Services; Application of Research; Communication and Application of Knowledge; and Utilization and Management of Resources (6 separate standards). SOP and SOPP are complementary standards and serve as evaluation resources. All indicators may not be applicable to all RDNs’ practice or to all practice settings and situations. RDNs operate within the directives of applicable federal and state laws and regulations as well as policies and procedures established by the organization in which they are employed. To determine whether an activity is within the scope of practice of the RDN, the practitioner compares their knowledge, skill, experience, judgment, and demonstrated competence with the criteria necessary to perform the activity safely, ethically, legally, and appropriately. The Academy’s Scope of Practice Decision Algorithm is specifically designed to assist practitioners with this process. The term client is used in the SOP as a universal term as these Standards relate to direct provision of nutrition care and services. Client could also mean patient, resident, participant, consumer, or any individual, group, or population who receives eating disorder treatment, care and services. Customer is used in the SOPP as a universal term. Customer could also mean client/patient, client/patient/customer, participant, consumer, or any individual, group, or organization or those in the client’s support system to which the RDN provides services. These services are provided to individuals throughout the lifespan. The SOP and SOPP are not limited to the clinical setting. In addition, it is recognized that the family and caregiver(s) or advocate of these clients, including individuals with special health care needs, play critical roles in overall health and are important members of the team throughout the assessment and intervention process. The term appropriate is used in the standards to mean selecting from a range of best practice or evidence-based possibilities, one or more of which would give an acceptable result in the circumstances. Each standard is equal in relevance and importance and includes a definition, a rationale statement, indicators, and examples of desired outcomes. A standard is a collection of specific outcome-focused statements against which a practitioner’s performance can be assessed. The rationale statement describes the intent of the standard and defines its purpose and importance in greater detail. Indicators are measurable action statements that illustrate how each specific standard can be applied in practice. Indicators serve to identify the level of performance of competent practitioners and to encourage and recognize professional growth. Standard definitions, rationale statements, core indicators, and examples of outcomes found in the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for RDNs have been adapted to reflect 3 levels of practice (competent, proficient, and expert) for RDNs in eating disorders (see image below). In addition, the core indicators have been expanded to reflect the unique competence expectations for the RDN in eating disorders treatment. Standards described as proficient level of practice in this document are not equivalent to the International Association of Eating Disorders Professionals (iaedp) certification as a Certified Eating Disorder Registered Dietitian (CEDRD). Rather, the CEDRD designation recognizes the skill level of a RDN who has developed and demonstrated, through successful completion of the certification examination and its qualifications, advanced knowledge and application beyond the competent practitioner and establishes, at a minimum, proficient-level skills. Standards described as expert level of practice in this document are not equivalent to the iaedp certification as a CEDRD-supervisor (CEDRD-S). Rather, the CEDRD-S designation recognizes the skill level of an RDN who has developed and demonstrated through successful completion of the certification examination and its qualifications, advanced knowledge and application beyond the proficient practitioner and establishes, at minimum, expert-level skills. |
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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 recently transitioning their practice to a new focus area of nutrition and dietetics. A focus area of nutrition and dietetics practice is a defined area of practice that requires focused knowledge, skills, and experience that apply to all levels of practice.
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A competent practitioner who has achieved credentialing as an RDN and is starting in professional employment consistently provides safe and reliable services by employing appropriate knowledge, skills, behavior, and values in accordance with accepted standards of the profession; acquires additional on-the-job skills; and engages in tailored continuing education to further enhance knowledge, skills, and judgment obtained in formal education.15
A general practice RDN may have responsibilities across several areas of practice, including community, clinical, consultation and business, research, education, and food and nutrition management.With safety and evidence-based practice
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as guiding factors when working with patients/clients/customers/residents/populations, the RDN identifies the level of evidence, clearly states research limitations, provides safety information from reputable sources, and describes the risk of the intervention(s), when applicable.The Academy offers a webinar, Evidence-Based Nutrition Using Scientific Evidence to Inform Clinical Practice (www.eatrightstore.org/cpe-opportunities/recorded-webinars) that presents the 5-step evidence-based process as a mechanism to acquire and critique evidence for practicing evidence-based nutrition care. The RDN is responsible for searching literature and assessing the level of evidence to select the best available evidence to inform recommendations. RDNs must evaluate and understand the best available evidence in order to converse authoritatively with the interprofessional team and adequately involve the patient/client/customer/population in shared-decision making.
Patients/clients with ED will present in a variety of practice areas, therefore, an RDN’s familiarity with resources and clinical guidelines for this population is recommended. Early recognition of nonverbal cues of ED pathology, sensitivity to body shape variances among ED clients, and clinician bias to this population are vital. Most critically, rapid referral to an experienced ED RDN (eg, CEDRD/-S) is necessary when treatment needs are beyond the RDN’s individual scope of practice.
The CEDRD credential requires advanced education through the International Association of Eating Disorders Professionals (iaedp) (http://www.iaedp.com/certification-overview/) and skill development in the diagnosis, assessment, treatment, and prevention of ED. To obtain the CEDRD credential, more than 2,500 clinical hours treating clients with ED under the supervision of an expert CEDRD-S, a minimum of 2 years practicing specifically within ED, and a passing score on an interdisciplinary comprehensive examination are required to qualify for the CEDRD credential. The CDR recognized the CEDRD in June of 2015 as the specialized certification for RDNs practicing in ED.
A CEDRD-S is an RDN who has obtained the CEDRD credential, worked 6,000 or more hours in the field of ED as an integral part of the interdisciplinary treatment team, and is trained and skilled in providing clinical supervision to RDNs and nutrition and dietetics students/interns specific to the treatment of and competency in ED.
Working with an experienced ED mentor (ie, supervisor [CEDRD-S]) is essential to RDNs new to the treatment of ED to increase exposure to experiences that facilitate professional excellence and mastery of underlying ED psychopathology. It is necessary to gain practical skills for recognizing and maintaining therapeutic boundaries with interprofessional team members and client(s). If planning to pursue the CEDRD certification through iaedp, seek out a qualified RDN (eg, CEDRD-S) in ED who can provide the required professional clinical supervision as the ED-specific practice hours are obtained. Furthermore, obtaining ED-related continuing education and shadowing experiences with ED interprofessional team members will build knowledge and skills in this area.
Proficient Practitioner
A proficient practitioner is an RDN who is generally 3 or more years beyond credentialing and entry into the profession and consistently provides safe and reliable service; has obtained operational job performance skills; and is successful in the RDN's chosen focus area of practice. The proficient practitioner demonstrates additional knowledge, skills, judgment, 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.
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An RDN who has chosen ED as their area of clinical practice is strongly encouraged to establish a professional clinical supervisory relationship with an expert RDN in ED to gain knowledge, skills, and insight into this area of practice. Supervision is an essential self-care tool for all professionals and provides opportunities for concept discussion, case review, and advanced learning. Because the CEDRD requires supervision with an expert RDN, this certification is recommended for practice in ED. Additional continuing education toward and understanding of interprofessional use of therapeutic modalities (eg, Dialectical Behavioral Therapy, Cognitive Behavioral Therapy, Acceptance Commitment Therapy, Exposure Response Prevention), principles of psychopathology, culinary medicine, research methods, administrative management, and business administration is also recommended. At this level, an RDN may have achieved the coursework, experience, professional supervision, and successfully completed the examination for the CEDRD certification.
Expert Practitioner
An expert practitioner is an RDN who is recognized within the profession and has mastered the highest degree of skill in, and knowledge of, nutrition and dietetics. Expert-level achievement is acquired through ongoing critical evaluation of practice and feedback from others. The individual at this level strives for additional knowledge, experience, and training. An expert has the ability to quickly identify “what” is happening and “how” to approach the situation. Experts easily use nutrition and dietetics skills to become successful through demonstrating quality practice and leadership, and to consider new opportunities that build upon nutrition and dietetics.
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An expert practitioner may have an expanded or specialist role or both, and may possess an advanced credential(s), such as the CDR Advanced Practitioner Certification in Clinical Nutrition or focus area credential, such as the CEDRD-S. Generally, the practice is more complex and has a high degree of professional autonomy and responsibility, while maintaining peer professional clinical supervision to assist with processing complex relational issues. The expert practitioner demonstrates the ability to independently manage the complexity of nutritional recovery for ED, including case management across all levels of care and supervision/professional development of competent- and proficient-level RDN practitioners. This RDN develops a perception and clarity to address countertransference or transference issues as they arise throughout the course of treatment.These Standards, along with the Academy/CDR Code of Ethics,
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answer the questions: Why is an RDN uniquely qualified to provide ED nutrition and dietetics care and services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, efficient, equitable, and quality ED nutrition care and service at the competent, proficient, and expert levels?Overview
The severity and inherent lethality of an ED is undisputed.
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The global prevalence rate for ED in individuals aged 5 to 17 years is 4.4% of the population17
; however, the rates of subclinical ED within broader populations are significant. Refer to Figure 4 for further explanation of a subclinical ED. Approximately 25% of female college athletes present with subclinical ED,18
and over 70% of individuals with anorexia nervosa (AN) or bulimia nervosa report at least 1 diagnosis of anxiety disorder within their lifetime.19
Within a survey group of more than 4,000 women aged 25 to 45 years, 31% of women with no history of AN or binge eating disorder (BED) purged for weight control, and almost 75% report that body shape and weight concerns interfere with quality of life.20
Figure 4Overview of eating disorders and multifactorial contributors.
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Clinical symptomology presents at varying developmental and sociocultural milestones (eg, biological maturation, onset of adulthood, parenthood, and interpersonal transitions), throughout the lifespan,
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,21
and with a myriad of symptoms.22
ED are globally inclusive23
of all cultures and genders.24
It is critical to acknowledge and advocate for vulnerable populations including lesbian, gay, bisexual, transgender and queer (or questioning) and others25
and those with all forms of disabilities who require and desire support and access to specialized, adequate ED support. Diet culture ideals and marketing are deeply rooted and entangled within systemic racism, fear, and discrimination against the Black body and other people of color.26
, 27
, 28
, 29
, 30
Each human is uniquely beautiful. A holistic view of ED recovery demands an inclusionary lens of perception.As a psychiatric condition with biopsychosocial mediators, each variant of an ED will be impacted by 4 primary variables: temperament,
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,26
,31
, 32
, 33
, 34
, 35
, 36
, 37
, 38
, - Brewerton T.D.
- Brady K.
The role of stress, trauma, and PTSD in the etiology and treatment of eating disorders, addictions, and substance abuse disorders.
in: Brewerton T.D. Dennis A.B. Eating Disorders, Addictions and Substance Use Disorders: Research, Clinical and Treatment Perspectives. Springer,
Heidelberg, Germany2014
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, 40
genetics,41
, 42
, 43
, 44
environment,45
, 46
, 47
, 48
, 49
, 50
, 51
and malnutrition.52
, 53
, 54
, 55
, 56
, 57
, 58
Figure 4 offers a graphical illustration of clinical diagnoses inclusive of the phrase eating disorder.59
, 60
, 61
, 62
Each manifestation of an ED is diagnosed by a licensed clinician using clinical symptoms as noted by the Diagnostic and Statistical Manual of Mental Disorder, 5th edition.63
, 64
, 65
The RDN does not provide an ED diagnosis. Every ED presents with a unique clinical manifestation66
that is subjectively significant to the client being impacted by the condition.67
Due to the individualization of an ED’s clinical severity and symptom presentation, the subjective nature of these illnesses offers additional rationale for the RDN to have ongoing education and professional clinical supervision.The biological understanding of malnutrition and subsequent development of an ED was founded on the Minnesota Starvation Experiment published in 1950.
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,68
Thirty-two men voluntarily participated in a laboratory simulation of severe famine to create scientific guidance for assisting famine victims after World War II. Their behavior and sleep patterns, cognitive status, and physiological parameters of health were evaluated. Results of this study offer the scientific framework demonstrating how malnutrition can create physiological, personality, and behavioral changes that lead to an ED independent of medical and psychiatric predisposition.ED may be prompted through environmental insults and societal prejudice of body size.
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The comparative attitudes alongside a sociocultural evaluation of beauty,70
,71
and drive for thinness perpetuate the biological manifestation of an ED.72
Societal reinforcement of “diet culture” ideals,73
including a metamorphosis of physical shape74
or psychological grit to achieve deprivation75
reinforces the intrinsic reward mechanism for maintaining a state of malnutrition.76
,77
Further investigation into dopamine receptor activation,78
behavioral strategies to support amygdala inhibition,79
regulation of default mode networks,73
and polyvagal theory80
supports best practices for theoretical and clinical treatment of ED.81
Full recovery from an ED is possible. The global burden of ED is 4½ times higher for females than males.
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,82
Treatment of an ED requires an interprofessional team that must include an RDN.83
, 84
, 85
ED recovery encompasses all dimensions of health. Best practices include a treatment framework that embraces the whole person and includes nutrition, psychotherapy, medicine, movement, spirituality, and relational aspects of self. Early detection alongside consistent and comprehensive treatment aiming to reverse malnutrition is paramount. Addressing psychological schemas and nutrition-related educational deficits are also critical to the overall framework for recovery.As a holistic view of ED treatment becomes best practice, the evaluation of religious, spiritual and relational dimensions of recovery support are necessary. The development of self-compassion, forgiveness, and an acceptance of personal behavioral patterns entangled within ED pathology are essential for lasting recovery.
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,87
A recent study revealed 16.8% of adolescents who fasted for religious purposes scored in the ED pathological range on the Eating Attitudes Test-26.88
Exploring underlying spiritual belief systems allows for the development of a purpose for engaging treatment beyond being a requirement. The spiritual aspect of treatment is not about religion, but rather a unification of self across all cultures and ethnicities for the common purpose of ED recovery.- Düzçeker Y.
- Akgul S.
- Durmaz Y.
- et al.
Is Ramadan fasting correlated with disordered eating behaviours in adolescents?.
Eat Disord. 2019; (Published online July 13, 2019): 1-14https://doi.org/10.1080/10640266.2019.1642032
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Physical activity/movement is supportive of the ED recovery process. Figure 5
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presents an integrative framework for the inclusion of exercise in the treatment of ED.90
Transforming physical activity/movement from being used as a tool of self-destruction into a source of interpersonal restoration is beneficial for all clients. Exploring both medical and psychological motivations for movement offers the RDN opportunities to provide appropriate corrective nutrition education. There is great benefit to be gained from integrating physical activity/movement into the ED recovery process as clinically indicated.
Figure 5Unified Model of Exercise in Eating Disorders. (Adapted from Beasley T, Cook B; 2019,74 with permission. No part of this content may be reproduced or transmitted in any form or by any means without the express written consent of the authors, except as permitted by applicable law.)
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Performance athletes with symptoms consistent with an ED
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warrant further evaluation by a proficient-/expert-level ED RDN practitioner to create an integrative treatment plan92
in collaboration with a sports RDN93
and other members of the athlete’s performance team given an athlete’s unique physiological demands.94
The RDN’s aim is to promote an inclusive lens of treatment in conjunction with an increase in self-efficacy to treat individuals with ED using the available practice standards95
, - Anderson Girard T.
- Russell K.
- Leyse-Wallace R.
Academy of Nutrition and Dietetics: Revised 2018 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Mental Health and Addictions.
J Acad Nutr Diet. 2018; 118: 1975-1986.e53
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and guidelines for the use of exercise in ED treatment.Each level of care (eg, inpatient, residential, partial hospitalization program, intensive outpatient program, and outpatient) for treatment of ED is designed to offer the appropriate intensity of nutrition, medical, and psychological support required to address underlying issues related to the manifestation of the ED. Assessment of standards of practice from international authorities and medical indices (eg, orthostatic blood pressure, bradycardia, tachycardia, laboratory values, and urine-specific gravity) that support evaluation of ED severity is a core responsibility of an RDN choosing to work with ED.
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Recognition of clinical symptoms, attitudes/food beliefs, and changes in personality features as a result of malnutrition offers support for early detection of ED.In 2013, the addition of BED and avoidant/restrictive food intake disorder (ARFID) to the Diagnostic and Statistical Manual of Mental Disorder, 5th edition,
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expanded the scope of ED beyond the assumption that body mass or physical appearance was the primary indicator of an ED. The inaugural addition of BED and ARFID illustrates the diversity of clinical manifestation for the ED.100
,101
Lifetime prevalence of BED in the United States is 2.6%.102
In contrast to other ED, the female to male ratio in BED is more balanced. However, symptoms of BED can be overlooked and dismissed due to gender bias.103
In comparison, ARFID101
,104
was more commonly diagnosed in early-onset eating disorder (EOED) and had a longer duration of stay compared with patients with AN. ARFID can be overlooked and dismissed due to the absence of body dissatisfaction or desire to alter one’s body shape.Early recognition of ED symptomology supports long-term recovery. A behavioral exploration of each human’s relationship with food and body is the core of ED treatment. Exploring food belief systems, patterns of disinhibition, and nutrition misinformation are core topics of discussion by the RDN and client.
