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Academy of Nutrition and Dietetics: Revised 2022 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Public Health and Community Nutrition

      Abstract

      Awareness of the social determinants of health has been increasing in recent years. These include equitable access to health care and foods that support healthy eating patterns. A wide range of issues related to these determinants influence practice in the public health and community nutrition field. In response to these evolving needs, the Public Health and Community Nutrition Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has developed Standards of Practice and Standards of Professional Performance as a tool for Registered Dietitian Nutritionist (RDNs) currently in practice or interested in working in public health and community nutrition, to assess their current skill levels and to identify areas for professional development. The Standards of Practice address the four steps of the Nutrition Care Process for community and public health RDNs: assessment, diagnosis, intervention, and evaluation/monitoring. The Standards of Professional Performance consists of six domains of professional performance for community and public health RDNs: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, specific indicators provide measurable action statements that illustrate the ways in which RDNs can address population nutrition and health. The indicators describe three skill levels (Competent, Proficient, and Expert) for RDNs. These tools highlight the unique scope of expertise that RDNs provide to the field of public health and community nutrition.
      Editor's note: Figures 4 and 5 that accompany this article are available online at www.jandonline.org.
      The Public Health and Community Nutrition Dietetic Practice Group (PHCN DPG) 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 Dietitian Nutritionists (RDNs) in Public Health and Community Nutrition originally published in 2015.
      • Bruening M.
      • Udarbe A.
      • Yates Jimenez E.
      • et al.
      Academy of Nutrition and Dietetics: Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Public Health and Community Nutrition.
      The revised document, Academy of Nutrition and Dietetics: Revised 2022 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Public Health and Community Nutrition, reflects advances in practice during the past 7 years and replace the 2015 Standards. This document builds on the Academy of Nutrition and Dietetics: Revised 2017 SOP in Nutrition Care and SOPP for Registered Dietitian Nutritionists.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      The Academy/Commission on Dietetic Registration (CDR) Code of Ethics for the Nutrition and Dietetics Profession,
      2018 Code of Ethics for the Nutrition and Dietetics Profession. Academy of Nutrition and Dietetics (Academy)/Commission on Dietetic Registration (CDR).
      along with the Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      and Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      guide the practice and performance of RDNs in all settings.
      All registered dietitians are nutritionists—but not all nutritionists are registered dietitians. The Academy’s Board of Directors and Commission on Dietetic Registration have determined that those who hold the credential Registered Dietitian may optionally use “Registered Dietitian Nutritionist” (RDN). The 2credentials 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.
      Approved March 2022 by the Quality Management Committee of the Academy of Nutrition and Dietetics (Academy) and the Executive Committee of the Public Health and Community Nutrition Dietetic Practice Group of the Academy. Scheduled review date: March 2028. Questions regarding the Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists in Public Health and Community Nutrition may be addressed to Academy Quality Management Staff: Dana Buelsing Sowards, MS, manager, Quality Standards Operations; and Karen Hui, RDN, LDN, scope/standards of practice specialist, Quality Management at [email protected].

      Overview

      Nutrition and health have a close relationship. Proper nutrition is vital for growth and development. However, most people in the United States do not consume foods consistent with healthy eating patterns; specifically, ones that include a variety of fruits and vegetables, whole grains, fat-free or low-fat dairy, proteins, and oils.
      2020-2025 Dietary Guidelines for Americans Executive Summary. USDA.
      Diets that are not nutrient-dense are of particular concern among certain populations throughout the life course, especially during transitional periods.
      • Herman D.R.
      • Baer M.T.
      • Adams E.
      • et al.
      Life course perspective: evidence for the role of nutrition.
      For example, the first 1,000 days are some of the most critical to promoting the long-term health of a child.
      • Cusick S.E.
      • Georgieff M.K.
      The role of nutrition in brain development: the golden opportunity of the “first 1000 days.”.
      ,
      • Schwarzenberg S.J.
      • Georgieff M.K.
      Advocacy for improving nutrition in the first 1000 days to support childhood development and adult health.
      When reviewing mortality, five of the six leading causes of death among the American population are related to poor-quality eating patterns: coronavirus disease 2019 (COVID-19), cardiovascular disease, stroke, type 2 diabetes, and some forms of cancer.
      2020-2025 Dietary Guidelines for Americans Executive Summary. USDA.
      ,
      Leading causes of death. National Center for Health Statistics. Centers for Disease Control and Prevention.
      “Community nutrition encompasses individual and interpersonal-level interventions that create changes in knowledge, attitudes, behavior, and health outcomes among individuals, families, or small, targeted groups within a community setting.”
      Definition of terms. Academy of Nutrition and Dietetics.
      “Public health nutrition is the application of nutrition and public health principles to design programs, systems, policies, and environments that aims to improve or maintain the optimal health of populations and targeted groups.”
      Definition of terms. Academy of Nutrition and Dietetics.
      Social determinants of health (SDoH), which are the conditions in which people are born, live, learn, work, play, worship, and age
      Definition of terms. Academy of Nutrition and Dietetics.
      continue to drive nutrition-related health disparities and chronic disease among populations and individuals. Access to food persists as an ongoing issue in the United States and abroad, with 10.5% of households facing food insecurity in the United States
      • Coleman-Jensen A.
      • Rabbitt M.P.
      • Gregory C.A.
      • Singh A.
      Household food security in the United States in 2020, ERR-298.
      and 22% of children are stunted globally.
      • Fanzo J.
      • Hawkes C.
      • Udomkesmalee E.
      • et al.
      2018 Global Nutrition Report: Shining a Light to Spur Action on Nutrition.
      The COVID-19 pandemic highlighted the need for preventative nutrition that promotes population health.
      • Carducci B.
      • Keats E.C.
      • Ruel M.
      • Haddad L.
      • Osendarp S.J.
      • Bhutta Z.A.
      Food systems, diets and nutrition in the wake of COVID-19.
      Public health models incorporating policy, systems, and environment initiatives that address SDoH allow RDNs to have a greater influence on the root causes of nutrition inequities. SDoH, which include but are not limited to racism, sexism, homophobia, ethnic discrimination, religious discrimination, socioeconomic, or other identity issues have intersecting and additive effects. This can influence food and nutrition security along with dietary intake, which are the cornerstones to the practice of PHCN RDNs. In understanding SDoH for populations and individuals, it is important that everyone has the opportunity to gain full potential in their health—or health equity.
      Definition of terms. Academy of Nutrition and Dietetics.
      The work to move the conversation from food security to nutrition security
      • Mozaffarian D.
      • Fleischhacker S.
      • Andrés J.R.
      Prioritizing nutrition security in the US.
      is one that is grounded in health equity. RDNs know that food security should not simply be about access to any food as an energy source. To promote health and well-being, populations and individuals need access to healthy, high-quality nutritious foods that are culturally accepted. By nature, PHCN RDNs work as part of interprofessional teams. To effect public health, PHCN RDNs must collaborate and cooperate to address SDoH and health equity. To influence policy and upstream interventions, RDNs must be at the table with other professionals, community partners, and community members, advocating and providing evidence for change.
      In promoting health equity, current best practices in PHCN call for high engagement of those from the community in their own care and services (see Figure 1
      10 Essential Public Health Services
      Centers for Disease Control and Prevention.
      ). Basing practice on an assets model
      • Morgan A.
      • Ziglio E.
      Revitalizing the evidence base for public health: an assets model.
      that values the lived experiences, cultural knowledge, and preferences of the populations with whom RDNs work will result in more sustainable outcomes.
      • Smedley B.D.
      The lived experience of race and its health consequences.
      ,
      • O’Mara-Eves A.
      • Brunton G.
      • Oliver S.
      • Kavanagh J.
      • Jamal F.
      • Thomas J.
      The effectiveness of community engagement in public health interventions for disadvantaged groups: a meta-analysis.
      PHCN aims for a developmental approach in progressively increasing the extent to which community members are engaged in planning interventions within their own communities. This follows a continuum from being merely informed of these, and engaging as participants, to being empowered to fully collaborate as full partners and leaders.
      Making the case for collaborative CHI
      Centers for Disease Control and Prevention.
      ,
      Community Health Assessment Toolkit. AHA Community Health Improvement.
      By providing populations and individuals with more agency over their nutritional health, better outcomes are achieved.
      Figure thumbnail gr1
      Figure 1The 10 Essential Public Health Services. Used with permission from the Centers for Disease Control and Prevention (CDC). Material available on CDC website for no charge. Reference to specific commercial products, manufacturers, companies, or trademarks does not constitute its endorsement or recommendation by the US Government, Department of Health and Human Services, or Centers for Disease Control and Prevention.
      Often, public health nutrition programs are centered around individuals experiencing poverty and food/nutrition insecurity. Poverty and food/nutrition insecurity are examples of traumatic experiences and additive effects of SDoH that influence well-being. Understanding how experiencing trauma, including community trauma, influences health and behaviors is critical for working in PHCN.
      • Dennett C.
      Trauma-informed nutrition care.
      ,
      Obesity course live events sessions and objectives: delivering trauma informed counseling
      Commission on Dietetic Registration.
      A competent practitioner reflects on the implications of individual and population trauma and integrates this understanding into his or her contributions to policy development, planning, and program leadership. A proficient practitioner is trauma-sensitive and trauma-responsive with skill development in practice and application and an expert practitioner is trauma-informed through the integration of policies, planning, and leadership commitment to the intersection of trauma science with nutrition science.
      Natural disasters, global pandemics, forest fires, and climate change all exacerbate disparities in public health, influencing food systems, food supply chains, labor shortages, and general access to food.
      • O'Hara S.
      • Toussaint E.C.
      Food access in crisis: food security and COVID-19.
      • Rizou M.
      • Galanakis I.M.
      • Aldawoud T.M.
      • Galanakis C.M.
      Safety of foods, food supply chain and environment within the COVID-19 pandemic.
      • Bruening M.
      • McClain D.
      • Moramarco M.
      • Reifsnider E.
      The role of SNAP in home food availability and dietary intake among WIC participants facing unstable housing.
      • Barrocas A.
      • Moten-Bickham P.
      • Tonini J.
      • Beck-McCullough C.
      Once upon a storm: Katrina and nutrition support or the lack thereof.
      Globally, social and political unrest drive an influx of refugees and asylum seekers expected to increase the need for PHCN services in regions receiving these people. This includes assistance in navigating nutrition/food assistance programs and access to healthy and culturally appropriate foods. With increasing frequency of public health emergencies, there is a greater need for RDNs trained and prepared to provide nutrition-related services to vulnerable populations. For example, schools became a convening point during the COVID-19 pandemic through their implementation of the Pandemic-Supplemental Nutrition Assistance Program (P-SNAP). SNAP-eligible families and those participating in the National School Lunch Program were able to access food for the whole family in new ways. Other PHCN RDNs pivoted to provide leadership and management oversight in COVID-19 response for their state or county. RDNs, especially those trained and working in public health, are well equipped to support public health emergencies.
      There is a long history of PHCN on a global scale. Nutritionists work with international nongovernmental organizations, public health organizations, ministries of health, the Food and Agriculture Organization of the United Nations, as well as the World Health Organization to provide food and nutrition services across the world. There is no global designation for RDNs, but the Academy strategic plan includes having a global influence in eliminating all forms of malnutrition.
      The Academy’s Strategic Plan
      Academy of Nutrition and Dietetics.
      PHCN RDNs are exceptionally qualified to support mitigation and elimination of acute and chronic malnutrition, ensuring that trauma-informed, culturally relevant, harm-reducing care is provided. PHCN RDNs work at the systems and policy levels to address global nutrition-related disease prevention.
      Population health is a term that is increasing in popularity. Sometimes the term population health is used interchangeably with public health,
      Public health and community
      Academy of Nutrition and Dietetics.
      ,
      • Roux A.V.
      On the distinction—or lack of distinction—between population health and public health.
      although there is no consensus on the term population health.
      Medicaid and Public Health Partnership Learning Series: public health and population health 101
      Association of State and Territorial Health Officials.
      For the purposes of this publication, the terms will be used interchangeably.
      RDNs in PHCN are charged with applying nutrition in supporting the health of populations (eg, gender diverse individuals,
      • Linsenmeyer W.
      • Garwood S.
      • Waters J.
      An Examination of the Sex-Specific Nature of Nutrition Assessment within the Nutrition Care Process: Considerations for Nutrition and Dietetics Practitioners Working with Transgender and Gender Diverse Clients.
      refugees,
      • Martin H.
      • Blankenship J.
      Nutrition Standards Called into Question at Border Detainment Facilities.
      individuals effected by climate change,