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The overlap between adverse childhood experiences106
and ED demands developmental and pediatric feeding strategies107
to overcome somatically engrained traumatic experiences108
that interfere with adequate nutrition consumption. A recent study revealed the mean age of ED presentation was 13.9 years; the most common form presenting in children was AN followed by atypical AN.109
Therefore, familiarity with and use of adultChew CSE, Kelly S, Baeg A, Oh JY, Rajasegaran K, Davis C. First presentation of restrictive early onset eating disorders in Asian children. Int J Eat Disord. Published online August 26, 2020. https://doi.org/10.1002/eat.23274.
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and pediatric malnutrition screening tools are critical for treatment of ED. It is the clinical responsibility of the RDN to judicially choose assessment measures to complete a comprehensive nutrition assessment, meanwhile, being mindful for the onset of negative symptoms indicative of psychological triggers.Trigger is a key term that must be understood to practice competently as an ED RDN.
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A trigger is an antecedent that generates or provokes an ED behavior as a coping mechanism. Each ED client will have unique triggers that are specific to their underlying psychopathology. The nutrient composition of food, environmental variables such as location and smell, and dysfunctional relationships with people are common triggers. The ED RDN needs to explore and recognize these variables and refer the client to the appropriate interprofessional team member for resolution.Every RDN can benefit from understanding available treatment modalities for ED. Role Examples of how RDNs in various practice areas would use the SOP and SOPP in Eating Disorders to assess their competence and identify resources in ED is in Figure 6. As the emergent field of nutritional psychiatry continues to unfold,
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the role of the RDN in ED treatment must also evolve. Understanding the differences within each level of competence is essential to develop a plan for continued professional growth. Ongoing education and clinical exploration of nutrition interventions for the management of psychiatric conditions is critical. Additional resources and references for ongoing learning are available in Figure 7.Figure 6Role Examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in Eating Disorders.
| Role | Examples of use of SOP and SOPP documents by RDNs in different practice roles |
|---|---|
| For presentation examples and common signs and symptoms of eating disorders, refer to indicators in Standard 1 of Figure 1 and the article overview. | |
| Clinical practitioner (acute care or psychiatric hospital) | A hospital-based RDN responsible for the medical and locked psychiatric units recognizes that some patients have symptoms of an eating disorder (ED). The medical and nutrition history provided insight into a patient’s eating-related behaviors and the duration of the psychopathology. The RDN reviews the SOP and SOPP in Eating Disorders to identify needed competence for recognizing the symptoms that suggest an eating disorder and to best support interprofessional collaboration for development of an appropriate plan of care. |
| Clinical practitioner–ED residential treatment center (RTC) | An RDN with the Certified Eating Disorders Registered Dietitian (CEDRD) certification employed by an RTC provides nutrition care to individuals with an ED who have chronically compromised medical and psychiatric status. The RDN recognizes the benefit of having an ongoing professional supervision relationship with a CEDRD-supervisor (CEDRD-S) for guidance and self-care. Review of the SOP and SOPP in Eating Disorders has helped identify areas for continuing education and for increased knowledge to benefit public policy advocacy. A career goal of this RDN is to pursue the distinction of qualifying for the CEDRD-S certification after practicing as a CEDRD for 7 years. |
| Clinical practitioner–ED partial hospitalization program (PHP) or Intensive outpatient program (IOP) | An experienced RDN employed by a PHP provides nutrition care to individuals diagnosed with an ED who require intensive behavioral and nutrition support in a structured and supervised setting. The RDN periodically reviews the SOP and SOPP in Eating Disorders and the identified resources with the goal of achieving the proficient-level performance indicators for quality and safe ED practice. A professional development goal of this RDN is to advance career and practitioner opportunities to ultimately qualify for the CEDRD certification. |
| Private practice practitioner | An RDN in private practice, who provides services to children, teens, and/or adults, has learned that some clients are exhibiting ED behaviors and motivations. The RDN uses the SOP and SOPP in Eating Disorders and other resources for appropriate screening indicators and maintains a network of expert ED RDNs (eg, CEDRD/-S) for collaborating with physicians to facilitate referrals. |
| Diabetes educator–inpatient or outpatient setting | An RDN diabetes educator refers to the SOP and SOPP in Eating Disorders and the SOP and SOPP in Diabetes Care for identifying and coordinating support for patients/clients with diabetes presenting with signs/symptoms of disordered eating. The RDN consults with the patient’s/client’s physician to develop a nutrition care plan, collaborates with consulting ED or mental health professional, and/or assists with referral to an ED professional or program experienced with treating individuals with diabetes. |
| Fitness, health club, collegiate athletic department | An RDN, employed by a collegiate athletic department, encounters individuals with ED behaviors. The RDN refers to the SOP and SOPP in Eating Disorders and SOP and SOPP in Sports and Human Performance Nutrition (forthcoming 2021) for information and resources to inform screening questions for disordered eating and signs/symptoms of malnutrition related to inconsistent nutrition intake. The RDN follows department protocol for making a referral to the student health services’ RDN with ED experience or to an RDN, CEDRD as appropriate. |
| ED nutrition program director | An RDN, CEDRD nutrition program director refers to the SOP and SOPP in Eating Disorders for support tools when developing position descriptions, performance competencies, and expectations, and for RDN staff and interprofessional team training. The director also uses the SOP and SOPP in Eating Disorders and other focus areas as resources with RDN staff to coordinate supervision needs, guide self-evaluation, and plan professional development activities. |
| Nutrition and dietetics faculty, preceptor, or researcher | An RDN faculty member preparing lecture materials and their own research uses the SOP and SOPP in Eating Disorders to integrate practical knowledge and skills to incorporate the required competencies for ED prevention and treatment in course syllabus, supervised practice activities, and research guidelines. |
a For each role, the RDN updates the professional development plan to include applicable essential practice competencies for eating disorders nutrition care and services.
Figure 7Eating disorder resources (not all inclusive).
| Resource | Address | Description |
|---|---|---|
| Academy of Nutrition and Dietetics (Academy) Behavioral Health Nutrition Dietetic Practice Group (BHN DPG) | https://www.bhndpg.org/ | This dietetic practice group encompasses more than 2,000 credentialed nutrition and dietetics practitioners, students, and interns who are passionate about 4 key areas of behavioral health nutrition practice: substance use disorders, eating disorders, intellectual and developmental disabilities, and mental health conditions. Members of BHN DPG receive no-cost training by global experts and access to both print and digital resources, such as the bi-annual newsletter, monthly updates, electronic mailing list, member forums, supervision/mentoring, webinars, and case studies. |
| Academy’s Chronic Disease, Sports, Wellness and Behavioral Health website | https://www.eatrightpro.org/practice/practice-resources/chronic-disease-and-wellness | This website offers resources related to chronic disease prevention, behavioral health, eating disorders, and sports nutrition. |
| Academy’s Pocket Guide to Eating Disorders, 2nd edition | https://www.eatrightstore.org/product-type/pocket-guides/academy-of-nutrition-and-dietetics-pocket-guide-to-eating-disorders-second-edition | This book, organized according to the nutrition care process, is a comprehensive guide that includes what the registered dietitian nutritionist (RDN) will need for nutrition assessment and intervention with an individual with an eating disorder. It includes sample PES statements, the role of the RDN within the interprofessional team, Diagnostic and Statistical Manual of Mental Disorders, 5th edition 63 diagnostic criteria, guidelines for providing nutrition education, communication in difficult situations, and more. |
| Academy’s Recognition and Treatment of Deficient Energy Intake Among Athletes | https://www.eatrightstore.org/dpg-products/scan/scan-fact-sheets/recognition-treatment-of-deficient-energy-intake-among-athletes | This fact sheet is for RDNs who work with athletes with an eating disorder or relative energy deficiency in sport (RED-S). This fact sheet highlights RED-S resources, such as a diagram that uses a stoplight to represent athletes who are high risk, moderate risk, or low risk. |
| Academy for Eating Disorders (AED) | https://www.aedweb.org/home | The AED is an organization dedicated to eating disorders research, education, treatment, and prevention. Their goal is to provide access to knowledge, research, and best practices for eating disorders. They provide key resources, such as A Guide to Medical Care, and the Nutrition Care Standards on the Treatment of Eating Disorders (forthcoming 2020) They also provide newsletters, journals, and fact sheets. |
| Alliance for Eating Disorders Awareness | https://www.allianceforeatingdisorders.com/ | “The Alliance for Eating Disorders Awareness is a national non-profit organization dedicated to providing programs and activities aimed at outreach, education, early intervention, and advocacy for all eating disorders.” |
| American Psychiatric Association | https://www.psychiatry.org/ | The American Psychiatric Association is an organization of psychiatrists who work to promote quality care for individuals with mental illness and promote psychiatric education and research. The American Psychiatric Association also provides information and resources on various disorders (eg, eating disorders). A key resource for eating disorders is the Diagnostic and Statistical Manual of Mental Disorder, 5th edition. 63 |
| American Psychological Association | www.apa.org | The American Psychological Association’s mission is to “advance the creation, communication and application of psychological knowledge to benefit society and improve people’s lives.” The American Psychological Association meets their mission by encouraging the development of psychology; promoting research and application of findings; and establishing standards of ethics, conduct, education and achievement. |
| Australia & New Zealand Academy for Eating Disorders (ANZAED) | https://www.anzaed.org.au/ | ANZAED is an organization that supports professionals in the field of eating disorders on issues related to prevention, treatment, and research. They provide access to guidelines such as Inpatient Services for Eating Disorders, Outpatient Services for Eating Disorders, The Role of Nutritional Management in Eating Disorders, and other member accessible resources. |
| Eating Disorder Registered Dietitians and Professionals (EDRDpro) | https://edrdpro.com/ | EDRDpro is an organization composed of a community of RDNs and other professionals in eating disorders. Member resources include articles, research, handouts, books, podcasts, and webinars in topics ranging from health at every size, family-based therapy, and the various eating disorders. |
| International Association of Eating Disorders Professionals (iaedp) Foundation | http://www.iaedp.com/ | The iaedp is an organization recognized for its education and training resources (eg, Eating Disorders Review) for health care practitioners who treat eating disorders. It established the certification process to promote standards within the field of eating disorders and offers the credentials Certified Eating Disorders Registered Dietitian (CEDRD) and the CEDRD-S (Supervision). |
| International Federation of Eating Disorder Dietitians (IFEDD) | http://www.eddietitians.com/ | IFEDD is an organization of RDNs and other professionals and IFEDD’s purpose is to support those who work with individuals with eating disorders. The IFEDD conducts eating disorder research, educates professionals and the public on eating disorders, and consults with eating disorder treatment facilities. IFEDD’s purpose is to improve quality of care of individuals with eating disorders by improving their access to eating disorder RDNs. |
| Intuitive Eating: An Anti-Diet Revolutionary Approach, 4th edition | Tribole E, Resch E. Intuitive Eating: An Anti-Diet Revolutionary Approach. 4th ed. New York, NY: St. Martin’s Press; 2020. | This book has information on rebuilding a healthy body image and making peace with food. It helps teach readers how to honor hunger and feel fullness, how to achieve a safe relationship with food, and how to follow the principles of intuitive eating among others. |
| Journal of the Academy of Nutrition and Dietetics Eating Disorders Collection | https://jandonline.org/content/eatingdisorders | The Journal collection has various articles dedicated to eating disorder topics, such as orthorexia, athletes and eating disorders, adolescents and eating disorders, in addition to ethical considerations when nutrition and dietetics students have an active eating disorder. |
| National Association of Anorexia Nervosa and Associated Disorders (ANAD) | https://anad.org/ | ANAD is a nonprofit organization working to raise support, awareness, advocacy, and increase education and prevention of eating disorders. They provide resources, such as an ANAD Approach Guide, blog, online forums and support groups, and other resources in various eating disorders areas, such as body image and athletes. |
| National Eating Disorders Association (NEDA) | https://www.nationaleatingdisorders.org/ | NEDA is a nonprofit organization that supports individuals and families affected by eating disorders. NEDA has various programs and services such as an eating disorder screening tool, helpline, support groups, and research studies. They also host the National Eating Disorders Awareness week. |
| Nutrition Counseling in the Treatment of Eating Disorders, 2nd edition | Herrin M, Larkin M. Nutrition Counseling in the Treatment of Eating Disorders. 2nd ed. New York, NY: Routledge; 2013. | This book highlights research-based approaches and clinically refined tools for managing food- and weight-related issues. It includes sections such as nutrition assessment guidelines, nutrition counseling interventions, and techniques for managing bingeing, purging, excessive exercise, and weight restoration. |
a PES = problem, etiology, and signs and symptoms.
ED treatment must include the RDN at all phases of recovery. Throughout the treatment process, an RDN serves as a clinical advocate for the nutritional needs of clients. Developing clinical sustainability as an ED RDN demands maintenance of professional best practices (eg, professional clinical supervision, advanced training/certification, and daily self-care). Given the commonality of RDNs and nutrition and dietetics students to present with disordered eating patterns or ED
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during their career, introspective evaluation of the personal motivation to work with this population is recommended. An evaluation of transference and countertransference that arise during clinical treatment is essential for every RDN treating ED and limits the development of compassion fatigue.115
As science advances, continued exploration into the role of nutrition on mental health,
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,117
psychobiotic neuroregulators,118
and the gut microbiome119
, 120
, 121
will offer the RDN new educational frameworks to provide medical nutrition therapy for treating ED through the lifespan.122
Best practices for ED include a culturally inclusive view of treatment, inclusion of physical activity/movement, and development of a personal spirituality. The call to action for every RDN is to use an assertive, evidence-based, and clinically relevant123
approach to treatment for ED.Academy Revised 2020 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Eating Disorders
An RDN can use the Academy Revised 2020 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in Eating Disorders (see Figures 1 and 2, available at www.jandonline.org, and Figure 3) to:
- •identify the competencies needed to provide ED nutrition and dietetics care and services;
- •self-evaluate whether they have the appropriate knowledge, skills, and judgment to provide safe, effective, efficient, equitable, and quality ED care and services for their level of practice;
- •identify the areas in which additional knowledge, skills, and experience are needed to practice at the competent, proficient, or expert level of ED nutrition and dietetics practice;
- •provide a foundation for public and professional accountability in ED nutrition and dietetics care and services;
- •support efforts for strategic planning, performance improvement, outcomes reporting, and assist management in the planning and communicating of ED nutrition and dietetics services and resources;
- •enhance professional identity and skill in communicating the nature of ED nutrition and dietetics care and services;
- •guide the development of ED nutrition and dietetics-related education and continuing education programs, job descriptions, practice guidelines, protocols, clinical models, competence evaluation tools, and career pathways; and
- •assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in ED nutrition 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 ED is learning the principles that underpin this focus area and is developing knowledge, skills, judgment, and gaining experience for safe and effective ED practice. This RDN, who may be new to the profession or may be an experienced RDN, 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 ED must accept the challenge of becoming familiar with the body of knowledge, required clinical judgment skills, practice guidelines, and available resources to support and ensure quality ED-related nutrition and dietetics practice.
At the proficient level, an RDN has developed a more in-depth understanding of ED practice and is more skilled at adapting and applying evidence-based guidelines and best practices than at the competent level. This RDN is able to modify practice according to unique situations (eg, refusal of food by mouth, splitting between interprofessional team members by client, and management of safety concerns for client as a result of malnutrition). A proficient-level RDN in ED can actively engage with the interprofessional team (eg, physicians, psychologists, iaedp-Certified Eating Disorders Registered Nurse, iaedp-Certified Eating Disorders Creative Arts Therapist), work with complex diagnoses and comorbidities, conduct research, and mentor competent-level RDNs or students/interns.
At the expert level, the RDN thinks critically about ED nutrition and dietetics, demonstrates a more intuitive understanding of the practice area, displays a range of highly developed clinical and technical skills, and formulates judgments acquired through a combination of education, experience, professional clinical supervision, and critical thinking. Practice at the expert level requires the application of composite nutrition and dietetics knowledge, with practitioners drawing not only on their practice experience, but also on the experience of the ED RDNs in various disciplines and practice settings. Expert RDNs, with their extensive experience and ability to see the significance and meaning of ED nutrition and dietetics within a contextual whole, are fluid and flexible, and have considerable autonomy in practice. They not only develop and implement ED nutrition and dietetics services, they also manage, drive and direct clinical care; conduct and collaborate in research and advocacy; accept organization leadership roles; engage in scholarly work; guide interprofessional teams; and lead the advancement of ED nutrition and dietetics practice. Expert RDNs in ED also provide leadership to credentialed nutrition and dietetics practitioners through education, mentoring, research, and public policy advocacy. An expanded role reflective of an expert RDN in ED with the CEDRD is to pursue the next level of certification as an approved supervisor (CEDRD-S) through iaedp. This certification enables the RDN to provide professional supervision to RDNs working to qualify for the CEDRD.
Indicators for the SOP and SOPP for RDNs in Eating Disorders are measurable action statements that illustrate how each standard can be applied in practice (Figures 1 SOP and 2 SOPP, available at www.jandonline.org). Within the SOP and SOPP for RDNs in Eating Disorders, an “X" in the competent column indicates that an RDN who is caring for patients/clients 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 ED could be an RDN starting practice after registration or an experienced RDN who has recently assumed responsibility to provide ED nutrition care for clients.
An “X" in the proficient column indicates that an RDN who performs at this level has a deeper understanding of ED care and services and has the ability to modify or guide therapy to meet the needs of patients/clients in various situations (eg, assessment of need for a higher level of care; and evaluation of the impact of malnutrition on psychopathology and client social eating experiences that create psychiatric distress).
An “X" in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of ED and a highly developed range of skills and judgments acquired through a combination of experience, education, and professional clinical supervision. The expert RDN builds and maintains the highest level of knowledge, skills, and behaviors, including leadership, clinical supervision and mentorship, vision, and credentials.
Standards and indicators presented in Figure 1 and Figure 2 (available at www.jandonline.org) in boldface type originate from the Academy’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs
2
and should apply to RDNs in all 3 levels. Additional indicators not in boldface type developed for this focus area are identified as applicable to all levels of practice. Where an "X" is placed in all 3 levels of practice, it is understood that all RDNs in ED 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 Eating Disorders is warranted. It is the totality of individual practice that defines a practitioner’s level of practice and not any one indicator or standard.RDNs should review the SOP and SOPP in Eating Disorders at determined intervals to evaluate their individual focus area knowledge, skill, and competence. Consistent self-evaluation is important because it helps identify opportunities to improve and enhance practice and professional performance and set goals for professional development. This self-appraisal, including guidance from professional clinical supervision, also enables RDNs in ED to better utilize these Standards as part of the Professional Development Portfolio recertification process,
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which encourages CDR-credentialed nutrition and dietetics practitioners to incorporate self-reflection and learning needs assessment for development of a learning plan for improvement and commitment to lifelong learning. CDR’s 5-year recertification cycle incorporates the use of essential practice competencies for determining professional development needs.125
In the 3-step process, the credentialed practitioner accesses an online Goal Wizard (step 1), which uses a decision algorithm to identify essential practice competency goals and performance indicators relevant to the RDN’s area(s) of practice (essential practice competencies and performance indicators replace the learning need codes of the previous process). The Activity Log (step 2) is used to log and document continuing professional education during the 5-year period. The Professional Development Evaluation (step 3) guides self-reflection and assessment of learning and how it is applied. The outcome is a completed evaluation of the effectiveness of the practitioner’s learning plan and continuing professional education. The self-assessment information can then be used in developing the plan for the practitioner’s next 5-year recertification cycle. For more information, see https://www.cdrnet.org/competencies-for-practitioners.RDNs are encouraged to pursue additional knowledge, skills, and 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.
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RDNs should collaborate with other RDNs in ED as learning opportunities and to promote consistency in practice and performance and continuous quality improvement.In some instances, components of the SOP and SOPP for RDNs in Eating Disorders do not specifically differentiate between proficient-level and expert-level practice. In these areas, it remains 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.
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A wealth of knowledge is embedded in the experience, discernment, and practice of expert-level RDN practitioners. The experienced practitioner observes events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. The knowledge and skills acquired through practice will continually expand and mature. The SOP and SOPP indicators are refined with each review of these Standards as expert-level RDNs systematically record and document their experiences, often through use of exemplars. Exemplary actions of individual ED RDNs in practice settings and professional activities that enhance patient/client/population care and/or services, can be used to illustrate outstanding practice models.Future Directions
The SOP and SOPP for RDNs in Eating Disorders are innovative and dynamic documents. Future revisions will reflect changes and advances in practice, changes to dietetics education standards, regulatory changes, and outcomes of practice audits. Continued clarity and differentiation of the 3 practice levels in support of safe, effective, efficient, equitable, and quality practice in ED remains an expectation of each revision to serve tomorrow's practitioners and their patients, clients, and customers.
Future revisions of ED standards will require ongoing integration of a multidimensional and interprofessional approach to treatment. Exploration of the interplay between the gut microbiome and neurochemical modulators of behavior,
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investigation of chemical substrates being consumed through the food supply that modulate perception/expression of human behavior and an understanding of the biopsychosocial model used for the treatment of ED, which allows for inclusion of all people seeking recovery, are needed. RDNs at each level of competence are responsible for contributing to the advancement of the field of ED.Summary
RDNs face complex situations every day. Addressing the unique needs of each situation and applying standards appropriately is essential to providing safe, timely, 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 for the Nutrition and Dietetics Profession, the Scope of Practice for RDNs, and the SOP in Nutrition Care and SOPP for RDNs, along with applicable federal and state regulations and facility accreditation standards. The SOP and SOPP for RDNs in Eating Disorders are complementary documents and are key resources for RDNs at all knowledge and performance levels. These standards can and should be used by RDNs in daily practice who provide care to individuals with ED to consistently improve and appropriately demonstrate competence and value as providers of safe, effective, efficient, equitable, and quality nutrition and dietetics care and services. These standards also serve as a professional resource for self-evaluation and professional development for RDNs specializing in ED 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 7 years.
Current and future initiatives of the Academy, as well as advances in ED care and services, will provide information to use in future 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 Behavioral Health Nutrition Dietetic Practice Group, these standards are an application of continuous quality improvement and represent an important collaborative endeavor.
These standards have been formulated for use by individuals in self-evaluation, practice advancement, development of practice guidelines and specialist credentials, and as indicators of quality. These standards do not constitute medical or other professional advice and should not be taken as such. The information presented in the standards is not a substitute for the exercise of professional judgment by the credentialed nutrition and dietetics practitioner. These standards are not intended for disciplinary actions, or determinations of negligence or misconduct. 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
Special acknowledgement and thanks to Jaimie Winkler, RD, LDN; Beth Harrell, MS, RD, LD, CEDRD-S; and Jillian Lampert, PhD, RD, LD, MPH, FAED, who willingly gave their time to review these standards, and to the Behavioral Health Nutrition Dietetic Practice Group’s Executive Committee. The authors also extend thanks to all who were instrumental in the process for the revisions of the article. Finally, the authors thank Academy staff, in particular, Carol Gilmore, MS, RDN, LD, FADA, FAND; Dana Buelsing, MS, CAPM; Karen Hui, RDN, LDN; and Sharon McCauley, MS, MBA, RDN, LDN, FADA, FAND, who supported and facilitated the development of these SOP and SOPP.
Author Contributions
Each author contributed to drafting and editing the components of the article (eg, article text and figures) and reviewed all drafts of the manuscript.
Supplementary Materials
Figure 1Standards of Practice for Registered Dietitian Nutritionists (RDNs) in Eating Disorders. Note: The terms patient, client, customer, resident, individual, person, group, or population are used interchangeably with the actual term used in a given situation depending on the setting and the individual/population receiving care or services.
| Standards of Practice for Registered Dietitian Nutritionists in Eating Disorders Standard 1: Nutrition Assessment The registered dietitian nutritionist (RDN) uses accurate and relevant data and information to identify nutrition-related problems. Rationale: Nutrition screening is the preliminary step to identify individuals who require a nutrition assessment performed by an RDN. Nutrition assessment is a systematic process of obtaining and interpreting data in order to make decisions about the nature and cause of nutrition-related problems and provides the foundation for nutrition diagnosis. It is an ongoing, dynamic process that involves not only initial data collection, but also reassessment and analysis of patient/client or community needs. Nutrition assessment is conducted using validated tools based in evidence, the 5 domains of nutrition assessment, and comparative standards. Nutrition assessment may be performed via in-person or facility/practitioner assessment application or Health Insurance Portability and Accountability Act (HIPAA)–compliant video conferencing telehealth platform. | |||||||
| Indicators for Standard 1: Nutrition Assessment | |||||||
|---|---|---|---|---|---|---|---|
| Bold Font Indicators are Academy Core RDN Standards of Practice Indicators | The “X” signifies the indicators for the level of practice | ||||||
| Each RDN: | Competent | Proficient | Expert | ||||
| 1.1 | Patient/client history: Assesses current and past information related to personal, medical, family, and psychosocial/social history | X | X | X | |||
| 1.1A | Evaluates nutrition screening documentation and determines risk for malnutrition (eg, diet history, physical assessment data, belief systems around eating, and environmental barriers to adequate nutrition, including food security) using evidence-based screening tools for the setting and/or population (adult or pediatric) | X | X | X | |||
| 1.1B | Assesses development, onset, and history of eating disorder(s) (ED) and related factors (eg, food issues, weight history, physical activity, sport-specific activities, previous dieting methods) | X | X | X | |||
| 1.1C | Assesses developmental history (eg, birth weight, early feeding history, growth pattern, menstrual history in females, onset of puberty) | X | X | ||||
| 1.1D | Assesses medical and disease conditions common in individuals with an ED:
| X | X | ||||
| 1.1E | Assesses behavioral health and physical activity-related comorbidities commonly associated with ED:
| X | X | ||||
| 1.1F | Assesses family history in relation to disordered eating:
| X | X | ||||
| 1.2 | Anthropometric assessment: Assesses anthropometric indicators (eg, stature, body size, physical composition), comparison to age-specific reference data, individual patterns, and history completed at a time appropriate to patient’s/client’s physical and/or mental readiness | X | X | X | |||
| 1.2A | Identifies and interprets trends in anthropometric indices taking into consideration cultural diversity | X | X | X | |||
| 1.3 | Biochemical data, medical tests, and procedure assessment: Assesses laboratory profiles (eg, acid–base balance, renal function, endocrine function, inflammatory response, vitamin/mineral profile, lipid profile, hepatic enzymes), and diagnostic medical tests and procedures | X | X | X | |||
| 1.3A | Reviews consultation reports (eg, behavioral, psychosocial, dental, physical therapy/occupational therapy, physician) and applicable diagnostic surveys (eg, Eating Disorder Examination Questionnaire [EDE-Q], Binge Eating Scale [BES], Eating Disorder Diagnostic Scale [EDDS], Eating Attitudes Test [EAT], Body Shape Questionnaire [BSQ], Generalized Anxiety Disorder 7 [GAD-7]) | X | X | ||||
| 1.3B | Reviews relevant biochemical and physiological measures, including micronutrient imbalances, hydration status, neuroendocrine status, endocrine markers, genetic mutations, and other tests to determine stage of illness (eg, complex metabolic profile, thyroid function, urinalysis, blood urea nitrogen to creatinine ratio, hepatic and reproductive function) | X | X | ||||
| 1.3C | Assesses implications of the results of diagnostic tests on the therapeutic process (eg, indirect calorimetry measurements or energy needs estimated from appropriate calculation [resting metabolic rate], GI diagnostic tests, cardiac electrocardiogram, electroencephalogram, functional magnetic resonance imaging, and bone health [dual-energy x-ray absorptiometry (DEXA) scan] evaluations) in relation to ED | X | X | ||||
| 1.3D | Assesses need for additional tests (eg, food intolerance, food allergy, or malabsorption studies) or periodic diagnostic measurements (eg, electrolytes, orthostatic blood pressure, valid body weight [actual and accurate]) | X | X | ||||
| 1.4 | Nutrition-focused physical examination (NFPE) may include visual and physical examination: Obtains and assesses findings from NFPE (eg, indicators of vitamin/mineral deficiency/toxicity, edema, muscle wasting, subcutaneous fat loss, altered body composition, oral health, feeding ability [suck/swallow/breathe], appetite, and affect) | X | X | X | |||
| 1.4A | Performs NFPE (or selective components) at appropriate stage for the client’s physical and/or mental readiness consistent with training and experience with the ED population; seeks assistance from more experienced RDN if needed | X | X | X | |||
| 1.4A1 | Conducts NFPE that includes, but is not limited to:
| X | X | X | |||
| 1.4B | Evaluates nutrition-related findings specific to eating disorders (eg, signs and symptoms of dehydration, lightheadedness, cold tolerance, fatigue, loss of concentration, acrocyanosis, insomnia, hair loss, dry skin) | X | X | ||||
| 1.4C | Evaluates more complex findings impacting nutrition status (eg, acrocyanosis, Russell’s signs, orthostatic changes, temperature shifts [as indicative of starvation-induced hyperactivity vs compulsive exercise], sialadenitis; and, when indicated, includes the “walk across the room” test 12 used for determining difference in “athletic heart” vs “starved heart”) | X | |||||
| 1.5 | Food and nutrition-related history assessment (ie, dietary assessment)— Evaluates the following components: | ||||||
| 1.5A | Food and nutrient intake, including composition and adequacy, meal and snack patterns, and appropriateness related to food allergies and intolerances | X | X | X | |||
| 1.5A1 | Evaluates pattern of food, beverage, energy, and nutrient intake, including timing, location, and frequency of meals and snacks | X | X | X | |||
| 1.5A2 | Evaluates current and historical efforts to use specialized and structured diets (eg, low fat, low sodium, low carbohydrate/high protein, liquids only, vegan/vegetarian, macrobiotic, food category restriction) | X | X | X | |||
| 1.5A3 | Integrates evaluation of food allergies and intolerances (clinical and/or self-diagnosed), clinical presentation, previous symptomology | X | X | ||||
| 1.5A4 | Evaluates nutrient imbalances related to avoidance, or excessive intake of certain foods or food groups as a means of manipulating or controlling weight | X | X | ||||
| 1.5B | Food and nutrient administration, including current and previous diets and diet prescriptions and food modifications, eating environment, and enteral and parenteral nutrition administration | X | X | X | |||
| 1.5B1 | Assesses compliance to previous nutrition prescription/intervention(s) (eg, previous type, frequency, and duration of ED treatment) | X | X | X | |||
| 1.5B2 | Assesses physiological and biological needs and processes related to stage of nutrition rehabilitation or weight restoration (eg, hypermetabolism, hypometabolism, dehydration) | X | X | X | |||
| 1.5B3 | Assesses nutritional philosophy, attitudes, and/or maladaptive feeding patterns | X | X | ||||
| 1.5C | Medication and dietary supplement use, including prescription and over-the-counter medications, and integrative and functional medicine products | X | X | X | |||
| 1.5C1 | Evaluates potential interactions between nutrients/nutritional status and prescribed and over-the-counter medications, illicit drugs, and caffeine | X | X | X | |||
| 1.5C2 | Evaluates drug/nutrient/food and dietary supplement/herbal/food interactions (eg, St John’s wort, valerian root, kava kava, grapefruit juice); refer to database resources (eg, Natural Medicine Database: https://naturalmedicines.therapeuticresearch.com/) | X | X | X | |||
| 1.5C3 | Evaluates current and past use of medications/dietary supplements/herbals for appropriate use or misuse including, but not limited to:
| X | X | ||||
| 1.5C4 | Evaluates nutrition-related side effects of common behavioral health medications (eg, weight gain, fluid retention, dry mouth, excessive thirst, constipation, altered glucose and/or lipid metabolism, GI discomfort, anorexia, increased appetite) | X | X | ||||
| 1.5D | Knowledge, beliefs, and attitudes (eg, understanding of nutrition-related concepts, emotions about food/nutrition/health, body image, preoccupation with food and/or weight, readiness to change nutrition- or health-related behaviors, and activities and actions influencing achievement of nutrition-related goals, including the genesis of food and nutrition belief systems) | X | X | X | |||
| 1.5D1 | Assesses client perceptions of previous nutrition interventions | X | X | X | |||
| 1.5D1i | Assesses reported effectiveness of previous nutrition therapy | X | X | X | |||
| 1.5D1ii | Assesses readiness for change (eg, stages of change) | X | X | X | |||
| 1.5D1iii | Assesses knowledge of nutrition and ED | X | X | ||||
| 1.5D1iv | Assesses knowledge of the long-term recovery process and impact of treatment | X | |||||
| 1.5D2 | Evaluates food beliefs for impact on nutrition status and implications for the nutrition intervention for ED
| X | X | ||||
| 1.5E | Food security defined as factors affecting access to a sufficient quantity of safe, healthful food and water, as well as food-/nutrition-related supplies | X | X | X | |||
| 1.5E1 | Assesses barriers to adequate food access (eg, economic, transportation, living situation, limited cooking proficiency combined with rigid food rules); reviews observations of health care professionals and family and social service reports | X | X | X | |||
| 1.5F | Physical activity, cognitive and physical ability to engage in developmentally appropriate nutrition-related tasks (eg, self-feeding and other activities of daily living [ADLs]), instrumental ADLs (eg, shopping, food preparation), and breastfeeding | X | X | X | |||
| 1.5F1 | Assesses limitations based on comorbid psychiatric diagnosis(es) (eg, attention deficits, executive functioning, ability to plan, impulse control) | X | X | ||||
| 1.5G | Other factors affecting intake and nutrition and health status (eg, cultural, ethnic, religious, lifestyle influencers, psychosocial, and social determinants of health) | X | X | X | |||