      Farr LT. Future Trends and the Pace of Change: Are We Ready? J Acad Nutr Diet. 121;21(4):633-635.

      and aging and disabled individuals
      • Clark R.
      • Zarutskie A.
      • Limlek I.
      • et al.
      Malnutrition across the Care Continuum in the Aging and Disabled Populations.
      ). Among the many roles and sectors where RDNs work, community RDNs may work with families to develop healthy eating behaviors, help mothers develop breastfeeding skills, advise and create community programs and systems, and advocate on behalf of their clients and communities at the local, state, tribal, and federal levels. Public health RDNs work at systems levels to coordinate cross-sector services, including nutrition policy, programs, and environments. RDNs work collaboratively across all sectors, including health, education, government, nonprofits, and industry, to understand the complex factors that impact population and individual health and to promote health equity and disease prevention for the populations with whom they work. Work is done in a variety of interprofessional settings to provide essential public health services in the United States and globally. This includes assessment and diagnosis of population health problems, grant writing, development, management and evaluation of intervention programs, generation of policy and research, as well as administration of nutrition education, counseling, and training to populations and individuals at all stages of prevention and across all stages of the life course.
      About 11% of RDNs currently report that their primary practice area is community nutrition—the majority of whom work in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), but the demand for RDNs with expertise in PHCN is expected to dramatically increase in the future.
      • Laramee S.
      • Tate M.
      Dietetics Workforce Demand Study Task Force supplement: an introduction.
      To meet the recommended staffing ratio of one public health nutritionist per 50,000 people, there is an immediate need for a 113% increase in the workforce. RDNs who focus on prevention and wellness are able to reduce health care expenditures. Prevention is often significantly less costly than treatment on the population level.
      • Willett W.C.
      • Koplan J.P.
      • Nugent R.
      • Dusenbury C.
      • Puska P.
      • Gaziano T.A.
      Prevention of chronic disease by means of diet and lifestyle changes.
      • Chokshi D.A.
      • Farley T.A.
      The cost-effectiveness of environmental approaches to disease prevention.
      • Barton P.
      • Andronis L.
      • Briggs A.
      • McPherson K.
      • Capewell S.
      Effectiveness and cost effectiveness of cardiovascular disease prevention in whole populations: modelling study.
      • Cecchini M.
      • Sassi F.
      • Lauer J.A.
      • Lee Y.Y.
      • Guajardo-Barron V.
      • Chisholm D.
      Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness.
      • Linsenmeyer W.
      • Garwood S.
      • Waters J.
      An Examination of the Sex-Specific Nature of Nutrition Assessment within the Nutrition Care Process: Considerations for Nutrition and Dietetics Practitioners Working with Transgender and Gender Diverse Clients.
      • Martin H.
      • Blankenship J.
      Nutrition Standards Called into Question at Border Detainment Facilities.

      Farr LT. Future Trends and the Pace of Change: Are We Ready? J Acad Nutr Diet. 121;21(4):633-635.