| 1.5G1 | Assesses developmental, functional, and mental status, and cultural, ethnic, and lifestyle factors using validated tools and observations of other interprofessional a team membersInterprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, psychiatrists, nurses, nurse practitioners, dietitian nutritionists, pharmacists, physician assistants, psychologists, licensed professional counselors, licensed marriage and family therapists, social workers, dentists, and occupational and physical therapists), depending on the needs of the client. Interprofessional could also mean interdisciplinary or multidisciplinary. | X | X | X | |||
| 1.5G2 | Assesses access to medical care and interprofessional team | X | X | X | |||
| 1.5G3 | Assesses barriers (eg, co-existing conditions, learning style, lack of support, availability of treatment resources) | X | X | X | |||
| 1.5G4 | Assesses for food- or eating-related ED behavior triggers (eg, specific foods or food situations, social eating) | X | X | ||||
| 1.5G5 | Assesses for significant subjective emotional/physical stressors or traumatic experiences that impact ED behaviors | X | X | ||||
| 1.5G6 | Assesses for psychological or physiological triggers for ED behaviors; evaluates:
| X | |||||
| 1.5G7 | Identifies client’s interpersonal boundaries and psychological defense mechanisms manifested through food behaviors that are preventing progress and collaborates with interprofessional treatment team for additional support as needed | X | |||||
| 1.5H | Assesses resources for affecting change (eg, financial, emotional, coping skills) over course of treatment | X | X | ||||
| 1.5I | Evaluates interpersonal social precipitants and stressors | X | X | ||||
| 1.5I1 | Evaluates:
| X | X | ||||
| 1.5I2 | Evaluates:
| X | |||||
| 1.5J | Evaluates food and body-related rituals before, during, and after meals | X | X | ||||
| 1.5J1 | Systematic eating patterns that may be associated with ED or a comorbid condition, including but not limited to:
| X | X | ||||
| 1.5J2 | Obsessive tracking of food intake and/or physical activity | X | X | ||||
| 1.5J3 | Systematic purging system and/or efforts to conceal purging | X | X | ||||
| 1.5J4 | Body checking (eg, reflection/mirror checking, body pinching, compulsively checking body weight or fit of clothing) | X | X | ||||
| 1.5K | Evaluates use of compensatory behaviors, including exercise, vomiting, colonic cleanses, diuretic use, laxative use, diet pills use, and/or insulin adjustments | X | X | ||||
| 1.6 | Comparative standards: Uses reference data and standards to estimate nutrient needs and recommended body weight, body mass index (BMI), and desired growth patterns | X | X | X | |||
| 1.6A | Identifies the most appropriate reference data and/or standards (eg, international, national, state, institutional, and regulatory) based on practice setting and patient-/client-specific factors (eg, age and disease state) | X | X | X | |||
| 1.6B | Uses anthropometric measurement standards (eg, BMI, growth charts) | X | X | X | |||
| 1.6C | Uses data from client health history (eg, healthy weight history before ED, family health history, weight at menses) | X | X | X | |||
| 1.6D | Uses evidence-based sources and scientific reports for ongoing refinement of “best practice” treatment guidelines | X | X | X | |||
| 1.6E | Evaluates epidemiological studies, identifying prevalence of ED as it applies to health and disease conditions for nutrition-related consequences | X | X | X | |||
| 1.6F | Compares laboratory findings (eg, heart rate, blood pressure, hydration status, electrolytes) to clinical standards in relation to current diagnosis | X | X | ||||
| 1.6G | References emerging data from clinical observations and research specific to ED that supports incorporating nutrition assessment throughout treatment | X | X | ||||
| 1.6H | Identifies limitations of evidence-based guidelines in personalizing the nutrition assessment to an individual with ED’s needs | X | |||||
| 1.7 | Physical activity habits and restrictions: Assesses physical activity, history of physical activity, and physical activity training | X | X | X | |||
| 1.7A | Evaluates energy expenditure from conscious movement patterns and physical activity (past and current), including length of time, intensity, compulsivity, sleep patterns, ADLs, and starvation-induced hyperactivity, such as fidgeting | X | X | X | |||
| 1.7B | Assesses use of self-monitoring behaviors—benefits vs risks (eg, health app, energy expenditure) | X | X | X | |||
| 1.7C | Evaluates history of physical activity or exercise dependence and adherence to interprofessional team recommendations | X | X | ||||
| 1.7D | Evaluates resistance to engaging in physical activity, including physical and emotional barriers | X | X | ||||
| 1.8 | Collects data and reviews data collected and/or documented by the nutrition and dietetics technician, registered (NDTR), other health care practitioner(s), patient/client, or staff for factors that affect nutrition and health status | X | X | X | |||
| 1.8A | Obtains and integrates data from members of the interprofessional treatment team | X | X | X | |||
| 1.9 | Uses collected data to identify possible problem areas for determining nutrition diagnoses | X | X | X | |||
| 1.9A | Recognizes role of client’s ability and perception to grasp magnitude and severity of their condition | X | X | X | |||
| 1.9A1 | Understands limitations (eg, under- or over-reporting by client of thoughts, feelings, and behaviors) | X | X | ||||
| 1.9A2 | Understands that interrelatedness of eating behaviors, cognitions, and psychopathology contribute to changing nutritional status | X | X | ||||
| 1.9B | Evaluates actual or risk of developing acute complications of ED (eg, refeeding syndrome, metabolic, cardiovascular, renal, hormonal, GI, neurologic, or psychiatric) | X | X | ||||
| 1.9C | Evaluates actual or risk of developing chronic complications of ED (eg, cardiovascular, dental, endocrine, stress fractures/poor bone health, growth retardation and delayed puberty, menstrual dysfunction, infertility, sleep apnea, or metabolic syndrome) | X | X | ||||
| 1.9D | Evaluates actual or risk of complications related to co-existing biopsychosocial factors (eg, psychiatric condition, intellectual/ developmental disability, status post bariatric surgery, pregnancy, lactation, disease states, exercise dependence, involvement in athletics, or career with implicit expectations regarding body size or shape) | X | |||||
| 1.10 | Documents and communicates: | X | X | X | |||
| 1.10A | Date and time of assessment | X | X | X | |||
| 1.10B | Pertinent data (eg, medical, social, behavioral) | X | X | X | |||
| 1.10C | Comparison to appropriate standards | X | X | X | |||
| 1.10D | Patient/client/population perceptions, values, and motivation related to presenting problems | X | X | X | |||
| 1.10E | Changes in patient/client/population perceptions, values, and motivation related to presenting problems | X | X | X | |||
| 1.10F | Reason for discharge/discontinuation or referral, if appropriate | X | X | X | |||
Examples of Outcomes for Standard 1: Nutrition Assessment
| |||||||
| 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: Analysis of the assessment data leads to identification of nutrition problems and a nutrition diagnosis(es), if present. The nutrition diagnosis(es) is the basis for determining outcome goals, selecting appropriate interventions, and monitoring progress. Diagnosing nutrition problems is the responsibility of the RDN. | |||||||
| Indicators for Standard 2: Nutrition Diagnosis | |||||||
| Bold Font Indicators are Academy Core RDN Standards of Practice Indicators | The “X” signifies the indicators for the level of practice | ||||||
| Each RDN: | Competent | Proficient | Expert | ||||
| 2.1 | Diagnoses nutrition problems based on evaluation of assessment data and identifies supporting concepts (ie, etiology, signs, and symptoms) | X | X | X | |||
| 2.1A | Organizes and groups data consisting of physical, clinical, psychosocial, behavioral-environmental, and nutrition assessment findings to determine nutrition diagnosis(es) (eg, significant and adequate information for drawing conclusions) | X | X | X | |||
| 2.1B | Evaluates findings systematically using critical thinking, and experience with the population when formulating the nutrition diagnosis; consults with interprofessional team as needed | X | X | X | |||
| 2.1C | Demonstrates understanding of psychiatric (ie, Diagnostic and Statistical Manual of Mental Disorders, 5th edition for ED) and medical diagnostic criteria (eg, amenorrhea, orthostatic hypotension, tachycardia, mania, and acute psychosis) | X | X | ||||
| 2.1D | Integrates complex information related to food intake, biochemical data, diagnostic tests, clinical complications, and their management within an interprofessional environment or need for consultation with other providers when formulating a nutrition diagnosis(es) | X | |||||
| 2.2 | Prioritizes the nutrition problem(s)/diagnosis(es) based on severity, safety, patient/client needs and preferences, ethical considerations, likelihood that nutrition intervention/plan of care will influence the problem, discharge/transitions of care needs, and patient/client/advocate b perception of importanceAdvocate: An advocate is a person who provides support and/or represents the rights and interests at the request of the patient/client. The person may be a family member or an individual not related to the patient/client who is asked to support the patient/client with activities of daily living or is legally designated to act on behalf of the patient/client, particularly when the patient/client has lost decision making capacity. (Adapted with permission The Joint Commission’s Glossary of Terms13 and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation6,7). | X | X | X | |||
| 2.2A | Evaluates assessment data to prioritize nutrition problems/diagnosis(es) considering:
| X | X | X | |||
| 2.2B | Recognizes limitations affecting best practices among ED professionals | X | X | ||||
| 2.2B1 | Recognizes lack of consensus among ED professionals (eg, philosophies around treatment approaches and interventions) | X | X | ||||
| 2.2B2 | Recognizes that working within an interprofessional team and setting priorities for treatment requires the ability to communicate relevant concerns using ED-specific terminology | X | X | ||||
| 2.2C | Consults with family/support system and interprofessional treatment team when evaluating nutrition diagnoses for recovery care plan | X | X | ||||
| 2.2D | Uses critical thinking, experience, and judgment when considering the complex nature of ED behaviors and possibility of comorbid conditions when ranking diagnoses in order of importance and urgency for the client | X | |||||
| 2.2E | Uses advanced reasoning and judgment that reflects recognizing the broad array of co-existing neuroendocrine and/or personality disorders seen in ED behaviors when ranking nutrition diagnoses in order of importance | X | |||||
| 2.3 | Communicates the nutrition diagnosis(es) to patients/clients/advocates, community, family members, or other health care professionals when possible and appropriate | X | X | X | |||
| 2.3A | Uses the most appropriate communication method (eg, written, oral, low literacy) to share information | X | X | X | |||
| 2.3B | Engages in ongoing communication and education with members of the interprofessional team and any other health care professionals involved in client assessment for ED and physical activity behaviors | X | X | X | |||
| 2.3C | Explains identified nutrition diagnosis(es) to the client/family/caregiver using appropriate communication methods, timing, and techniques | X | X | X | |||
| 2.4 | Documents the nutrition diagnosis(es) using standardized terminology and clear, concise written statement(s) (eg, using Problem [P], Etiology [E], and Signs and Symptoms [S] [PES statements] or Assessment [A], Diagnosis [D], Intervention [I], Monitoring [M], and Evaluation [E] [ADIME statements]) | X | X | X | |||
| 2.5 | Re-evaluates and revises nutrition diagnosis(es) when additional assessment data become available | X | X | X | |||
| 2.5A | Uses most current information that may impact nutrition diagnosis(s), revises if needed, and communicates change to interprofessional team, client/family/caregiver as appropriate in a timely manner | X | X | X | |||
Examples of Outcomes for Standard 2: Nutrition Diagnosis
| |||||||
| Standard 3: Nutrition Intervention/Plan of Care The registered dietitian nutritionist (RDN) identifies and implements appropriate, person-centered interventions designed to address nutrition-related problems, behaviors, risk factors, environmental conditions, or aspects of health status for an individual, target group, or the community at large. Rationale: Nutrition intervention consists of 2 interrelated components—planning and implementation.
| |||||||
| Indicators for Standard 3: Nutrition Intervention/Plan of Care | |||||||
| Bold Font Indicators are Academy Core RDN Standards of Practice Indicators | The “X” signifies the indicators for the level of practice | ||||||
| Each RDN: | Competent | Proficient | Expert | ||||
| Plans the nutrition intervention/plan of care: | |||||||
| 3.1 | Addresses the nutrition diagnosis(es) by determining and prioritizing appropriate interventions for the plan of care | X | X | X | |||
| 3.1A | Evaluates readiness for change upon initiation of treatment and throughout process | X | X | X | |||
| 3.1B | Identifies available resources and clinical support team for recovery process | X | X | ||||
| 3.1C | Recognizes mental health concerns (eg, safety and psychiatric status) and co-occurring maladaptive behaviors | X | X | ||||
| 3.1D | Prioritizes assessment measures and hierarchy of interventions for medical conditions based upon severity of condition at initiation of treatment | X | |||||
| 3.1E | Identifies the impact of personality traits (eg, obsessive compulsive tendencies, perfectionism, borderline personality traits) throughout the treatment process | X | |||||
| 3.2 | Bases intervention/plan of care on best available research/evidence and information, evidence-based guidelines, and best practices | X | X | X | |||
| 3.2A | Consults nationally developed adult and pediatric evidence-based practice guidelines and position papers (eg, Academy of Nutrition and Dietetics [Academy] position and practice papers, Academy Evidence Analysis Library, and Adult and Pediatric Nutrition Care Manuals) for guidelines for control or improvement of the disease or conditions as defined and supported in the literature | X | X | X | |||
| 3.2B | Contributes to the development of clinical guidelines and up-to-date intervention tools | X | X | ||||
| 3.2C | Monitors and critically evaluates progress of intervention and recognizes when it is appropriate to deviate from established guidelines | X | X | ||||
| 3.3 | Refers to policies and procedures, protocols, and program standards | X | X | X | |||
| 3.3A | Adheres to departmental/organizational program policies, procedures, guidelines, and protocols related to behavioral health and nutrition | X | X | X | |||
| 3.4 | Collaborates with patient/client/advocate/population, caregivers, interprofessional team, and other health care professionals | X | X | X | |||
| 3.4A | Communicates with support team while maintaining appropriate confidentiality and HIPAA guidelines | X | X | X | |||
| 3.4B | Identifies essential and relevant interprofessional team members | X | X | ||||
| 3.4C | Engages and educates support team to optimize the maximum positive influence towards recovery of client | X | |||||
| 3.5 | Determines motivation and commitment to change throughout the course of treatment | X | X | X | |||
| 3.5A | Asks open-ended questions and listens to responses | X | X | X | |||
| 3.5B | Expresses empathy, develops clarity between personal and professional boundaries, acknowledges resistance, and supports self-efficacy | X | X | X | |||
| 3.5C | Affirms, reflects, and elicits discussion of recovery-oriented change | X | X | ||||
| 3.5D | Supports motivation to change elicited from the client when motivation is recovery-oriented (eg, weight-neutral goals vs weight suppression or weight loss goals) | X | X | ||||
| 3.5E | Provides the client with information regarding the course of illness and recovery reflecting the complex nature of ED | X | |||||
| 3.6 | Works with patient/client/advocate/population and caregivers to identify goals, preferences, discharge/transitions of care needs, plan of care, and expected outcomes | X | X | X | |||
| 3.6A | Addresses client concerns related to physical change, food selection, and body shape using an appropriate, recovery-oriented framework (eg, general healthy eating principles, liberalizing food selections, weight-neutral, or health at every size approaches) | X | X | X | |||
| 3.6B | Establishes measurable and realistic behavior goals and expected outcomes | X | X | X | |||
| 3.6C | Identifies potential barriers to successful implementation of plan (eg, continued focus on weight loss or weight suppression, client compliance, food availability and preparation issues, social support, readiness to change) | X | X | ||||
| 3.6D | Develops and uses nonverbal attending skills, verbal leading skills, active listening, and appropriate use of self-disclosure and/or self-involvement in counseling | X | X | ||||
| 3.6E | Reviews philosophical approaches and treatment in relation to individual goals, resources, knowledge, skills, ability to change or take risks; prioritizes options | X | |||||
| 3.6F | Anticipates and addresses possible lapses in recovery, and identifies strategies to prevent lapses and/or re-establish recovery-oriented behaviors following lapses | X | |||||
| 3.7 | Develops the nutrition prescription and establishes measurable patient-/client-focused goals to be accomplished | X | X | X | |||
| 3.7A | Tailors nutrition prescription by taking into consideration factors affecting nutrition status (eg, health risks associated with overweight and obesity, addictions, and comorbidities, such as intellectual and developmental disabilities and living situation) | X | X | X | |||
| 3.7B | Considers the following when developing a nutrition prescription:
| X | X | X | |||
| 3.7C | Identifies interventions based on individual needs, goals, and resources; selects appropriate education and behavior change tools | X | X | X | |||
| 3.7D |
| X | X | ||||
| 3.7E | Considers severity of nutritional issues, and/or pending medical and/or behavioral/psychiatric interventions that are influenced by or may influence nutrition status | X | X | ||||
| 3.7F | Uses critical thinking and synthesis skills to guide decision-making in complicated, unpredictable, and dynamic situations | X | X | ||||
| 3.7G | Considers emerging/alternative treatment strategies (eg, for severe and enduring eating disorders) that are supported by scientific evidence (evidence-based research, guidelines, and information) | X | |||||
| 3.8 | Defines time and frequency of care, including intensity, duration, and follow-up | X | X | X | |||
| 3.9 | Uses standardized terminology for describing interventions | X | X | X | |||
| 3.10 | Identifies resources and referrals needed | X | X | X | |||
| 3.10A | Establishes and maintains a directory of various resources based on client population intervention needs | X | X | X | |||
| 3.10B | Coordinates referral(s) for other services and uses interprofessional networks | X | X | ||||
| 3.10C | Researches, recommends, and coordinates, as appropriate, referral to appropriate or best available higher level of care (eg, treatment program/facility) | X | X | ||||
| Implements the Nutrition Intervention/Plan of Care: | |||||||
| 3.11 | Collaborates with colleagues, interprofessional team, and other health care professionals | X | X | X | |||
| 3.11A | Participates in communications within the interprofessional team | X | X | X | |||
| 3.11B | Collaborates for guidance or assistance or refers to other members of the interprofessional team when need is outside scope of practice or experience of RDN (eg, psychiatrist, social worker, occupational therapist, speech therapist, RDN with expertise in ED) | X | X | X | |||