      • Clark R.
      • Zarutskie A.
      • Limlek I.
      • et al.
      Malnutrition across the Care Continuum in the Aging and Disabled Populations.
      The demand for RDNs with unique expertise in PHCN is increasing. A 2021 mixed-methods study from the Academy indicated that whereas RDNs have the capacity in PHCN, existing dietetics education models
      • El-Kour T.Y.
      • Kelley K.
      • Bruening M.
      • Robson S.
      • Vogelzang J.
      • Yang J.
      • et al.
      Dietetic workforce capacity assessment for public health nutrition and community nutrition.
      need more emphasis in PHCN. This may require more undergraduate education in public health principles as well as more opportunities for experiential learning in public health. Representation from diverse practitioners who have lived experience with the populations they serve is critical for advancing nutrition health equity within PHCN.
      • Whitt-Glover M.C.
      Diversifying the healthcare workforce can mitigate health disparities.
      ,
      • Valantine H.A.
      • Davis A.F.
      Workforce diversity and capacity building to address health disparities.
      PHCN RDNs have public health competencies
      Core Competencies for Public Health Professionals.
      Public Health/Community Nutrition Practice Group of the Academy of Nutrition and Dietetics
      PHCNP Publications.
      Training our workforce: a new guide for training public health and community nutrition professionals
      Academy of Nutritition and Dietetics.
      and skills that complement and enhance their dietetics practice. Figures 1 and 2 describe the 10 Essential Services of Public Health and the 8 Public Health Competencies, respectively. Although these public health competencies and services do not map directly to the SOP and SOPP, there is significant overlap.
      • Kemp J.D.
      • Hamady C.M.
      • Ludy M.J.
      Data analysis outside of clinical practice: an innovative application of the Nutrition Care Process and Model.
      One example is the core competency in public health of communication skills, and Standard 5 in the SOPP is Communication and Application of Knowledge. Assessment is a core competency and key service in public health, nutrition assessment is the first component of the Nutrition Care Process and Standard 1 in the SOP. In public health, it is also a core competency and key service in public health. Areas that are innate to public health, but not yet entry-level dietetics, include but are not limited to systems thinking and cultural competence.
      2022 Standards and templates
      Accreditation Council for Education in Nutrition and Dietetics.
      Whereas these competencies are incorporated into other areas in dietetics (eg, Code of Ethics), these competencies are at the forefront of practice for a public health practitioner. Similarly, health equity is at the core of public health services and is integral to every public health practice. It is a PHCN RDN’s responsibility to ensure that these factors are incorporated into their dietetics practice. Other resources related to PHCN practice are identified in Figure 3.
      Figure 3Resources for registered dietitian nutritionists (RDNs) in public health and community nutrition (PHCN) (not all inclusive).a aThis figure is structured by the Public Health Foundation’s Eight Core Competencies in Public Health: http://www.phf.org/resourcestools/Pages/Competency_Assessments_For_Public_Health_Professionals.aspx. bCDC = Centers for Disease Control and Prevention. cNHANES = National Health and Nutrition Examination Survey. dHP = Healthy People. eAcademy of Nutrition and Dietetics. eWIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
      ResourceURLDescription
      Analytical and Assessment Skills
      CDCb: NHANESchttps://www.cdc.gov/nchs/nhanes/index.htmNHANES is a study that began in the 1960s and is designed to assess the health and nutritional status of adults and children in the United States. This website provides links to survey data and documentation, publications and products, and data analysis tutorials.
      Community Tool Box, Center for Community Health and Development, University of Kansashttps://ctb.ku.edu/en/table-of-contents/overview/models-for-community-health-and-development/logic-model-development/mainThe website provides an overview of the components and how to develop logic models.
      National Library of Medicine: Making Sense of the Numbers: Understanding Risk and Benefits. Communicating Numerical Health Informationhttps://nnlm.gov/training/class-catalog/making-sense-numbers-understanding-risks-and-benefits-communicatingThis webinar is designed to help participants improve communication of health information that involves numeracy.
      Northwest Center for Public Health Practicehttps://www.nwcphp.org/training/training-search?keys=&field_training_formats_tid=All&field_training_series_tid=20&field_training_competencies_tid=AllThis website provides a five-part series on the basic concepts in public health data interpretation, analysis, and presentation useful in community health assessments.
      Trust for America’s Healthhttps://www.tfah.org/This website provides federal and state public health statistics, including obesity, diabetes, breastfeeding rates, fruit/vegetable intake, and physical activity.
      Policy Development and Program Planning Skills
      Academye Evidence Analysis Libraryhttps://www.andeal.org/The Evidence Analysis Library is an online resource of systematic reviews and evidence-based nutrition practice guidelines that provides recommendations and guiding statements to assist RDNs in providing evidence-based care. Each review includes a conclusion statement with a grade that indicates the quality and extent of the support evidence.
      Academy of Nutrition and Dietetics Foundation Prioritizing Food Security Solutionshttps://www.eatrightfoundation.org/why-it-matters/public-education/food-security-solutions/This toolkit consists of a four-step Food Security Solutions Prioritization Process that identifies the best solutions to improve food security in the community using the resources available.
      Association of Maternal and Child Health Programs: Innovation Hubhttps://www.amchpinnovation.org/This online platform provides tools and resources to explore, build, and share successful and effective practices. It includes a searchable repository of cutting-edge, emerging, promising, or best practices.
      HPd 2030 Browse Evidence-Based Resourceshttps://health.gov/healthypeople/tools-action/browse-evidence-based-resourcesThis database features evidence-based resources, review articles, toolkits, expert opinions, and relevant white papers. Database information includes resource descriptions, evidence sources and strength, related HP 2030 objectives, and connected PubMed citations.
      Maternal Child Health Evidence: Evidence Toolshttps://www.mchevidence.org/tools/strategies/This database features resources and policies categorized according to related Maternal Child Health National Performance Measures. Database information includes resource descriptions, evidence sources and strength, appropriate audiences, expected outcomes, models, and suggested evaluation measures.
      National Cancer Institute: Transforming Research into Community and Clinical Practicehttps://rtips.cancer.gov/rtips/index.doThis website provides a database featuring evidence-based interventions to control and prevent cancer, as well as cancer-associated modifiable risk-factors. Database information includes resource descriptions, evidence strength based on external peer reviewers’ ratings, appropriate audiences and settings, associated products or materials, costs, and time demands.
      US Department of Agriculturehttps://www.fns.usda.gov/