| 3.11C | Facilitates and fosters active communication, learning, partnerships, and collaboration within the interprofessional team and other providers as appropriate | X | X | ||||
| 3.11D | Leads or directs the interprofessional team and others as appropriate | X | |||||
| 3.11E | Identifies and seeks out opportunities for interprofessional and interagency collaboration, specific to the client’s needs | X | |||||
| 3.12 | Communicates and coordinates the nutrition intervention/plan of care | X | X | X | |||
| 3.12A | Documents ongoing care and progress for short- and long-term interventions and communicates to team and others as appropriate | X | X | X | |||
| 3.12B | Ensures communication of nutrition plan of care with team members and others as appropriate; and transfer of nutrition-related data between care settings as needed | X | X | X | |||
| 3.12C | Initiates behavioral contract between client and team members to support nutrition-related treatment goals | X | X | ||||
| 3.12D | Coordinates care for the client with multiple diagnoses or repeat admissions with other members of the interprofessional team (eg, physician, psychiatrist, psychologist, social workers, behavioral therapist) | X | |||||
| 3.13 | Initiates the nutrition intervention/plan of care | X | X | X | |||
| 3.13A | Uses approved clinical privileges, physician/nonphysician practitioner c –driven orders (ie, delegated orders), protocols, or other facility-specific processes for order writing or for provision of nutrition-related services consistent with applicable specialized training, competence, medical staff, and/or organizational policyNon-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.6,7 The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.9,10 | X | X | X | |||
| 3.13A1 | Implements, initiates, or modifies orders for therapeutic diet/meal plan orders as authorized by institution/treatment facility, nutrition-related pharmacotherapy management, or nutrition-related services (eg, medical foods/nutrition/dietary supplements, food texture modifications, enteral and parenteral nutrition, intravenous fluid infusions, laboratory tests, medications, and education and counseling) | X | X | X | |||
| 3.13A1i | Provides education and counseling on the use of prescribed or recommended over-the-counter medications or dietary supplements for safety, to minimize interactions with prescribed medications and treatments | X | X | ||||
| 3.13A2 | Manages nutrition support therapies (eg, formula selection, rate adjustments, addition of designated medications and vitamin/mineral supplements to parenteral nutrition solutions or supplemental water for enteral nutrition) | X | X | X | |||
| 3.13A2i | Consistent with privileging or physician delegated orders, if applicable, or organization/program guidelines and regulations; manages or oversees care for clients receiving enteral or parenteral nutrition in collaboration with physician or interprofessional team; seeks assistance, if needed | X | X | X | |||
| 3.13A3 | Initiates and performs nutrition-related services (eg, bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, and indirect calorimetry measurements, or other permitted services) | X | X | X | |||
| 3.13B | Considers client learning style, culture, and method of communication when selecting or combining intervention approaches and adapting general nutrition education tools | X | X | X | |||
| 3.13C | Uses appropriate therapeutic and behavior change theories (eg, states of change, motivational interviewing, behavior modification, modeling) to prioritize health, safety, and appropriate level of care to support client success using a treatment team approach | X | X | X | |||
| 3.13D | Tailors nutrition intervention to developmental life stage of the client and makes changes to the intervention as appropriate (eg, during puberty, pregnancy, aging) | X | X | X | |||
| 3.13E | Uses tools for nutrition education that are appropriate to the client’s (and/or family’s) educational needs, learning style, culture, and method of communication; uses interpersonal teaching, training, coaching, counseling, or technological approaches as appropriate | X | X | X | |||
| 3.13F | Uses higher level of therapeutic modalities (eg, psychoeducation, advanced interviewing skills, cognitive behavior therapy, acceptance commitment therapy, modeling) to promote behavior change and empower the client to make necessary/required progress in an appropriate/reasonable time frame | X | X | ||||
| 3.13G | Anticipates, identifies, and effectively addresses client’s psychological barriers to making progress (eg, ambivalence, resistance, and defiance) | X | X | ||||
| 3.13Gi | Anticipates and recognizes psychological issues and works with the treatment team to make changes to the intervention as appropriate | X | |||||
| 3.13H | Anticipates risks related to the influence of ED behaviors on others, competition, self-disclosure, and establishes professional boundaries accordingly | X | X | ||||
| 3.13I | Uses synthesis skills for combining multiple intervention approaches as appropriate | X | |||||
| 3.13J | Draws on professional experiential knowledge and current body of scientific evidence about the client population to individualize the strategy for complex interventions | X | |||||
| 3.14 | Assigns activities to NDTR and other professional, technical, and support personnel in accordance with qualifications, organizational policies/protocols, and applicable laws and regulations | X | X | X | |||
| 3.14A | Supervises professional, technical, and support personnel | X | X | X | |||
| 3.14B | Provides professional, technical, and support personnel with information and guidance needed to complete assigned activities | X | X | X | |||
| 3.15 | Continues data collection | X | X | X | |||
| 3.15A | Collaborates with interprofessional team in the collection of pertinent data, including changes in food and fluid intakes, laboratory values, skin conditions, body weight, and advanced directives | X | X | X | |||
| 3.15B | Reassesses client nutrition intake and eating behaviors in relation to current physiological needs and requirements | X | X | X | |||
| 3.15C | Uses measurable, standardized indicators based on goals and outcomes and documents using prescribed/standardized format for recording data | X | X | X | |||
| 3.15D | Reassesses client’s nutritional intake, eating behaviors, and exercise dependence (eg, flexibility, anxiety level, recognition, and response to hunger and satiety cues) in relation to current and future physiological needs/requirements | X | X | ||||
| 3.15E | Leads and directs in collecting empirical evidence toward further understanding and promotion of recovery, including effectiveness and acceptance of treatment(s) | X | |||||
| 3.16 | Documents: | ||||||
| 3.16A | Date and time | X | X | X | |||
| 3.16B | Specific and measurable treatment goals and expected outcomes | X | X | X | |||
| 3.16C | Recommended interventions | X | X | X | |||
| 3.16D | Patient/client/advocate/caregiver/community receptiveness | X | X | X | |||
| 3.16E | Referrals made and resources used | X | X | X | |||
| 3.16F | Patient/client/advocate/caregiver/community comprehension | X | X | X | |||
| 3.16G | Barriers to change | X | X | X | |||
| 3.16G1 | Influencing factors or barriers affecting ability and/or willingness to implement and adhere to nutrition care plan (eg, living environment, psychosocial factors, emotional intelligence, cognitive impairment, change in mental or physical ability, financial status) | X | X | X | |||
| 3.16H | Other information relevant to providing care and monitoring progress over time | X | X | X | |||
| 3.16I | Plans for follow-up and frequency of care | X | X | X | |||
| 3.16J | Rationale for discharge or referral if applicable | X | X | X | |||
Examples of Outcomes for Standard 3: Nutrition 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, preferences, and intervention strategies to determine the progress made in achieving desired results of nutrition care and whether planned interventions should be continued or revised. Rationale: Nutrition monitoring and evaluation are essential components of an outcomes management system in order to assure quality, patient-/client-/population-centered care and to promote uniformity within the profession in evaluating the efficacy of nutrition interventions. Through monitoring and evaluation, the RDN identifies important measures of change or patient/client/population outcomes relevant to the nutrition diagnosis and nutrition intervention/plan of care; describes how best to measure these outcomes; and intervenes when intervention/plan of care requires revision. | |||||||
| Indicators for Standard 4: Nutrition Monitoring and Evaluation | |||||||
| Bold Font Indicators are Academy Core RDN Standards of Practice Indicators | The “X” signifies the indicators for the level of practice | ||||||
| Each RDN: | Competent | Proficient | Expert | ||||
| 4.1 | Monitors progress: | X | X | X | |||
| 4.1A | Assesses patient/client/advocate/population understanding and compliance with nutrition intervention/plan of care | X | X | X | |||
| 4.1A1 | Documents progress in meeting energy, fluid, and nutrient intake needs | X | X | X | |||
| 4.1A2 | Verifies client’s understanding of nutrition intervention by having the client/family/caregiver verbalize and/or demonstrate understanding | X | X | X | |||
| 4.1A3 | Assesses compliance considering stage of recovery and client’s goals and objectives | X | X | X | |||
| 4.1A4 | Determines whether barriers to understanding are present and impacting the client’s/family’s/caregiver’s compliance with the nutrition intervention/plan of care | X | X | ||||
| 4.1A5 | Reassesses client’s stage of behavior change and learning style to evaluate need to revise nutrition intervention | X | X | ||||
| 4.1B | Determines whether the nutrition intervention/plan of care is being implemented as prescribed | X | X | X | |||
| 4.1B1 | Assesses GI tolerance | X | X | X | |||
| 4.1B2 | Communicates and collaborates with members of the interprofessional team and/or others to verify progress and share observations and concerns | X | X | X | |||
| 4.1B3 | Evaluates intervention plan implementation in conjunction with team members, including family, if applicable, regarding client’s prescribed goals and objectives (eg, parents’ or support systems’ report whether food intake improves) | X | X | X | |||
| 4.1B4 | Evaluates intervention plan implementation considering special situations (eg, holidays, moving, relationship change) | X | X | X | |||
| 4.1B5 | Assesses progress in adjusting beliefs related to food to support recovery | X | X | X | |||
| 4.1B6 | Assesses progress in adjusting beliefs related to body image/body experience | X | X | ||||
| 4.1B7 | Assesses advancement in social and interpersonal skills through observation and interactions | X | X | ||||
| 4.1B8 | Facilitates interprofessional team communication of nutrition status, current barriers to treatment, and behavioral strategies that enhance compliance with meal plan | X | X | ||||
| 4.1B9 | Collaborates with the interprofessional team to tailor tools and methods based on emerging information/client response to ensure desired outcomes | X | X | ||||
| 4.1B10 | Uses advanced expertise to identify additional resources and/or avenues of therapy to enhance effectiveness of intervention | X | |||||
| 4.2 | Measures outcomes: | X | X | X | |||
| 4.2A | Selects the standardized nutrition care measurable outcome indicator(s) | X | X | X | |||
| Considers: | |||||||
| 4.2A1 | Anthropometric measures (eg, weight, body mass/BMI, body composition, rate of weight change, bone density) | X | X | X | |||
| 4.2A2 | Laboratory measures (eg, electrolytes, ferritin) | X | X | X | |||
| 4.2A3 | Behavioral measures (eg, activity level, cognitive functioning, food selection/choice, purging, food rituals) | X | X | X | |||
| 4.2A4 | Quality of life measures (eg, social eating, level of obsessiveness) | X | X | ||||
| 4.2A5 | Treatment outcomes (eg, possible barriers, mood and cognitive function changes, treatment delays, signs of relapse) and need for more advanced/involved treatment options | X | |||||
| 4.2B | Identifies positive or negative outcomes, including impact on potential needs for discharge/transitions of care | X | X | X | |||
| 4.2B1 | Collaborates with treatment team to assess impact of treatment history specifically related to frequency and effectiveness of prior admissions to higher level of care | X | X | X | |||
| 4.2B2 | Identifies unintended consequences (eg, continued weight loss, blood glucose variability), or the use of inappropriate methods of achieving goals (eg, medication or dietary supplement erratic use/noncompliance, self-imposed dietary restrictions, personal beliefs) | X | X | ||||
| 4.2B3 | Leads the development or revision of protocols for timely review and documentation of client’s clinical, metabolic, and nutrition status (including growth and development) | X | |||||
| 4.3 | Evaluates outcomes: | X | X | X | |||
| 4.3A | Compares monitoring data with nutrition prescription and established goals or reference standard | X | X | X | |||
| 4.3A1 | Monitors and analyzes clinical data relative to achieving client outcomes; seeks assistance as needed | X | X | X | |||
| 4.3A2 | Compares and analyzes the data for each problem area to nutrition prescription/goal using experience and clinical judgment skills, and incorporates additional consideration of progress with ED treatment plan, the client’s learning style, readiness, and willingness to change | X | X | ||||
| 4.3A3 | Analyzes data considering the complexity of problems and correlates one problem to another (eg, using expert clinical judgment skills reflecting on the holistic focus of ED as a complex disorder) | X | |||||
| 4.3A4 | Conducts comprehensive data analysis to identify trends in collaboration with interprofessional team | X | |||||
| 4.3B | Evaluates impact of the sum of all interventions on overall patient/client/population health outcomes and goals | X | X | X | |||
| 4.3B1 | Evaluates positive and negative outcomes in context of overall treatment plan, including impact on potential needs for discharge/transitions of care | X | X | X | |||
| 4.3C | Evaluates progress or reasons for lack of progress related to problems and interventions | X | X | X | |||
| 4.3C1 | Uses most appropriate measures for evaluation of goal attainment (eg, changes in food intake, anthropometrics, biochemical data) | X | X | X | |||
| 4.3C2 | Elicits feedback from client/advocate about success with behavior change (eg, food, physical activity, and health outcome goals) | X | X | X | |||
| 4.3C3 | Reviews progress with meeting nutrition goals with interprofessional team to determine if any revisions are indicated | X | X | X | |||
| 4.3C4 |
| X | X | ||||
| 4.3C5 | Identifies complex underlying problems beyond the scope of nutrition that are interfering with the intervention and suggests possible adjustments to interprofessional team members | X | |||||
| 4.3D | Evaluates evidence that the nutrition intervention/plan of care is maintaining or influencing a desirable change in the patient/client/population behavior or status | X | X | X | |||
| 4.3D1 | Uses direct observation, interviews, and/or other factors specific to the client (eg, social, cognitive, environmental) to evaluate progress; and, when there is lack of response, identifies contributors influencing response to nutrition interventions | X | X | X | |||
| 4.3D2 | Communicates with interprofessional team members regarding clinical findings related to client behavior or nutritional status | X | X | X | |||
| 4.3D3 | Monitors emotional, social, cognitive, environmental factors that may influence response to nutrition intervention | X | X | ||||
| 4.3D4 | Assesses motivators and incentives to change and/or consequences of change | X | X | ||||
| 4.3D5 | Evaluates the client’s variance from planned outcomes and incorporates findings into future individualized treatment recommendations | X | X | ||||
| 4.3D6 | Evaluates client outcomes in relationship to goals of program or facility | X | X | ||||
| 4.3E | Supports conclusions with evidence (Examples in 4.2A1 to 4.2A4) | X | X | X | |||
| 4.3E1 | Demonstrates that prescribed nutrition intervention is successful/unsuccessful through documentation of clinical, cognitive, and psychosocial indicators | X | X | X | |||
| 4.4 | Adjusts nutrition intervention/plan of care strategies, if needed, in collaboration with patient/client/population/advocate/caregiver and interprofessional team | X | X | X | |||
| 4.4A | Improves or adjusts intervention/plan of care strategies based upon outcomes data, trends, best practices, and comparative standards | X | X | X | |||
| 4.4A1 | Collaborates with interprofessional team for additional resources to modify nutrition prescription(s) for consistent achievement of therapeutic goals | X | X | X | |||
| 4.4A2 | Provides client-centered evidence-based education, while supporting the client to review and emotionally process the risks, benefits, and consequences of engagement in ED recovery | X | X | X | |||
| 4.4A3 | Develops and executes innovative strategies in collaboration with interprofessional team members to support ED recovery | X | X | ||||
| 4.4A4 | Consults with other expert RDNs to make adjustments in unpredictable and dynamic situations (eg, family dysfunction, past or current substance abuse, presence of a primary psychiatric diagnosis) | X | |||||
| 4.4B | Seeks professional supervision for adjusting behavioral intervention strategies in complex ED cases and engages necessary introspective evaluation of transference and countertransference (ie, therapeutic interference due to the projection of positive or negative thoughts, emotions, or behaviors) due to complexity of client population | X | X | X | |||
| 4.5 | Documents: | X | X | X | |||
| 4.5A | Date and time | X | X | X | |||
| 4.5B | Indicators measured, results, and the method for obtaining measurement | X | X | X | |||
| 4.5C | Criteria to which the indicator is compared (eg, nutrition prescription/goal or a reference standard) | X | X | X | |||
| 4.5D | Factors facilitating or hampering progress | X | X | X | |||
| 4.5E | Other positive or negative outcomes | X | X | X | |||
| 4.5E1 | Changes in client level of understanding and food-related behaviors | X | X | X | |||
| 4.5F | Changes in clinical or psychological status | X | X | X | |||
| 4.5G | Adjustments to the nutrition intervention/plan of care, if indicated; and communications with interprofessional team as needed | X | X | X | |||
| 4.5H | Future plans for nutrition care, nutrition monitoring and evaluation, follow-up, referral, transfer to another setting or level of care, or discharge | X | X | X | |||
Examples of Outcomes for Standard 4: Nutrition Monitoring and Evaluation
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a Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, psychiatrists, nurses, nurse practitioners, dietitian nutritionists, pharmacists, physician assistants, psychologists, licensed professional counselors, licensed marriage and family therapists, social workers, dentists, and occupational and physical therapists), depending on the needs of the client. Interprofessional could also mean interdisciplinary or multidisciplinary.
b Advocate: An advocate is a person who provides support and/or represents the rights and interests at the request of the patient/client. The person may be a family member or an individual not related to the patient/client who is asked to support the patient/client with activities of daily living or is legally designated to act on behalf of the patient/client, particularly when the patient/client has lost decision making capacity. (Adapted with permission The Joint Commission’s Glossary of Terms
13
and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation6
,Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual.
7
).Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
c Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.
6
,Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual.
7
The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements, or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
9
,US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final Rule (FR DOC#2016; pp 68688-68872) – Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178).
10
Figure 2Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Eating Disorders. Note: The term customer is used in this evaluation resource as a universal term. Customer could also mean client/patient/customer, family, resident, participant, consumer, or any individual, group, or organization to which the RDN provides service.
| Standards of Professional Performance for Registered Dietitian Nutritionists in Eating Disorders Standard 1: Quality in Practice The registered dietitian nutritionist (RDN) provides quality services using a systematic process with identified ethics, leadership, accountability, and dedicated resources. Rationale: Quality practice in nutrition and dietetics is built on a solid foundation of education and supervised practice, 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: | Competent | Proficient | Expert | ||||
| 1.1 | Complies with applicable laws and regulations as related to their area(s) of practice (eg, Health Insurance Portability and Accountability Act [HIPAA]) | X | X | X | |||
| 1.1A |
| X | X | X | |||
| 1.2 | Performs within individual and statutory scope of practice and applicable laws and regulations, including requirements of additional credentialing (eg, Certified Eating Disorders Registered Dietitian [CEDRD], Certified Specialist in Pediatrics [CSP]) | X | X | X | |||
| 1.2A | Adheres to the practice boundaries related to nutrition vs behavioral health counseling unless qualified through additional credentials and state-specific regulations | X | X | X | |||
| 1.3 | Adheres to sound business and ethical billing practices applicable to the role and setting (eg, payer billing codes, type of nutrition visit) | X | X | X | |||
| 1.4 | Uses national quality and safety data (eg, National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division, National Quality Forum (NQF), Institute for Healthcare Improvement) to improve the quality of services provided and to enhance customer-centered services | X | X | X | |||
| 1.4A | Uses nationally standardized and consensus-based behavioral health performance measures (eg, American Psychological Association [APA] Clinical Practice Guidelines) in design and evaluation of nutrition care and services | X | X | X | |||
| 1.4B | Contributes to or leads efforts to maximize eating disorders (ED) nutrition services using national quality and safety data | X | X | ||||
| 1.4C | Leads program’s interprofessional a team meetings and promotes use of national consensus-based standards and measures in performance monitoring processesInterprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, psychotherapists, certified counselor, clinical social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary. | X | |||||
| 1.5 | Uses a systematic performance improvement (PI) model that is based on practice knowledge, evidence, research, and science for delivery of the highest-quality services | X | X | X | |||
| 1.5A | Identifies and participates in using an appropriate organization-approved PI model(s)/process(es) | X | X | X | |||
| 1.5B | Leads or contributes to the design of PI activities, collaborating with other health care practitioners to address process and outcome goals for the ED program | X | X | ||||
| 1.5C | Trains and guides interprofessional PI activities across program | X | |||||
| 1.6 | Participates in or designs an outcomes-based management system to evaluate safety, effectiveness, quality, person-centeredness, equity, timeliness, and efficiency of practice | X | X | X | |||
| 1.6A | Involves colleagues and others, as applicable, in systematic outcomes management | X | X | X | |||
| 1.6A1 | Participates in outcomes management activities and advocates for existing or improved coordination of interprofessional ED care | X | X | X | |||
| 1.6A2 | Participates in and coordinates interprofessional efforts to evaluate and improve ED client population outcomes | X | X | ||||
| 1.6A3 | Leads interprofessional efforts to create and evaluate systems, processes, and programs that promote and support the program’s ED and nutrition-related objectives | X | |||||
| 1.6B | Defines expected outcomes | X | X | X | |||
| 1.6B1 | Identifies quality outcomes to measure (eg, standardized measures of mood states, level of psychological distress, biological markers, or program-specific measures) | X | X | ||||
| 1.6B2 | Determines desired nutrition-specific outcomes for the client population through direct evaluation, benchmarking (eg, national programs, standards, recognized practice guidelines), and evaluation of environmental trends | X | |||||
| 1.6C | Uses indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.) | X | X | X | |||
| 1.6D | Measures quality of services in terms of structure, process, and outcomes | X | X | X | |||
| 1.6D1 | Uses and/or develops systematic quality improvement approach to collect and organize data to measure quality of care and services against desired outcomes using data from multiple sources | X | X | X | |||
| 1.6D2 | Selects criteria for data collection, and advocates for and participates in developing data collection tools (eg, clinical, operational, and financial) | X | X | ||||
| 1.6D3 | Uses and/or adapts existing systems for evaluating nutrition and food/dining service specific to the population and setting | X | X | ||||
| 1.6D4 | Leads clinical or operational PI activities (eg, designs and implements evaluative protocols) and data analysis | X | |||||
| 1.6E | Incorporates electronic clinical quality measures to evaluate and improve care of patients/clients at risk for malnutrition or with malnutrition (www.eatrightpro.org/emeasures) | X | X | X | |||
| 1.6E1 | Ensures that screening for nutrition risk is a component of program admission process or nutrition assessment using evidence-based screening tools for the setting and/or population | X | X | X | |||
| 1.6E2 | Collects data using clinical quality measures applicable to population and setting (eg, screening time frames, severity of malnutrition, and services provided [eg, nutrition assessment, nutrition counseling]) | X | X | X | |||
| 1.6F | Documents outcomes and patient reported outcomes (eg, PROMIS) | X | X | X | |||
| 1.6F1 | Participates in collecting and evaluating outcomes data specific to client population needs and treatment goals | X | X | X | |||
| 1.6F2 | Evaluates client and service outcomes data against client population needs, treatment and program goals, and community impact | X | X | ||||
| 1.6F3 | Leads or collaborates in program/organization-approved efforts to reinforce current practices or implement changes in practice(s) and to share outcomes data with the ED community | X | |||||
| 1.6G | Participates in, coordinates, or leads program participation in local, regional or national registries and data warehouses used for tracking, benchmarking, and reporting service outcomes | X | X | X | |||
| 1.6G1 | Promotes the inclusion of RDN-provided medical nutrition therapy and ED nutrition services data in local, regional, state, and/or national data registries | X | X | X | |||
| 1.7 | Identifies and addresses potential and actual errors and hazards in provision of services or brings to attention of supervisors and team members as appropriate | X | X | X | |||
| 1.7A | Collaborates with medical provider and/or other members of ED team (eg, pharmacist) to:
| X | X | X | |||
| 1.7B | Anticipates the potential for errors (eg, medical errors, miscommunications, foodservice errors, signs of refeeding syndrome, gastrointestinal distress), addresses and/or alerts supervisors/administrators, as appropriate | X | X | ||||
| 1.7C | Develops safety alert systems to monitor key indicators of ED clients’ comorbid medical conditions | X | X | ||||
| 1.7D | Recognizes possible drug–nutrient interactions and potential interactions between prescribed treatments and integrative and functional medicine therapies | X | X | ||||
| 1.7E | Develops policies and procedures, and/or best practices to identify, address, and prevent errors and hazards in the delivery of nutrition care and services | X | |||||
| 1.8 | Compares actual performance to performance goals (ie, Gap Analysis, SWOT Analysis [Strengths, Weaknesses, Opportunities, and Threats], PDCA Cycle [Plan-Do-Check-Act], DMAIC [Define, Measure, Analyze, Improve, Control]) | X | X | X | |||
| 1.8A | Reports and documents action plan to address identified gaps in care and/or service performance | X | X | X | |||
| 1.8B | Compares program/service performance to established goals and outcomes; and to national programs and standards | X | X | ||||
| 1.8C | Monitors clinical measures (eg, weight range, menstrual health, testosterone levels, bone health) to program/organization goals | X | |||||
| 1.9 | Evaluates interventions and workflow process(es) and identifies service and delivery improvements | X | X | X | |||
| 1.9A | Uses evaluation data and/or collaborates with interprofessional team to identify program/service improvements | X | X | ||||
| 1.9B | Leads the development, testing, and redesign of program/service evaluation systems | X | |||||
| 1.10 | Improves or enhances patient/client/population care and/or services working with others based on measured outcomes and established goals | X | X | X | |||
Examples of Outcomes for Standard 1: Quality in Practice
| |||||||
| Standard 2: Competence and Accountability The registered dietitian nutritionist (RDN) demonstrates competence in and accepts accountability and responsibility for ensuring safe, quality practice and services. Rationale: Competence and accountability in practice includes continuous acquisition of knowledge, skills, experience, and judgment in the provision of safe, quality customer-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: | Competent | Proficient | Expert | ||||
| 2.1 | Adheres to the code(s) of ethics (eg, Academy/Commission on Dietetic Registration [CDR], APA, other national organizations, and/or employer code of ethics) | X | X | X | |||
| 2.2 | Integrates the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) into practice, self-evaluation, and professional development | X | X | X | |||
| 2.2A | Integrates applicable focus area(s) SOP and/or SOPP into practice (www.eatrightpro.org/sop) (eg, Mental Health and Addictions) | X | X | X | |||
| 2.2B | Uses the SOP and SOPP for RDNs in ED to assess performance at the appropriate level of practice; develops and implements a professional development plan to improve quality of practice and performance; and advance practice | X | X | X | |||
| 2.2C | Develops program policies, guidelines, human resource materials (eg, job descriptions, career ladders, care and service activities for each performance level) using the SOP and SOPP for RDNs in ED | X | X | ||||
| 2.2D | Defines roles, actions, and guidelines for each level of practice based on advanced practice knowledge and experience; and consistent with the SOP and SOPP for RDNs in ED | X | |||||
| 2.3 | Demonstrates and documents competence in practice and delivery of customer-centered service(s) | X | X | X | |||
| 2.3A | Documents examples of expanded professional responsibility (eg, quality assurance and PI, leadership responsibilities, corporate-/system-level role(s), state and/or national advisory board participation) | X | X | ||||
| 2.4 | Assumes accountability and responsibility for actions and behaviors | X | X | X | |||
| 2.4A | Identifies, acknowledges, and corrects errors | X | X | X | |||
| 2.4B | Displays professionalism and integrity in ED nutrition and strives for improvement in practice (eg, manages change effectively; demonstrates assertiveness and conflict resolution skills; demonstrates ability to network and build coalitions); seeks assistance if needed | X | X | X | |||
| 2.4C | Demonstrates responsible behavior regarding scope of practice, supervision, referrals, collaboration, and self-disclosure | X | X | X | |||
| 2.4D | Develops and implements policies and procedures that ensure staff accountability and responsibility | X | X | ||||
| 2.5 | Conducts self-evaluation at regular intervals | X | X | X | |||
| 2.5A | Identifies needs for professional development | X | X | X | |||
| 2.5A1 | Evaluates current level of practice to identify areas for professional development:
| X | X | X | |||
| 2.5A2 | Seeks to learn and use advanced psychoeducational knowledge and skills in areas such as:
| X | X | X | |||
| 2.6 | Designs and implements plans for professional development | X | X | X | |||
| 2.6A | Develops plans and documents professional development activities in career portfolio (eg, organizational policies and procedures, credentialing agency[ies]) to maintain and advance practice | X | X | X | |||
| 2.6A1 | Includes professional goals around key dimensions of ED, PI, research, service, and leadership | X | X | X | |||
| 2.6A2 | Includes a plan for achieving the knowledge, skills, and experience needed to qualify for or maintain certification(s) (eg, CEDRD) to support role(s) and responsibilities | X | X | ||||
| 2.7 | Engages in evidence-based practice and uses best practices | X | X | X | |||
| 2.7A | Interprets current research, trends, and best practices in the prevention and treatment of ED, co-occurring mental health and/or substance use disorders | X | X | ||||
| 2.7B | Contributes as a reviewer of original research and/or evidence-based guidelines relevant to ED nutrition practice | X | |||||
| 2.8 | Participates in peer review of others as applicable to role and responsibilities | X | X | X | |||
| 2.8A | Engages in peer-review activities consistent with setting, responsibilities, and client population (eg, peer evaluation, peer supervision, clinical chart review, performance evaluations); seeks assistance if needed | X | X | X | |||
| 2.8B | Participates in scholarly review (eg, educational materials, professional articles, and resource materials) | X | X | X | |||
| 2.8C | Demonstrates knowledge and skills to train, mentor, and guide credentialed nutrition and dietetics practitioners and other support staff | X | X | ||||
| 2.8D | Leads/serves on editorial board for review of professional articles, chapters, and books | X | |||||
| 2.9 | Mentors and/or precepts others | X | X | X | |||
| 2.9A | Participates in mentoring and/or precepting students/interns, entry-level RDNs in ED and credentialed nutrition and dietetics practitioners; seeks to be inclusive of marginalized or diverse individuals | X | X | X | |||
| 2.9B | Obtains knowledge and experience to mentor RDNs interested in gaining further ED treatment experience and to recognize when to obtain the expertise of other disciplines | X | X | ||||
| 2.9C | Provides leadership, mentoring, and professional guidance to RDNs and other health care professionals (eg, behavioral care team, family therapists, performance advisor, ie, coach, trainer) for the continued advancement of ED recognition and treatment | X | |||||
| 2.9D | Provides case consultation and/or formal supervision to other RDNs in the treatment of ED | X | |||||
| 2.10 | Pursues opportunities (education, training, credentials, certifications) to advance practice in accordance with laws and regulations, and requirements of practice setting | X | X | X | |||
| 2.10A | Actively participates in case consultation and/or professional supervision related to the treatment of ED to learn from interactive and collegial sharing/guidance | X | X | X | |||
| 2.10B | Develops programs, tools, and resources in support of assisting RDNs to obtain specialty certification in ED (eg, CEDRD) | X | X | ||||
| 2.10C | Leads effort to develop, establish, or advance education, training, and credentialing opportunities for ED specialization for RDNs | X | |||||
| 2.10D | Seeks advanced fellowships, training, and certifications to support application for the International Association of Eating Disorders Professionals (iaedp)–approved CEDRD supervisor designation (CEDRD-S) or to support applications for other advanced certifications (eg, Academy for Eating Disorders [AED] Fellow) | X | |||||
Examples of Outcomes for Standard 2: Competence and Accountability
| |||||||
| Standard 3: Provision of Services The registered dietitian nutritionist (RDN) provides safe, quality service based on customer expectations and needs and the mission, vision, principles, and values of the organization/business. Rationale: Quality programs and services are designed, executed, and promoted based on the RDN’s knowledge, skills, experience, judgment, and competence in addressing the needs and expectations of the organization/business and its customers. | |||||||
| 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: | Competent | Proficient | Expert | ||||
| 3.1 | Contributes to or leads in development and maintenance of programs/services that address needs of the customer or target population(s) | X | X | X | |||
| 3.1A | Aligns program/service development with the mission, vison, principles, values, and service expectations and outputs of the organization/business | X | X | X | |||
| 3.1A1 | Participates in strategic planning for internal and external resources for ED nutrition programs (ie, staff, budget) | X | X | ||||
| 3.1A2 | Develops and manages nutrition services tailored to the mission and needs of the ED program and client population | X | X | ||||
| 3.1A3 | Leads efforts to identify and provide program/facility-specific outcomes data to support current and new ED nutrition-related services | X | |||||
| 3.1B | Uses the needs, expectations, and desired outcomes of the customers/populations (eg, patients/clients, families, community, decision makers, administrators, client organization[s]) in program/service development | X | X | X | |||
| 3.1B1 | Routinely assesses needs, expectations, and desired outcomes of clients, families, organization leaders, and community stakeholders; seeking assistance as needed | X | X | X | |||
| 3.1B2 | Develops and participates in community education programs that promote safe and effective nutrition services for ED treatment | X | X | ||||
| 3.1B3 | Advocates for and leads the development of resources and nutrition services to meet under-served population needs at the systems level | X | |||||
| 3.1C | Makes decisions and recommendations that reflect stewardship of time, talent, finances, and environment | X | X | X | |||
| 3.1C1 | Shapes and adapts program and service delivery to align with budget (eg, staffing reflective of the time intensive nature of ED population) | X | X | ||||
| 3.1D | Proposes programs and services that are customer-centered, culturally appropriate, and minimize disparities | X | X | X | |||
| 3.1D1 | Adapts practice(s) to minimize or eliminate health disparities associated with culture, race, gender, socioeconomic status, age, and other factors | X | X | X | |||
| 3.2 | Promotes public access and referral to credentialed nutrition and dietetics practitioners for quality food and nutrition programs and services | X | X | X | |||
| 3.2A | Contributes to or designs referral systems that promote access to qualified, credentialed nutrition and dietetics practitioners | X | X | X | |||
| 3.2A1 | Participates in or designs the referral process between practitioners based on client population needs (eg, social worker, psychologist, psychiatrist, pharmacist, physician, or case manager) | X | X | ||||
| 3.2A2 | Designs and manages referral systems | X | |||||
| 3.2B | Refers customers to appropriate providers when requested services or identified needs exceed the RDN’s individual scope of practice (eg, physician, therapist, social worker, psychiatrist, or occupational/speech-language pathologist) | X | X | X | |||