      https://snapedtoolkit.org/interventions/find/

      https://www.nutrition.gov/

      https://wicworks.fns.usda.gov/
      US Department of Agriculture has several websites that include fact sheets, guidance documents, policy memos, webinars, curricula for low-income populations, and related federal register documents and resources for federal nutrition assistance programs. In addition, there are tools to use in practice to help individuals make healthful eating choices.
      Communication Skills
      Building Workforce Capacity in Public Health Nutrition and Community Nutritionhttps://www.eatrightstore.org/dpg-products/phcn/building-workforce-capacity-in-public-health-nutrition-and-community-nutritionThis Public Health and Community Nutrition Dietetic Practice Group webinar describes the results of a study that examined the preparedness and capacity of RDNs to work in public health and community nutrition. The webinar includes the recording of a panel discussion that addresses pragmatic ways to increase RDN interest in and ability to pursue careers and leadership positions in public health and community nutrition.
      Association of State Public Health Nutritionists: See It. Say It. Share It.https://www.seeitsayitshareit.org/This website promotes the role and value of public health nutritionists including tools, resources, and the Public Health Nutrition Hall of Fame.
      Community Dimensions of Practice Skills
      Association of State Public Health Nutritionists: Moving to the Futurehttps://movingtothefuture.org/This website offers step-by-step instructions for conducting a community assessment, writing objectives, developing a plan, and evaluating a program, including downloadable forms, surveys, worksheets, and opportunities for skill-building training programs and webinars.
      CDC: Community Health Online Resource Centerhttps://wwwn.cdc.gov/chidatabaseThis CDC website provides a database of environment and system change resources to decrease tobacco use and prevent obesity. Database information includes resource descriptions, appropriate audiences or settings, and related links.
      Community Prevention Services Task Force: The Community Guidehttps://www.thecommunityguide.org/A database featuring only evidence-based recommendations from the Community Preventive Services Task Force, an independent committee of public health experts. All recommendations are based on systematic reviews of peer-reviewed literature. Database information includes strength of evidence, economic value, intervention resources, and implementation considerations.
      Robert Wood Johnson Foundation: What Works for Healthhttps://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-healthA database featuring programs and interventions to address community needs. Database information includes intervention descriptions, expected outcomes, influence on health disparities, specific intervention evidence, strength of evidence, models, and additional resources.
      Rural Health Information Hubhttps://www.ruralhealthinfo.org/project-examplesRural Health Information Hub features toolkits compiling evidence-informed programs to improve rural health. Database information includes intervention descriptions, why interventions work, examples, implementation considerations, suggested evaluation measures, and relevant resources.
      Public Health Science Skills
      American Public Health Associationhttps://www.apha.org/The American Public Health Association champions the health of all people and communities. It provides resources on public health, policy and advocacy, and specific topics such as health equity and climate change. Resources include the American Journal of Public Health, continuing professional education, fact sheets, and reports and issue briefs.
      CDC: Healthy Livinghttps://www.cdc.gov/HealthyLiving/This CDC website offers information on government resources and knowledge on public health topics, life stages, and specific populations.
      CDC: National Public Health Improvement Initiativehttps://www.cdc.gov/stltpublichealth/nphii/index.htmlThe CDC National Public Health Improvement Initiative supports health departments in accelerating public health accreditation readiness activities and implementing performance and improvement management practices.
      Public Health Foundation: Core Competencies for Public Health Professionalshttp://www.phf.org/resourcestools/pages/core_public_health_competencies.aspxThe Public Health Foundation Core Competencies for Public Health Professionals were developed by the Council on Linkages Between Academia and Public Health Practice and are a consensus set of skills for the broad practice of public health.
      Financial Planning and Management Skills
      National Association of County and City Health Officials: Public Health Financehttps://www.naccho.org/programs/public-health-infrastructure/public-health-financeNational Association of County and City Health Officials developed a website that includes an e-learning course on public health infrastructure and resources on Public Health Financial Management Competencies.
      Public Health Emergency Management Fellowshiphttps://www.cdc.gov/cpr/eoc/EmergencyManagementFellowship.htmThe CDC holds a twice per year Emergency Management Fellowship that provides training, mentorship, and technical assistance for mid-career professionals who work in public health preparedness.
      Cultural Competency Skills
      CDC: Social Determinants of Health: Know What Affects Healthhttps://www.cdc.gov/socialdeterminants/This website provides CDC resources with social determinants of health data, research, tools for action, programs, and policy. It is intended to be used by people in public health, community organizations, research organizations, and health care systems to improve community well-being.
      HP 2030: Social Determinants of Healthhttps://health.gov/healthypeople/objectives-and-data/social-determinants-healthHP 2030 highlights the importance of addressing social determinants of health and identifying ways to establish environments that foster good health for all. The report includes an overview, objectives, interventions and resources, and national snapshots.
      Michigan State University, Center for Regional Food Systems:www.canr.msu.edu/resources/structural_racism_in_us_food_systemThe website provides an annotated bibliography that provides current research and outreach on structural racism in the US food system for food system practitioners, researchers, and educators.
      World Health Organization: Social Determinants of Healthhttps://www.who.int/teams/social-determinants-of-healthThe World Health Organization Social Determinants of Health website works to compile and disseminate evidence on how to effectively address social determinants of health, build capacity, and advocate for action. It offers facts, publications, and frequently asked questions on applicable topics.
      W.K. Kellogg Foundationhttps://www.racialequityresourceguide.org/This website offers guides and workshops to provide structure for having dialogue on issues of race, activities focused on helping achieve racial equity, and trainings designed to raise awareness and inspire action.
      Leadership and Systems Thinking Skills
      Academy PHCN Practice Grouphttps://www.phcnpg.org/The PHCN practice group works to empower its members to be leaders in the practice of public health and community nutrition. The Dietetic Practice Group offers resources for RDNs such as an electronic mailing list, newsletter, continuing professional education, practitioner tools and resources, patient/consumer education, and information on community/public health internships for students. Of particular interest may be the Guide for Developing and Enhancing Skills in Public Health and Community Nutrition and the accompanying webinar: https://www.phcnpg.org/phcn/resources/2018-3rd-edition-the-guide and https://www.eatrightstore.org/dpg-products/phcn/training-our-workforce-a-new-guide-for-training-public-health-and-community-nutrition-professionals.
      Academy Public Health and Community webpagehttps://www.eatrightpro.org/practice/practice-resources/public-health-and-communityThis Academy webpage provides various links to resources regarding public health and community nutrition. These include links to the National Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Association, USDA Food and Nutrition Service, and others.
      Association of State Public Health Nutritionistshttps://www.asphn.org/The Association of State Public Health Nutritionists mission is to strengthen nutrition policy, programs, and environments for all people through development of public health nutrition leaders and collective action of members nationwide. It offers training, webinars, toolkits, publications, and annual conferences. This website offers links to webinars and trainings on public health nutrition initiatives, success stories, resources, and more.
      National WICf Associationhttps://www.nwica.org/The National WIC Association is the nonprofit education arm and advocacy voice of WIC. This member-based website provides press releases, blogs, advocacy guidance, resources, and education.

      Academy Quality and Practice Resources

      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.
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist.
      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 https://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. Training and certification programs can support attainment of these expanded roles. Examples in PHCN include: the Certificate of Training in Public Health Nutrition from the Academy, Public Health Nutrition Certificate of Training from the Association of State Public Health Nutritionists, the International Board Certified Lactation Consultant credential, and master’s degrees in related areas such as master of public health or master’s degree in public administration, for example. 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.
      Scope of Practice decision algorithm
      Academy of Nutrition and Dietetics.
      The Centers for Medicare and Medicaid Services (CMS), Department of Health and Human Services, Hospital
      State Operations Manual: 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.
      and Critical Access Hospital
      State 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.
      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 (http://www.eatrightpro.org/dietorders/). For assistance, refer questions to the Academy’s State Affiliate organization.
      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.
      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 actual privileges granted will be based on the RDN’s knowledge, skills, experience, and specialist certification, if required, and demonstrated and documented competence.
      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.
      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)
      US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      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 who work in long-term care facilities should review the Academy’s updates on CMS that outline the regulatory changes to §483.60 Food and Nutrition Services (https://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).
      State Operations Manual. Appendix PP: Guidance to surveyors for long-term care facilities (Rev. 173, 11-22-17); § 483.30 Physician Services, § 483.60 Food and Nutrition Services
      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed June 7, 2022.
      CMS periodically revises the State Operations Manual Conditions of Participation; obtain the current information at https://www.cms.gov/files/document/appendices-table-content.pdf.
      The Academy’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      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 four standards consistent with the Nutrition Care Process and clinical workflow elements as applied to the care of patients/clients/populations in all settings.
      • Swan W.I.
      • Vivanti A.
      • Hakel-Smith N.A.
      • et al.
      Nutrition Care Process and Model update: toward realizing people-centered care and outcomes management.
      The SOPP consists of standards representing six domains of professional performance: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. The SOP and SOPP for RDNs are designed to promote the provision of safe, effective, efficient, equitable, and 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 PHCN provide a guide for self-evaluation and expanding practice, a means of identifying areas for professional development, and a tool for demonstrating competence in delivering PHCN care and services. They are used by RDNs to assess their current level of practice and to determine the education and training required to maintain competency in their focus area and advancement to a higher level of practice. In addition, the standards can be used to assist RDNs 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 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists,
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      the indicators (ie, measurable action statements that illustrate how each standard can be applied in practice) (see Figures 4 and 5, available at www.jandonline.org) for the SOP and SOPP for RDNs in PHCN were revised with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDNs in PHCN were reviewed and approved by the Executive Committee of the PHCN DPG and the Academy Quality Management Committee.