| 3.2B1 | Builds relationships with other health care practitioners to facilitate collaborative referrals within the interprofessional team | X | X | X | |||
| 3.2B2 | Verifies potential referral practitioner’s care reflects evidence-based information and professional standards of practice | X | X | X | |||
| 3.2B3 | Establishes and maintains networks to support the continual recovery of clients transitioning to home or another care setting | X | X | ||||
| 3.2B4 | Supports referral resources with curriculum and training regarding complex nutrition needs of clients with an ED | X | |||||
| 3.2C | Monitors effectiveness of referral systems and modifies as needed to achieve desirable outcomes | X | X | X | |||
| 3.2C1 | Tracks data to evaluate efficiency and effectiveness of the nutrition referral processes | X | X | X | |||
| 3.2C2 | Manages and/or leads data review and revision of the nutrition referral process and collaborative tools within the interprofessional team | X | X | ||||
| 3.3 | Contributes to or designs customer-centered services | X | X | X | |||
| 3.3A | Assesses needs, beliefs/values, goals, resources of the customer, and social determinants of health | X | X | X | |||
| 3.3A1 | Recognizes the influences that culture, health literacy, and socioeconomic status have on clients’ health/illness experiences and access to health care services | X | X | X | |||
| 3.3A2 | Applies goal-setting and behavior-change strategies and techniques (eg, stages of change, transtheoretical model [TTM], or MI) to design client-centered services | X | X | X | |||
| 3.3B | Uses knowledge of the customer’s/target population’s health conditions, cultural beliefs, and business objectives/services to guide design and delivery of customer-centered services | X | X | X | |||
| 3.3B1 | Adapts practice to meet the needs of an ethnically and culturally diverse population | X | X | X | |||
| 3.3B2 | Connects clients/families with established resources and services within the specific ethnic/cultural community | X | X | X | |||
| 3.3B3 | Secures additional resources to enhance health-related decision-making within the clients’ immediate support network | X | X | ||||
| 3.3C | Communicates principles of disease prevention and behavioral change appropriate to the customer or target population | X | X | X | |||
| 3.3C1 | Advises on and uses systems or tools to communicate disease prevention and behavioral change approaches for individuals with an ED within specific populations considering age and needs | X | X | ||||
| 3.3C2 | Develops and implements treatment guidelines to address clients with complex needs for other nutrition and health care practitioners | X | |||||
| 3.3D | Collaborates with the customers to set priorities, establish goals, and create customer-centered action plans to achieve desirable outcomes | X | X | X | |||
| 3.3D1 | Collaborates with clients/caregivers, health care practitioners, and other support resources to create person-centered action plans that reflect clients’ needs, desired outcomes, and program/service objectives | X | X | X | |||
| 3.3D2 | Adapts practice to address barriers to change and/or barriers to the use of health care services to meet clients’ need | X | X | ||||
| 3.3D3 | Participates in or initiates development of tools to guide shared decision making and goal setting to maximize outcomes for clients and/or their support networks | X | X | ||||
| 3.3D4 | Demonstrates willingness and ability to initiate and/or sustain effective long-term communication with interprofessional team and clients’ support team (eg, family, friends, performance advisor) | X | X | ||||
| 3.3D5 | Leads in the research and development of prevention and treatment protocols to address multiple levels (eg, intensity of treatment, approach when using telehealth, during a disaster) of care | X | |||||
| 3.3E | Involves customers in decision making | X | X | X | |||
| 3.3E1 | Follows and participates in organization/program discussions with interprofessional team to ensure person-centered care and services | X | X | X | |||
| 3.3E2 | Reviews information shared by client/family/caregiver with interprofessional team for planning and problem solving to support consistency in treatment plans to assure person-centered care | X | X | ||||
| 3.4 | Executes programs/services in an organized, collaborative, cost-effective, and customer-centered manner | X | X | X | |||
| 3.4A | Collaborates and coordinates with peers, colleagues, stakeholders, and within interprofessional teams for safe quality care | X | X | X | |||
| 3.4A1 | Interacts with interprofessional team to:
| X | X | X | |||
| 3.4A2 | Facilitates and fosters active communication, learning partnerships, and collaboration within an interprofessional ED team and with other practitioners as needed | X | X | ||||
| 3.4A3 | Contributes to improving collaboration between clients and health care practitioners | X | X | ||||
| 3.4B | Uses and participates in, or leads in the selection, design, execution, and evaluation of customer programs and services (eg, nutrition screening system, medical and retail foodservice, electronic health records, interprofessional programs, community education, grant management) | X | X | X | |||
| 3.4B1 | Evaluates evidence-based practices for application to services provided (eg, meal, snack and supplement guidelines, sustainability practices, use of social media for consumer outreach) | X | X | X | |||
| 3.4B2 | Identifies and uses population- and setting-specific nutrition and ED screening tools based on level of care | X | X | ||||
| 3.4B3 | Establishes nutrition screening guidelines, indicators, and care recommendations for individuals with ED | X | |||||
| 3.4B4 | Directs and serves as primary consultant regarding the planning, development, and implementation of comprehensive nutrition services program within an interprofessional system of care | X | |||||
| 3.4C | Uses and develops or contributes to selection, design and maintenance of policies, procedures (eg, discharge planning, transitions of care, emergency planning), protocols, standards of care, technology resources (eg, HIPAA-compliant telehealth platforms), and training materials that reflect evidence-based practice in accordance with applicable laws and regulations | X | X | X | |||
| 3.4C1 | Uses and collaborates with interprofessional team to develop and maintain program and nutrition policies, procedures, practice tools, and services to meet needs of client population (eg, nutrition and other screenings, treatment team meetings, educational needs, and family observations) | X | X | X | |||
| 3.4C2 | Develops and/or maintains ED nutrition programs, policies, and protocols based on research, evidence-based guidelines, best practices, trends, and national and international guidelines for practice setting, such as:
| X | X | ||||
| 3.4C3 | Leads department and interprofessional process of developing, monitoring, evaluating, and improving the protocols, guidelines, and practice tools/process as needed | X | |||||
| 3.4C4 | Negotiates and/or updates policies and procedures at a systems level for new advances in treatment of ED | X | |||||
| 3.4D | Uses and participates in or develops processes for order writing and other nutrition-related privileges, in collaboration with the medical staff or medical director (eg, post-acute care settings, public health, community, free-standing clinic settings), consistent with state practice acts, federal and state regulations, organization policies, and medical staff rules, regulations, and bylaws | X | X | X | |||
| 3.4D1 | Uses and participates in or leads development of processes for privileges or other facility-specific processes related to (but not limited to) implementing physician/nonphysician practitioner d –driven delegated orders or protocols, initiating or modifying medical foods/nutrition supplements, dietary supplements, enteral and parenteral nutrition, laboratory tests, medications, and adjustments to fluid therapies or electrolyte replacementsNon-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.6,7 The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.9,10 | X | X | X | |||
| 3.4D1i | Adheres to setting-specific approved medical provider protocols/delegated orders for including in scope of work: ordering or revising meal plan (preferred terminology in ED settings rather than diet orders), medical food and dietary supplements | X | X | X | |||
| 3.4D1ii | Contributes to organization or program medical staff/medical director process for identifying RDN privileges to support ED care and services (eg, meal plan orders, medical food and dietary supplements) | X | X | ||||
| 3.4D1iii | Obtains privileges or develops medical director-approved protocol for ordering and monitoring laboratory and diagnostic testing as part of ED treatment plan | X | |||||
| 3.4D2 | Uses and participates in or leads development of processes for privileging for provision of nutrition-related services, including (but not limited to) inserting and/or monitoring nasoenteric feeding tubes, providing home enteral nutrition or infusion management services (eg, ordering formula and supplies), and indirect calorimetry measurements | X | X | X | |||
| 3.4D2i | Establishes collaborative practice with other health care practitioners at organization or systems level (eg, participate in treatment team meetings, and/or a disease management program, case management) | X | X | ||||
| 3.4E | Complies with established billing regulations, organization policies, grant funder guidelines, if applicable to role and setting, and adheres to ethical and transparent financial management and billing practices | X | X | X | |||
| 3.4F | Communicates with the interprofessional team and referring party consistent with the HIPAA rules for use, disclosure, and storage of customer’s personal health information | X | X | X | |||
| 3.5 | Uses professional, technical, and support personnel appropriately in the delivery of customer-centered care or services in accordance with laws, regulations, and organization policies and procedures | X | X | X | |||
| 3.5A | Assigns activities, including direct care to patients/clients, consistent with the qualifications, experience, and competence of professional, technical, and support personnel | X | X | X | |||
| 3.5A1 | Identifies capabilities/expertise of support staff to delegate client population tasks as needed | X | X | ||||
| 3.5B | Supervises professional, technical, and support personnel | X | X | X | |||
| 3.5B1 | Trains professional, technical, and support personnel and evaluates their competence/skills | X | X | ||||
| 3.6 | Designs and implements food delivery systems to meet the needs of customers | X | X | X | |||
| 3.6A | Collaborates in or leads the design of food delivery systems to address health care needs and outcomes (including nutrition status), ecological sustainability, and to meet the culture and related needs and preferences of target populations (ie, health care patients/clients, employee groups, schools, child and adult daycare centers) | X | X | X | |||
| 3.6A1 | Participates in foodservice planning and delivery for health care and community settings that provide ED services | X | X | X | |||
| 3.6A2 | Develops ED nutrition-related guidelines for foodservice system planning and delivery | X | X | ||||
| 3.6A3 | Serves as consultant to organization/program leadership in determining foodservices to be provided | X | |||||
| 3.6A4 | Develops nutrition and ED-related guidelines reflecting global standards (eg, AED, iaedp, Eating Disorders Coalition, and International Federation of Eating Disorder Dietitians), and applicable federal or state regulations (eg, menu-related regulations, food safety standards, and food assistance programs) to guide food delivery system according to the population served | X | |||||
| 3.6B | Participates in, consults/collaborates with, or leads the development of menus to address health, nutritional, and cultural needs of target population(s) consistent with federal, state, or funding source regulations or guidelines | X | X | X | |||
| 3.6B1 | Reviews or participates in the development of master menus and snack options with modifications to address health and nutrition needs of ED population across the lifespans; refers to Adult and Pediatric Nutrition Care Manuals for guidance | X | X | X | |||
| 3.6B2 | Designs or provides consultation on menus and snack options that reflect and encourage normalized eating (ie, attention to satiety and hunger, somatic and hedonic preferences, biological and psychological autoimmune responses to food, as well as food rituals and behaviors) | X | X | ||||
| 3.6C | Participates in, consults/collaborates with, or leads interprofessional process for determining medical foods/nutritional supplements, dietary supplements, enteral and parenteral nutrition formularies, and delivery systems for target population(s) | X | X | X | |||
| 3.6C1 | Provides guidance regarding products and formulas in accordance with best practices (eg, American Society for Parenteral and Enteral Nutrition guidelines) | X | X | X | |||
| 3.6C2 | Provides expertise in addressing drug-dietary supplement-food interactions with medications. | X | X | ||||
| 3.6C3 | Designs or consults on organization/program protocols for nutrition support best practices for individuals with ED | X | |||||
| 3.7 | Maintains records of services provided | X | X | X | |||
| 3.7A | Documents according to organization policies, procedures, standards, and systems, including electronic health records | X | X | X | |||
| 3.7A1 | Maintains documentation as mandated by regulatory agencies, accrediting/credentialing bodies, local, state, and federal regulations and/or laws, and consistent with the Nutrition Care Process (see: electronic Nutrition Care Process Terminology related to the Behavioral Domain; https://www.ncpro.org/pubs/encpt-en/page-044), where appropriate | X | X | X | |||
| 3.7A2 | Uses and participates in the development and/or revision of electronic health records as appropriate | X | X | X | |||
| 3.7B | Implements data management systems to support interoperable data collection, maintenance, and utilization | X | X | X | |||
| 3.7C | Uses data to document outcomes of services (ie, staff productivity, cost/benefit, budget compliance, recovery outcomes, remission rates, quality of services) and provide justification to maintain or expand services (eg, staffing) | X | X | X | |||
| 3.7C1 | Advocates for and participates in developing clinical, operational, and financial databases to support data collection, analysis, and use of data to communicate value of nutrition services to client population and program outcomes/goals | X | X | ||||
| 3.7C2 | Uses data to pursue expanded services (eg, community outreach programs, research program), and to obtain the necessary resources (eg, additional support and specialized clinical staff, research associates, and public policy/clinical translation experts) | X | |||||
| 3.7D | Uses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulations | X | X | X | |||
| 3.7D1 | Communicates clinical and quality improvement outcomes to interprofessional stakeholders to support improvement of clinical care and services | X | X | ||||
| 3.7D2 | Prepares and presents analysis of nutrition care services and outcomes data for organization and accrediting bodies | X | X | ||||
| 3.8 | Advocates for provision of quality food and nutrition services as part of public policy | X | X | X | |||
| 3.8A | Communicates with policy-makers regarding the benefit/cost of quality food and nutrition services | X | X | X | |||
| 3.8A1 | Networks and participates in development of policies/regulations related to ED food and nutrition services at the local and/or state level | X | X | X | |||
| 3.8A2 |
| X | X | ||||
| 3.8A3 | Provides leadership regarding advocacy activities/issues (eg, authors peer-reviewed articles, serves on state/national/international boards) | X | |||||
| 3.8A4 | Serves as an expert to legislative and policy-makers, and payers on nutrition-related issues; proposes policies and supports legislative efforts to benefit the population with ED | X | |||||
| 3.8B | Advocates in support of food and nutrition programs and services for populations with special needs and chronic conditions | X | X | X | |||
| 3.8B1 | Initiates and coordinates advocacy activities/issues (eg, authors article[s], delivers presentation on topics, networks) | X | X | ||||
| 3.8C | Advocates for protection of the public through multiple avenues of engagement (eg, legislative action, establishing effective relationships with elected leaders and regulatory officials, participation in various Academy committees, workgroups and task forces, Dietetic Practice Groups, Member Interest Groups, and State Affiliates) | X | X | X | |||
| 3.8C1 | Participates in advocacy activities (eg, responds to Academy Action Alerts, other calls to action via Action Center, letters, e-mails, and/or phone calls) | X | X | X | |||
Examples of Outcomes for Standard 3: Provision of Services
| |||||||
| Standard 4: Application of Research The registered dietitian nutritionist (RDN) applies, participates in, and/or generates research to enhance practice. Evidence-based practice incorporates the best available research/evidence and information 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: | Competent | Proficient | Expert | ||||
| 4.1 | Reviews best available research/evidence and information for application to practice | X | X | X | |||
| 4.1A | Understands basic research design and methodology and application of research findings | X | X | X | |||
| 4.1B | Maintains awareness of peer-reviewed publications, evidence-based guidelines, clinical consensus standards (eg, APA), and practice guidelines in the fields of nutrition and ED | X | X | X | |||
| 4.1C | Demonstrates the experience and critical thinking skills required to evaluate strength of original research, including limitations and potential bias, and evidence-based guidelines relevant to ED | X | X | ||||
| 4.1D | Applies evidence-based tools/resources (eg, Academy Evidence Analysis Library [EAL], practice guidelines) to stimulate awareness and integration of current evidence into clinical practice | X | X | ||||
| 4.1E | Functions as a primary or senior author of research, academic, and/or organization position and scholarly practice papers | X | |||||
| 4.2 | Uses best available research/evidence and information as the foundation for evidence-based practice | X | X | X | |||
| 4.2A | Demonstrates use and adherence to evidence-based practice guidelines and clinical consensus standards to:
| X | X | X | |||
| 4.2B | Evaluates and recognizes the gap in available scientific literature where evidence-based guidelines for ED are not yet established | X | X | ||||
| 4.2C | Critically evaluates and applies available scientific literature in situations where evidence-based guidelines for ED are not yet established (eg, multisystem disease processes) | X | |||||
| 4.3 | Integrates best available research/evidence and information with best practices, clinical and managerial expertise, and customer values | X | X | X | |||
| 4.3A | Identifies and uses evidence-based guidelines, clinical consensus standards, and cultural contributors (ie, goals, family heritage, spiritual orientation or practices, and/or geographical influences) to incorporate client values in the development of treatment plans | X | X | X | |||
| 4.3B | Develops familiarity with and accesses commonly used sources of evidence in identifying applicable courses of action for client care and services (eg, NQF; ED, mental health and other resources; Substance Abuse Mental Health Services Administration [SAMHSA]) | X | X | X | |||
| 4.3C | Manages integration of evidence-based guidelines into policies, procedures, and protocols for ED care processes and education | X | X | ||||
| 4.3D | Integrates ED guidelines, policies, and procedures with information from consultation with national and international stakeholders for development and oversight of treatment approach | X | |||||