      Three Levels of Practice

      The Dreyfus model
      • Dreyfus H.L.
      • Dreyfus S.E.
      Mind over Machine: The Power of Human Intuition and Expertise in the Era of the Computer.
      identifies levels of proficiency (novice, advanced beginner, competent, proficient, and expert) (refer to Figure 6) during the acquisition and development of knowledge and skills. The first two levels are components of the required didactic education (novice) and supervised practice experience (advanced beginner) that precede credentialing for nutrition and dietetics practitioners. Upon successfully attaining the RDN 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 PHCN. In Academy focus areas, the three levels of practice are represented as Competent, Proficient, and Expert.
      With safety and evidence-based practice
      Definition of terms. Academy of Nutrition and Dietetics.
      as guiding factors when working with patients/clients/customers/populations, a registered dietitian nutritionist (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 the Evidence Analysis Library (www.andeal.org/) as a resource, which provides a synthesis of systematic reviews on a variety of nutrition and dietetics topics, including health disparities, HIV/AIDS, obesity, reproduction, and pregnancy. 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 to converse authoritatively with the interprofessional team and adequately involve the patient/client/customer/population in shared decision making.
      Figure 6Registered Dietitian Nutritionists (RDNs) in Public Health and Community Nutrition Practice Level Delineation
      Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for registered dietitian nutritionists (RDNs) (Competent, Proficient, and Expert) in public health and community nutrition (PHCN). SOPs are authoritative statements that describe practice demonstrated through nutrition assessment, nutrition diagnosis (problem identification), nutrition intervention (planning, implementation), and outcomes monitoring and evaluation (four separate standards) and the responsibilities for which RDNs are accountable. The SOP for RDNs in PHCN presuppose that the RDN uses critical thinking skills; analytical abilities; theories; best-available research findings; current accepted nutrition, dietetics, public health, and medical knowledge; and the systematic holistic approach of the nutrition care process as they relate to the application of the standards. SOPP for RDNs in PHCN 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 (six separate standards).
      SOP and SOPP are complimentary 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, tribal, state, and/or local laws and regulations as well as policies and procedures established by the organization in which they are employed. To determine whether or not 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 of Nutrition and Dietetics (Academy) Scope of Practice Decision Algorithm is specifically designed to assist practitioners with this process.
      The term population/individual is used in the SOP as a universal term as these Standards relate to direct provision of nutrition care and services. Population/individual could also mean client/patient, resident, participant, consumer, community, stakeholder or any individual or group who receives public health and community nutrition 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, population, or organization to which the RDN provides services. These services are provided to individuals and population groups of all ages. The SOP and SOPP are not limited to the clinical setting. In addition, it is recognized that the family and caregiver(s) of population/individuals of all ages, 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’s Revised 2017 SOP in Nutrition Care and SOPP for RDNs have been adapted to reflect three levels of practice (Competent, Proficient, and Expert) for RDNs in PHCN. In addition, the core indicators have been expanded to reflect the unique competence expectations for the RDN working in PHCN.
      Figure thumbnail gr3

      Competent Practitioner

      In nutrition and dietetics, a competent practitioner is an RDN who is either just starting practice after having obtained RDN registration by CDR or an experienced RDN 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 applies to all levels of practice.
      Definition of terms. Academy of Nutrition and Dietetics.
      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.
      Definition of terms. Academy of Nutrition and Dietetics.
      A general practice RDN can include responsibilities across several areas of practice, including, but not limited to community/public health, clinical, consultation and business, research, education, and food and nutrition management.
      A competent RDN in PHCN takes into consideration social determinants of health and policy, systems, and environments that influence a population and an individual’s nutritional status and behaviors. They use an asset-based approach to incorporate lived-experience into their practice with consideration for trauma.
      • Raja S.
      • Hasnain M.
      • Hoersch M.
      • Gove-Yin S.
      • Rajagopalan C.
      Trauma informed care in medicine.
      ,
      • Racine N.
      • Killam T.
      • Madigan S.
      Trauma-informed care as a universal precaution: beyond the adverse childhood experiences questionnaire.
      An asset-based approach focuses on strengths of the community and considers diversity in thought, culture, and traits as positive assets. The competent RDN is learning how to apply and adapt the individual-centered nutrition care process to communities and populations. Examples of types of practice that competent PHCN RDNs provide include the implementation of evidence-based public health programs to populations and individuals (eg, the SNAP Education Program [SNAP-Ed] and WIC), collection of nutrition-related surveillance data (eg, Behavioral Risk Factor Surveillance System, Pregnancy Risk Assessment Monitoring System), and ongoing evaluation of services. Competent PHCN RDNs seek community input into their work, and partner with other interprofessional stakeholders to provide services, adding depth and breadth to their skills. Additional training may be obtained from the Academy’s Certificate of Training Programs that include Policy and Advocacy, Sustainable Food Systems, and Health and Wellness Coaching.
      Certificates of Training
      Academy of Nutrition and Dietetics.

      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, when available, to demonstrate proficiency in a focus area of practice.
      Definition of terms. Academy of Nutrition and Dietetics.
      Whereas a competent PHCN RDN implements programming, a proficient PHCN RDN coordinates programming, initiatives, and partner and stakeholder engagement in the delivery of services. A proficient-level practitioner has a deeper, more nuanced understanding of the social determinants of health and how they influence those with whom they work. Building upon their experiences as competent RDNs in PHCN, proficient RDNs examine and synthesize evidence to create, adapt, and evaluate programming. Proficient PHCN RDNs may serve as conveners for interprofessional work, ensuring that the nutrition needs and access to healthy, culturally appropriate foods are considered. Typically, the proficient RDN in PHCN supplements their dietetics education with additional public health training (eg, Masters in Public Health), ensuring that the 10 Essential Services of Public Health practice are implemented in their work
      10 Essential Public Health Services
      Centers for Disease Control and Prevention.
      (see Figure 1).

      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.
      Definition of terms. Academy of Nutrition and Dietetics.
      An expert practitioner may have an expanded or specialist role or both, and may possess an advanced credential(s) such as the CDR Board Certified Specialist in Pediatric Nutrition or other focus area credential. Generally, the practice is more complex and the practitioner has a high degree of professional autonomy and responsibility.
      The expert PHCN RDN leads organizations, agencies, and initiatives, advancing evidence-based practice. The expert practitioner in PHCN works with interprofessional partners and stakeholders to use systems-level approaches to strategically develop, implement, and evaluate services for populations and communities. Expert PHCN RDNs work with complex public health systems and have the experience and knowledge to understand and implement effective nutrition-related programming. Critical thinking and collaboration with community stakeholders, advocating for health equity, and applying evidence-based practice are cornerstones of practice at the expert level.
      These Standards, along with the Academy/CDR Code of Ethics,
      2018 Code of Ethics for the Nutrition and Dietetics Profession. Academy of Nutrition and Dietetics (Academy)/Commission on Dietetic Registration (CDR).
      answer the questions: Why is an RDN uniquely qualified to provide PHCN care and services? What knowledge, skills, and competencies does an RDN need to demonstrate for the provision of safe, effective, efficient, equitable, and quality PHCN care and service at the Competent, Proficient, and Expert levels?

      Academy Revised 2022 SOP AND SOPP for RDNs (Competent, Proficient, and Expert) in PHCN

      An RDN can use the Academy Revised 2022 SOP and SOPP for RDNs (Competent, Proficient, and Expert) in PHCN (see Figures 4 and 5, available at www.jandonline.org, and Figure 6) to:
      • identify the competencies needed to provide PHCN care and services;
      • self-evaluate whether or notthey have the appropriate knowledge, skills, and judgment to provide safe, effective, and quality PHCN care and service 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 PHCN practice;
      • provide a foundation for public and professional accountability in PHCN care and services;
      • support efforts for strategic planning, performance improvement, outcomes reporting, and assist management in the planning and communicating of PHCN services and resources;
      • enhance professional identity and skill in communicating the nature of PHCN care and services;
      • guide the development of PHCN-related education and continuing education programs, job descriptions, practice guidelines, protocols, theoretical 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 PHCN, 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 PHCN is learning the principles that underpin this focus area and is developing knowledge, skills, judgment, and gaining experience for safe and effective PHCN 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, an RDN new to the focus area of PHCN must accept the challenge of becoming familiar with the body of knowledge, practice guidelines, and available resources to support and ensure quality PHCN-related nutrition and dietetics practice. Competent RDNs assist in the implementation of federal and state public health nutrition programming, including at the individual level. Often, competent practitioners start in community nutrition, commonly as WIC RDNs
      • Rogers D.
      • Griswold K.
      • Sauer K.
      • et al.
      Entry-level registered dietitian and dietetic technician, registered practice today: results from the 2020 Commission on Dietetic Registration Entry-Level Dietetics Practice Audit.
      because they can be relatively new to some aspects of public health practice. In their work, these RDNs begin to see the connection between individual counseling/motivational interviewing and SDOH. They observe the connection between the inability to follow nutrition recommendations and lack of access. This can be access to food, storage, or cooking appliances. Competent RDNs see the influence that social determinants of health such as transportation, low-paying wages, and systemic racism influence families’ ability to make healthy choices at a population level. They work to provide services within the real context where families and communities live.
      At the proficient level, an RDN has developed a more in-depth understanding of PHCN practice, and is more skilled at adapting and applying evidence-based guidelines, and best practices than at the competent level. A proficient RDN may lead program development, coordinate services, and conduct needs assessments with community stakeholders and a variety of professions. For example, a proficient RDN may oversee the implementation of the Double Up Food Bucks program, or produce prescription program
      Gus Schumacher Nutrition Incentive Program
      National Institute of Food and Agriculture USDA.
      at a local farmers market, coordinating with farmers’ market managers, producers, and state agencies. This RDN is able to modify practice according to unique situations (eg, providing culturally appropriate food and assisting in enrollment in food assistance programs to refugees and internationally displaced persons). An RDN at the proficient level may possess a specialist credential(s) and/or advanced degrees such as a Master of Public Health. Future efforts could focus on consideration of a specialization credential for RDNs in PHCN given the complexity of this area of practice.
      At the expert level, an RDN thinks critically about PHCN, 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, and critical thinking. Essentially, 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 PHCN RDNs in various disciplines and practice settings. Expert RDNs, with their extensive experience and ability to see the significance and meaning of PHCN within a contextual whole, are fluid and flexible, and have considerable autonomy in practice. They not only develop and implement PHCN services, but 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 PHCN practice.
      Indicators for the SOP and SOPP for RDNs in PHCN are measurable action statements that illustrate how each standard can be applied in practice (Figures 4 and 5, available at www.jandonline.org). Within the SOP and SOPP for RDNs in PHCN, an X in the competent column indicates that an RDN who is caring for populations/individuals is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. A competent RDN in PHCN could be an RDN starting practice after registration or an experienced RDN who has recently assumed responsibility to provide PHCN care for populations/individuals. Population is a broad term that can include community-based groups (eg, neighborhood), regional or state groups, national or international groups. In public health, working with subpopulations is common by stage in the life course (eg, children or seniors), disease state/risk (eg, those at risk or with type 2 diabetes), or by demographic factors (eg, low income or specific racial/ethnic group). An individual receiving PHCN services can be someone from any population or subpopulation. Given the known influence of SDoH outcomes,
      • Adler N.E.
      • Glymour M.M.
      • Fielding J.
      Addressing social determinants of health and health inequalities.
      ,
      • James W.P.
      • Nelson M.
      • Ralph A.
      • Leather S.
      Socioeconomic determinants of health: the contribution of nutrition to inequalities in health.
      increasing needs for public health nutrition services are being identified in clinical settings.
      • Carino S.
      • Elliott A.
      • Palermo C.
      • Holden S.
      • Collins J.
      ‘Sustainable Food Systems Dietitian’: a novel role to champion food in hospitals.
      This practice can include health care organizations providing produce prescription programs and on-site access to food pantries for patients. These programs show the overlap that can occur between clinical settings and PHCN.
      • Aiyer J.N.
      • Raber M.
      • Bello R.S.
      • et al.
      A pilot food prescription program promotes produce intake and decreases food insecurity.
      ,
      • Xie J.
      • Price A.
      • Curran N.
      • Østbye T.
      The impact of a produce prescription programme on healthy food purchasing and diabetes-related health outcomes.
      An “X” in the proficient column indicates that an RDN who performs at this level has a deeper understanding of PHCN and has the ability to modify or guide interventions to meet the needs of populations/individuals in various situations (eg, collaborates within and across agencies and organizations, including other governmental sectors, nonprofits, community partners, business/insurance companies, industry, and coalitions that work on addressing population health issues).
      An “X” in the expert column indicates that the RDN who performs at this level possesses a comprehensive understanding of PHCN and a highly developed range of skills and judgments acquired through a combination of experience and education. An Expert RDN builds and maintains the highest level of knowledge, skills, and behaviors, including leadership, vision, and credentials.
      Standards and indicators presented in Figure 4 and Figure 5 (available at www.jandonline.org) in boldface type originate from the Academy’s Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists
      Academy of Nutrition and Dietetics Quality Management Committee
      Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists.
      and should apply to RDNs in all three 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 three levels of practice, it is understood that all RDNs in PHCN are accountable for practice within each of these indicators. However, the depth with which an RDN performs each activity will increase as the individual moves beyond the competent level. Several levels of practice are considered in this document; thus, taking a holistic view of the SOP and SOPP for RDNs in PHCN is warranted. It is the totality of individual practice that defines a practitioner’s level of practice and not any one indicator or standard.
      RDNs should review the SOP and SOPP in PHCN 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 also enables PHCN RDNs to better utilize these Standards as part of the Professional Development Portfolio recertification process,
      • Weddle D.O.
      • Himburg S.P.
      • Collins N.
      • Lewis R.
      The professional development portfolio process: Setting goals for credentialing.
      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.
      • Worsfold L.
      • Grant B.L.
      • Barnhill C.
      The essential practice competencies for the Commission on Dietetic Registration’s credentialed nutrition and dietetics practitioners.
      In the 3-step process, the credentialed practitioner accesses the online Competency Plan Builder (Step 1), which is a digital tool that assists practitioner in creating a continuing education Learning Plan. It helps identify focus areas during each 5-year recertification cycle for verified CDR credentialed nutrition and dietetics practitioners.
      Competency plan builder instructions
      Commission on Dietetic Registration.
      The Activity Log (Step 2) is used to log and document continuing professional education over 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.
      • Peregrin T.
      The Ethics of Competence, a Self-Assessment is Key.
      RDNs should collaborate with other RDNs in PHCN as learning opportunities and to promote consistency in practice and performance and continuous quality improvement. See Figure 7 for role examples of how RDNs in different roles, at different levels of practice, may use the SOP and SOPP in PHCN.
      Figure 7Role examples of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitian Nutritionists (RDNs) (Competent, Proficient, and Expert) in public health and community nutrition (PHCN). aFor each role, the RDN updates the professional development plan to include applicable essential practice competencies for PHCN services. bWIC = Special Supplemental Nutrition Program for Women, Infants, and Children.
      RoleExamples of use of SOP and SOPP documents by RDNs in different practice rolesa
      Public health nutritionist/nutrition program coordinator (in federal, state, or local program)A registered dietitian nutritionist (RDN) working in public health and community nutrition (PHCN) programs uses the SOP and SOPP in PHCN to serve as a guide for identifying competency and areas to strengthen the delivery of nutrition program services. The RDN refers individuals accessing public health nutrition programs to an RDN providing medical nutrition therapy for individuals with acute and chronic conditions when needs are identified outside of the scope of PHCN. The SOP and SOPP are used as a resource for guiding quality improvement and program outcomes
      WICb dietitian/nutritionist (in federal, state, or local position)A state agency RDN working with WIC programs in community health departments, refers to the SOP and SOPP in PHCN for information, resources, and quality practice expectations to apply to the nutrition assessment, nutrition education, and certification procedures and processes that guide care and services for individuals participating in the WIC program. The SOP and SOP are used for personal self-evaluation and in the design of tools for assessing WIC program RDN and support staff competencies.
      Clinical practitioner,