| 4.4 | Contributes to the development of new knowledge and research in nutrition and dietetics | X | X | X | |||
| 4.4A | Participates in efforts to extend research to practice (eg, journal clubs, collection of client baseline/outcomes data, listserv participation, group supervision) | X | X | X | |||
| 4.4B | Participates in practice-based research networks (ie, Academy’s Nutrition Research Network or EAL workgroup) and the development and/or implementation of practice-based research, national research databases, and adheres to Institutional Review Board protocols and confidentiality guidelines | X | X | ||||
| 4.4C | Contributes to the body of knowledge for the profession (eg, presentations, publications, research) | X | X | ||||
| 4.4D | Identifies and initiates research relevant to ED practice; acts as principal or co-investigator as part of collaborative research or with health care teams examining nutrition and ED care | X | |||||
| 4.4E | Mentors others in developing skills to critically assess and analyze research for application to practice | X | |||||
| 4.4F | Serves as advisor, preceptor, and/or committee member for graduate and doctoral level research | X | |||||
| 4.4G | Develops research grant proposals and professional conference request for proposals to support continuing education of scientific community about ED | X | |||||
| 4.5 | Promotes application of research in practice through alliances or collaboration with food and nutrition and other professionals and organizations | X | X | X | |||
| 4.5A | Identifies research issues/questions and participates in studies related to ED nutrition care and services | X | X | X | |||
| 4.5B | Collaborates with interprofessional and/or interorganizational teams to perform and disseminate nutrition research on ED | X | X | X | |||
| 4.5C | Advocates to stakeholder organizations, groups, and/or agencies to prioritize and fund ED research projects | X | X | ||||
| 4.5D | Leads interprofessional and/or multi-organizational collaborative research activities | X | |||||
Examples of Outcomes for Standard 4: Application of Research
| |||||||
| Standard 5: Communication and Application of Knowledge The registered dietitian nutritionist (RDN) effectively applies knowledge and expertise in communications. Rationale: The RDN works with others to achieve common goals by effectively sharing and applying 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: | Competent | Proficient | Expert | ||||
| 5.1 | Communicates and applies current knowledge and information based on evidence | X | X | X | |||
| 5.1A | Demonstrates critical thinking and problem-solving skills (ie, educational sensitivity of audience, dynamic adjustment to audience’s needs, and language reflective of technical understanding of intended audience) when communicating with others | X | X | X | |||
| 5.1A1 | Integrates learned clinical wisdom along with scientific evidence to provide effective educational environments (eg, online, academic, community, treatment team collaborations) for clients, colleagues, health care practitioners, and other interested parties | X | X | ||||
| 5.1A2 | Demonstrates the ability to convey comprehension of foundational and dynamic ED concepts (eg, Minnesota Starvation Experiment, “set point theory,” gut–brain axis, biopsychosocial triggers, and nutritional epigenetics) to other health care practitioners, clients, and the public | X | X | ||||
| 5.1B | Interprets regulatory, accreditation, and reimbursement programs and standards for programs/settings and providers that are specific to ED care and education (eg, CMS, state regulations, Joint Commission, or applicable accrediting organization); seeks assistance if needed | X | X | X | |||
| 5.1C | Evaluates public health trends and epidemiological reports related to ED prevalence, prevention, and treatment, and applies data in clinical practice, professional activities, and work settings | X | X | ||||
| 5.1D | Consults on complex ED service issues with other health care practitioners, organizations, and the community | X | |||||
| 5.2 | Selects appropriate information and the most effective communication method or format that considers customer-centered care and the needs of the individual/group/population | X | X | X | |||
| 5.2A | Uses communication methods (ie, oral, print, one-on-one, group, visual, electronic, and social media) targeted to various audiences | X | X | X | |||
| 5.2B | Uses information technology to communicate, disseminate, manage knowledge, and support decision making | X | X | X | |||
| 5.2B1 | Recognizes advantages and disadvantages of technology related to privacy, confidentiality, effectiveness, and safety for clients | X | X | X | |||
| 5.2B2 | Creates nutrition education materials and intervention strategies through technology | X | X | ||||
| 5.2B3 | Leads the development of client- and system-specific technology that effectively conveys nutrition information on ED-related issues to diverse audiences | X | |||||
| 5.2C | Investigates and uses a wide array of technology platforms to establish a stronger voice of scientific expertise (eg, blogs, podcasts, and social media) | X | X | X | |||
| 5.3 | Integrates knowledge of food and nutrition with knowledge of health, culture, social sciences, communication, informatics, sustainability, and management | X | X | X | |||
| 5.3A | Applies current and emerging scientific knowledge of ED when considering population’s health status, behavior barriers, communication skills, and interprofessional team involvement; seeks assistance if needed | X | X | X | |||
| 5.3B | Participates in and/or leads the integration of evidence-based knowledge, knowledge from professional supervision, and experience in ED nutrition in management of complex problems | X | X | ||||
| 5.4 | Shares current, evidence-based knowledge, and information with various audiences | X | X | X | |||
| 5.4A | Guides customers, families, students, and interns in the application of knowledge and skills | X | X | X | |||
| 5.4A1 | Contributes to the education and professional development of RDNs, Nutrition and Dietetics Technicians, Registered, students/interns, performance advisors, and health care practitioners in all disciplines related to ED through formal and informal teaching and mentoring; seeks assistance if needed | X | X | X | |||
| 5.4A2 | Participates and leads target populations through experiential food and culinary activities (eg, personalized menu creation, food safety principles, budgeting, individual and group food exposures, farmers market and grocery store tours, customer service principles, and somatic awareness during eating experiences) | X | X | X | |||
| 5.4A3 | Develops educational programs or experiential opportunities using evidence-based science and clinical consensus in the treatment of ED | X | X | ||||
| 5.4A4 | Develops and provides educational opportunities for health care practitioners in ED on current and emerging ED nutrition treatment modalities and challenges | X | |||||
| 5.4A5 | Designs training curriculum (eg, experientials, didactic simulation, case studies, and peer-to-peer evaluation) to advance skills in the treatment of ED | X | |||||
| 5.4B | Assists individuals and groups to identify and secure appropriate and available educational and other resources and services (eg educational, financial, and technological) | X | X | X | |||
| 5.4B1 | Identifies and recommends current, evidence-based ED educational resources to specific client populations to positively influence care | X | X | X | |||
| 5.4B2 | Develops/manages systematic process to identify, track, and update resources available to clients, their support team, and health care practitioners | X | X | ||||
| 5.4C | Uses professional writing and verbal skills in all types of communications | X | X | X | |||
| 5.4C1 | Demonstrates professional writing and oral communication skills with the ability to translate complex scientific and policy information to the public | X | X | X | |||
| 5.4C2 | Develops sensitivity to methods of communication that encourage and support recovery (eg, client-centered words/pronouns, tone, and body language) | X | X | X | |||
| 5.4C3 | Practices sensitive word selection, tone, and body language for the purpose of confronting and correcting inappropriate behaviors and language that impair recovery | X | X | ||||
| 5.4C4 | Develops, trains, and implements organizational protocols to ensure sensitive word selection, tone and body language are practiced; participates in corrective action as needed | X | |||||
| 5.4D | Reflects knowledge of population characteristics in communication methods (eg, literacy and numeracy levels, need for translation of written materials and/or a translator, communication skills, and learning, hearing or vision disabilities) | X | X | X | |||
| 5.4D1 | Considers culture, literacy, and communication styles in dialogue, written communications, and educational activities for all audiences (eg, clients, program staff/leaders, community stakeholders); seeks assistance if needed | X | X | X | |||
| 5.5 | Establishes credibility and contributes as a food and nutrition resource within the interprofessional health care and management team, organization, and community | X | X | X | |||
| 5.5A | Promotes the use of evidence-based guidelines and the Academy’s EAL with the interprofessional team and others to integrate food, nutrition, and lifestyle behaviors with ED treatment | X | X | X | |||
| 5.5B | Communicates effectively with members of the treatment team (eg, physicians, therapists, nurses), client, and support team (eg, family, loved ones, friends) | X | X | X | |||
| 5.5C | Educates other significant individuals (eg, family members, friends, teachers, school counselors, performance advisors) about health-related consequences of ED within HIPAA boundaries | X | X | ||||
| 5.6 | Communicates performance improvement and research results through publications and presentations | X | X | X | |||
| 5.6A | Presents information on evidence-based ED guidelines and research at the local level (eg, community groups and colleagues) | X | X | X | |||
| 5.6B | Presents evidence-based ED nutrition research, guidelines, and information at professional meetings and conferences (eg, local, regional, national, international) | X | X | ||||
| 5.6C | Authors peer-reviewed ED publications and authoritative articles for consumers, credentialed nutrition and dietetics practitioners, and other health care practitioners | X | X | ||||
| 5.6D | Serves in leadership roles for local, national, and international program/conference planning or to the media (eg, invited reviewer, presenter) | X | X | ||||
| 5.6E | Directs collation of research data into publications (eg, systematic reviews and position/practice papers), as well as national/international presentations | X | |||||
| 5.7 | Seeks opportunities to participate in and assume leadership roles with local, state, national, and international professional and community-based organizations (eg, government-appointed advisory boards, community coalitions, schools, foundations or nonprofit organizations serving the food insecure) providing food and nutrition expertise | X | X | X | |||
| 5.7A | Participates in professional and work-related leadership activities | X | X | X | |||
| 5.7B | Serves on ED prevention, awareness, and treatment task forces or committees | X | X | X | |||
| 5.7C | Leads and supports the development of population-based and specialty-focused health promotion/prevention programs and education materials based on client population needs, culture, evidence-based strategies, and available resources | X | X | ||||
| 5.7D | Identifies new opportunities for leadership and cross discipline dialogue to promote nutrition and dietetics in a broader context | X | X | ||||
| 5.7E | Initiates and proactively develops professional alliances for the benefit of care and advancement of ED prevention and education | X | |||||
| 5.7F | Represents nutrition and dietetics at the national and international level and serves as lead collaborator for national projects and professional organizations (eg, Academy dietetic practice groups, APA, AED, NQF) | X | |||||
| 5.7G | Serves as a consultant/content expert to organizations, health care practitioners, and other professionals interacting with individuals with an ED to provide education on ED risks/screening/treatment, and highlight the contribution of RDNs in ED | X | |||||
Examples of Outcomes for Standard 5: Communication and Application of Knowledge
| |||||||
| 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, natural 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: | Competent | Proficient | Expert | ||||
| 6.1 | Uses a systematic approach to manage resources and improve outcomes | X | X | X | |||
| 6.1A | Participates in operational planning and program development of ED nutrition programs and services | X | X | X | |||
| 6.1B | Recognizes and uses existing resources (eg, educational/training tools and materials, and staff time) as needed in the provision of ED nutrition services | X | X | X | |||
| 6.1C | Manages and ensures effective delivery of programs and services (eg, business planning, budget, program administration, foodservice management and food safety, emergency management) and collaborates with administrative, medical, and foodservice staff, if applicable | X | X | ||||
| 6.1D | Directs or manages the design and delivery of ED nutrition services, and holds responsibility for accurate management of grants when applicable | X | |||||
| 6.2 | Evaluates management of resources with the use of standardized performance measures and benchmarking as applicable | X | X | X | |||
| 6.2A | Uses the Standards of Excellence Metric Tool to self-assess quality in leadership, organization, practice, and outcomes for an organization (www.eatrightpro.org/excellencetool) | X | X | X | |||
| 6.2B | Collects or contributes data and participates in analyzing program resources/service participation and expense data to evaluate and adjust programs and services | X | X | X | |||
| 6.2C | Monitors, documents, and evaluates program and service resource use against budget or other metrics (eg, staff hours, staff to client ratio, referral requests, program participation rate, reimbursement data, supplies, training and professional development, technology, and food cost, if applicable) | X | X | ||||
| 6.2D | Leads operational review reflecting evaluation of performance and benchmarking data to manage resources and modifications to design and delivery of ED nutrition programs and services | X | |||||
| 6.3 | Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and products | X | X | X | |||
| 6.3A | Assures nutrition services and foodservice comply with regulations (eg, food safety, CMS or state regulations), and accreditation standards (eg, The Joint Commission) when applicable | X | X | X | |||
| 6.3B | Participates in the evaluation and selection of equipment, tools, and products (eg, enteral nutrition, specialty food items, medical foods/nutrition supplements, web-based programs, monitoring systems) to assure safe, optimal, and cost-effective delivery of care and services | X | X | X | |||
| 6.3C | Evaluates and selects new products (eg enteral nutrition formulas, food/meals, medical foods/nutrition supplements) that are specific to the nutrition needs of ED clients | X | X | ||||
| 6.3D | Evaluates safety, effectiveness, productivity, sustainability practices, and value of services at the systems level | X | |||||
| 6.4 | Participates in quality assurance and performance improvement (QAPI) and documents outcomes and best practices relative to resource management | X | X | X | |||
| 6.4A | Participates in QAPI activities or data collection and analyzes to improve outcomes and identify best practices | X | X | X | |||
| 6.4B | Uses data to proactively recognize needs, anticipate outcomes, and make necessary modifications to achieve desired client-related and program/service resource allocation outcomes | X | X | ||||
| 6.4C | Integrates quality measures and PI processes into management of human and financial resources and information technology | X | |||||
| 6.5 | Measures and tracks trends regarding internal and external customer outcomes (eg, satisfaction, key performance indicators) | X | X | X | |||
| 6.5A | Participates in conducting regular surveys with clients/families/advocates, interprofessional team members, community participants and stakeholders to assess satisfaction; and in communicating results and recommendations for change(s) | X | X | X | |||
| 6.5B | Resolves internal and external problems that may affect the delivery of ED nutrition services | X | X | ||||
| 6.5C | Implements, monitors, and evaluates changes based on data collection and analysis | X | |||||
Examples of Outcomes for Standard 6: Utilization and Management of Resources
| |||||||
a Interprofessional: The term interprofessional is used in this evaluation resource as a universal term. It includes a diverse group of team members (eg, physicians, nurses, dietitian nutritionists, physician assistants, pharmacists, psychologists, psychotherapists, certified counselor, clinical social workers, and occupational and physical therapists), depending on the needs of the customer. Interprofessional could also mean interdisciplinary or multidisciplinary.
b PROMIS: The Patient-Reported Outcomes Measurement Information System (PROMIS) (https://commonfund.nih.gov/promis/index), is a reliable, precise measure of patient-reported health status for physical, mental, and social well-being. PROMIS is a web-based resource and is publicly available.
c Medical staff: A medical staff is composed of doctors of medicine and osteopathy and may in accordance with state law, including scope of practice laws, include other categories of physicians, and nonphysician practitioners who are determined to be eligible for appointment by the governing body.
6
Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual.
d Non-physician practitioner: A non-physician practitioner may include a physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, anesthesiologist’s assistant, qualified dietitian or qualified nutrition professional. Disciplines considered for privileging by a facility’s governing body and medical staff must be in accordance with state law.
6
,Appendix A-Survey protocol, regulations and interpretive guidelines for hospitals (Rev. 200, 02-21-20); §482.12(a)(1) Medical Staff, non-physician practitioners; §482.23(c)(3)(i) Verbal Orders; §482.24(c)(2) Orders. US Department of Health and Human Services, Centers for Medicare and Medicaid Services. State Operations Manual.
7
The term privileging is not referenced in the Centers for Medicare and Medicaid Services long-term care (LTC) regulations. With publication of the Final Rule revising the Conditions of Participation for LTC facilities effective November 2016, post-acute care settings, such as skilled and LTC facilities, may now allow a resident’s attending physician the option of delegating order writing for therapeutic diets, nutrition supplements or other nutrition-related services to the qualified dietitian or clinically qualified nutrition professional, if consistent with state law, and organization policies.Operations Manual. Appendix W-Survey protocol, regulations and interpretive guidelines for critical access hospitals (CAHs) and swing-beds in CAHs (Rev. 200, 02-21-20); §485.635(a)(3)(vii) Dietary Services; §458.635 (d)(3) Verbal Orders; §458.635 (d)(9) Swing-Beds. US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
9
,US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; reform of requirements for long-term care facilities. 42 CFR Parts 405, 431, 447, 482, 483, 485, 488, and 489. Final Rule (FR DOC#2016; pp 68688-68872) – Federal Register October 4, 2016; 81(192):68688-68872; §483.30(f)(2) Physician services (pp 65-66), §483.60 Food and Nutrition Services (pp 89-94), §483.60 Food and Nutrition Services (pp 177-178).
10
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