      ambulatory care
      An RDN working in an ambulatory care setting notices an increase in the number of patients with food insecurity. The RDN uses the SOP and SOPP in PHCN for information, resources, and to evaluate expected outcomes; and the level of competence needed to provide equitable and culturally relevant support to individuals, including referrals to nutrition assistance programs and RDNs in community nutrition settings for follow-up.
      Food and nutrition services manager/directorA food and nutrition services manager for a large congregate senior feeding program notes an increasing number of participants requesting additional items or larger portions because they are experiencing food insecurity. The manager uses the SOP and SOPP in PHCN to determine the process of identifying issues and assist in developing action plans to provide additional services for participants reporting food insecurity. The RDN consults with a colleague experienced with care of this population for suggestions on relevant continuing education activities and on where to refer participants who need assistance with managing their dietary needs.
      Community nutrition practitionerAn RDN working in a nonprofit organization as the nutrition program manager provides nutrition consultations for individuals experiencing food insecurity. The RDN recognizes the need for more in-depth knowledge and skills to stretch nutrition assistance funds for the purchasing of healthy and culturally relevant foods. The RDN reviews the SOP and SOPP in PHCN to identify outcomes for competent practice, resources to review to increase knowledge, possible continuing education activities to pursue; and identifies when to refer to a more experienced RDN when the individual’s nutrition management needs exceed the RDN’s current level of knowledge/experience.
      ResearcherAn RDN working in a research setting is awarded a grant to demonstrate the role of RDNs and the influence of nutrition interventions provided by an RDN on health outcomes of populations and individuals participating in the Supplemental Nutrition Assistance Program. The RDN uses the SOP and SOPP in PHCN in consultation with proficient and expert-level PHCN RDNs as a resource in designing the research protocol.
      Faculty, nutrition, and dietetics education programAn RDN faculty member reviews the SOP and SOPP in PHCN to gain familiarity with the needs of populations and individuals experiencing health inequities in order to expand lecture content and assigned readings for students. The RDN also contacts practicing RDNs for key principles, practice guidelines, and information related to practicing in the supplemental nutrition assistance settings. The RDN uses the SOP and SOPP in PHCN as well as other focus area SOPs and/or SOPPs (eg, pediatric nutrition, diabetes care, and sustainable, resilient, and healthy food and water systems) to identify roles and outcomes for entry-level competent practice, and focus area resources for lectures and assignments.
      Telehealth practitionerAn RDN working in a telehealth setting who provides nutrition consultations to individuals through a federally qualified community health center setting considers the SOP and SOPP in PHCN when determining expertise needed. The RDN refers to all relevant state laws and regulations, the Academy of Nutrition and Dietetics telehealth resources, and organization policies regarding the practice of telehealth, including requirements if an individual lives in another state.
      Emergency preparedness practitionerAn RDN working in emergency preparedness is planning and coordinating the delivery of emergency food relief to those affected by a disaster or pandemic. The RDN uses the SOP and SOPP in PHCN to support assessment, decision making, and coordination of care in alignment with competency and available resources. The RDN uses the SOP and SOPP to evaluate knowledge, skills, and competence for the delivery and design of a plan and quality improvement process for effectively managing food and water safety and access in alignment with population characteristics.
      In some instances, components of the SOP and SOPP for RDNs in PHCN do not specifically differentiate between proficient-level and expert-level practice. In these areas, it 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.
      • Chambers D.W.
      • Gilmore C.J.
      • Maillet J.O.
      • Mitchell B.E.
      Another look at competency-based education in dietetics.
      A wealth of knowledge is embedded in the experience, discernment, and practice of expert-level RDN practitioners. The 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 PHCN RDNs in practice settings and professional activities that enhance population/individual care and/or services, can be used to illustrate outstanding practice models. Tagtow and colleagues
      • Tagtow A.
      • Herman D.
      • Cunningham-Sabo L.
      Next-generation solutions to address adaptive challenges in dietetics practice: the I+ PSE Conceptual Framework for Action.
      discusses the Individual plus Policy, System, and Environmental Conceptual Framework for Action as a model for dietetics, a model that is grounded in public health leadership and emphasizes system thinking. This framework suggests the importance of incorporating Individual plus Policy, System, and Environmental Conceptual Framework for Action not only in PHCN, but also across all areas of practice. As such, the SOP and SOPP in PHCN may also be applicable for other cross-cutting areas of practice.

      Future Directions

      The SOP and SOPP for RDNs in PHCN 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 three practice levels in support of safe, effective, equitable, and quality practice in PHCN remains an expectation of each revision to serve tomorrow's practitioners, populations, and individuals with whom they work. There is a need for expertise in preventive and public health nutrition; RDNs in this area of practice would benefit from specialist or advanced practice certification. A continued focus on health equity coupled with trauma-informed care is critical to the field. SOPs and/or SOPPs may want to consider adding specific standards for these public health competencies. Improving access to the dietetics profession for underrepresented populations will improve the influence of PHCN and this SOP and SOPP. Creation of this clarity, differentiation, and definition are the challenges of today's public health and community RDNs to better serve tomorrow's practitioners and their patients, clients, and communities/populations.

      Conclusions

      RDNs face complex situations every day. Addressing the unique needs of each situation and applying standards appropriately 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, tribal, state, and local regulations and facility accreditation standards. The SOP and SOPP for RDNs in PHCN are complementary documents and are key resources for RDNs at all knowledge and performance levels. These standards can and should be used by RDNs in daily practice who provide care to individuals in PHCN settings to consistently improve and appropriately demonstrate competence and value as providers of safe, effective, 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 PHCN practice. Just as a professional’s self-evaluation and continuing education process is an ongoing cycle, these standards are also a work in progress and will be reviewed and updated every 7 years.
      Current and future initiatives of the Academy, as well as advances in PHCN 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 PHCN DPG, 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

      The authors thank Kathleen Cullinen, PhD, MS, RDN, who reviewed these standards and to the Academy of Nutrition and Dietetics staff, in particular, Karen Hui, RDN, LDN; Dana Buelsing Sowards, MS, CAPM; Carol Gilmore, MS, RDN, LD, FADA, FAND; and Sharon M. McCauley, MS, MBA, RDN, LDN, FADA, FAND who supported and facilitated the development of these Standards of Practice and Standards of Professional Performance. Additional thanks go to the Public Health and Community Nutrition Dietetic Practice Group’s Executive Committee. Finally, the authors acknowledge the significant influence of registered dietitian nutritionists currently practicing in public health and community nutrition fields in the shaping of these standards.

      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 4Standards of Practice for registered dietitian nutritionists (RDNs) in Public Health and Community Nutrition. The term population/individual could also mean client/patient, resident, participant, consumer, community, stakeholder or any individual or group who receives public health and community nutrition care and services.
      Standards of Practice for Registered Dietitian Nutritionists in Public Health and Community Nutrition

      Standard 1: Nutrition Assessment

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

      Rationale:

      Nutrition screening is the preliminary step to identify populations and 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 five domains of nutrition assessment, and comparative standards, as well as public health approaches to assessment. 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. Given that population-level programs involve policy, system, and environmental interventions, direct care for public health and community RDNs can involve the assessment of policies, systems, and/or environments.
      Indicators for Standard 1: Nutrition Assessment
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      1.1Population/individual history: Assesses current and past information related to personal, medical, family, psychosocial/social, cultural, and community historyXXX
      1.1AReviews nutrition surveillance and risk screening data (eg, risk of food/nutrition insecurity) from public health agencies or referring facility/provider, if available, or incorporates into nutrition assessment data collection using evidence-based screening toolsXXX
      1.1BAssesses population health status in relation to community healthXXX
      1.1CUses population-based data to inform history and assessmentXXX
      1.1DTracks changes in personal history and population-based healthXXX
      1.1ELeads interprofessional team in identifying plan and tools for assessing populations initially and over timeXX
      1.1FImplements and connects history assessment tools to develop and inform population-level health interventions and policyX
      1.2Anthropometric assessment: Assesses anthropometric indicators (eg, height, weight, body mass index [BMI], waist circumference, arm circumference), comparison to reference data (eg, percentile ranks/z-scores), and population/individual patterns and historyXXX
      1.2AUses culturally appropriate and inclusive methods for anthropometric assessments (eg, making accommodations for religious head coverings or hair styles)XXX
      1.2BMonitors population/individual-based anthropometric measuresXXX
      1.2CParticipates in collecting measures for population-based programs (eg, WICa database, BRFSSb, YRBSSc)XXX
      1.2DLeads the collection of measures for population-based programs (eg Head Start)XX
      1.2EManages systems for anthropometric assessment (ie, provides training, quality assurance, updating, monitoring)XX
      1.2FApplies quantitative skills in evaluation of diet and anthropometric relationships in epidemiologic studiesXX
      1.2GDesigns and contributes to improvements of systems of assessments for anthropometric data collection across populationsX
      1.2HInterprets anthropometric data to design program and policy strategies while minimizing harmX
      1.3Biochemical data, medical tests, and procedure assessment: Assesses laboratory profiles (eg, acid-base balance, renal function, endocrine function, inflammatory response, vitamin/mineral profile, lipid profile), and medical tests and procedures (eg, gastrointestinal study, metabolic rate)XXX
      1.3AInterprets and applies diagnosis-related data from medical providers (eg, anemia, cancer, diabetes) in assessmentsXXX
      1.3BInitiates and participates in collection of biochemical data (eg, nutritional anemia profile, oral glucose tolerance test to screen for gestational diabetes; elevated blood lead or mercury levels, population-based lab data from health surveillance systems, electronic health record data)XXX
      1.3CDesigns protocols and systems for nutrition biochemical assessment at population levelsXX
      1.3DApplies quantitative skills in evaluation of diet and disease relationships in epidemiologic studiesXX
      1.3EInterprets biomedical data to design program and policy strategies while minimizing harmX
      1.4Nutrition-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)XXX
      1.4AParticipates in collection of self-reported and objective dataXXX
      1.4BTrains staff on applying NFPE findings into health care and public health programming (including direct care of individuals and with other health care providers)XX
      1.4CApplies quantitative skills to evaluate diet and NFPE relationships in epidemiologic studiesXX
      1.4DInterprets NFPE data to design program and policy strategies while minimizing harmX
      1.5Food and nutrition-related history assessment (ie, dietary assessment)-Evaluates the following components:
      1.5AFood and nutrient intake including composition and adequacy, meal and snack patterns, and appropriateness related to food allergies and intolerances as well as cultural relevance, preferences, and normsXXX
      1.5A1Applies and participates in multiple population/individual assessment methods (eg, interviews, surveys, nutrient analysis software, nutrition surveillance systems)XXX
      1.5A2Incorporates culturally appropriate and relevant approaches in assessmentXXx
      1.5A3Initiates collecting data using multiple population/individual group assessment methods (eg, interviews, surveys, nutrient analysis software, meal patterns, food/nutrition assistance programs, nutrition surveillance systems)XX
      1.5A4Applies quantitative skills to evaluate food and nutrition-related history assessmentXX
      1.5A5Interprets food and nutrition-related history data to design program and policy strategies while minimizing harmX
      1.5A6Designs systems and tools for multiple population/individual group assessment methods (eg, interviews, surveys, questionnaires, nutrient analysis, meal patterns in food programs, nutrition surveillance systems)X
      1.5BFood and nutrient administration including current and previous diets and diet prescriptions and food modifications, eating environment, and enteral and parenteral nutrition administrationXXX
      1.5B1Accommodates and tailors approach (eg, for cultural appropriateness, and/or with special needs) for participants participating in federal food/nutrition assistance programs (eg, NSLPd, WIC, special formulas, congregate and home delivered meals)XXX
      1.5CMedication and dietary supplement use, including prescription and over-the-counter medications, and integrative and functional medicine productsXXX
      1.5C1Considers potential diet interactions with medications, as well as dietary and herbal supplement use across the life course on population/individual levelsXXX
      1.5C2Considers cultural beliefs and preferences in medication and dietary supplement useXXX
      1.5C3Addresses any potential toxicities on population/individual levels (eg, contaminated water, endocrine disrupting chemicals in the food system); seeks assistance as neededXXX
      1.5C4Assesses substance abuse effects on population/individual levels; seeks assistance as neededXXX
      1.5C5Considers population/individual use of and need for dietary and herbal supplementation, including cultural norms and beliefs; seeks assistance as neededXXX
      1.5DKnowledge, 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)XXX
      1.5D1Assesses behavioral and environmental influences using the socioecological approach or other health behavior theoriesXXX
      1.5D2Uses an asset-based approach that honors the lived experience and knowledge of populations/individualsXXX
      1.5D3Identifies how population/individual culture impacts behaviorXX
      1.5D4Considers how knowledge, beliefs, and attitudes and lived experiences impacts behaviorsXX
      1.5D5Creates community-engaged assessments on knowledge, beliefs, and attitudes that incorporates health equityX
      1.5EFood security defined as factors affecting access to a sufficient quantity of safe, healthful food and water, as well as food-/nutrition-related suppliesXXX
      1.5E1Evaluates access to food at population/individual level (eg, availability and use of food/nutrition assistance programs such as NSLP, emergency preparedness, congregate and home delivered meals, and presence of food deserts)XXX
      1.5E1iDetermines influence of policy/systems and other individual and environmental factors on food access (eg, emergency preparedness)XX
      1.5FPhysical activity, cognitive and physical ability to engage in developmentally appropriate nutrition-related tasks (eg, self-feeding and other activities of daily living [ADLs]), instrumental activities of daily living (IADLs) (eg, shopping, food preparation), and breastfeedingXXX
      1.5F1Assesses interaction of federal food/nutrition assistance programs with other federal assistance programs that promote equal access to care (eg, Title V home visiting programs collaborating with WIC)XX
      1.5GOther factors affecting intake and nutrition and health status (eg, cultural, ethnic, religious, lifestyle influencers, psychosocial, trauma, and social determinants of health)XXX
      1.5G1Collaborates with promotoras/peer/community health workers in assisting with assessmentsXXX
      1.5G2Trains and mentors promotoras/peer/community health workers on proper assessment techniquesXX
      1.6Comparative standards: Uses reference data and standards to estimate nutrient needs and recommended body weight, body mass index, and desired growth patternsXXX
      1.6AIdentifies 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)XXX
      1.6BUses reference standards for guidance (eg, food safety, NAMe and US Preventative Services Taskforce recommendations, DGAsf, CDCg and WHOh [infant growth charts] guidelines)XXX
      1.7Physical activity habits and restrictions: Assesses physical activity, history of physical activity, and physical activity trainingXXX
      1.7AAnalyzes factors of accessibility, adequacy, and safety of the physical environment for both individuals and populationsXXX
      1.7BApplies Physical Activity Guidelines for Americans, NASPEi, and CDC guidelines in assessmentsXXX
      1.7CConsults with exercise scientists, kinesiologists, and physical therapists as appropriateXXX
      1.8Collects 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 statusXXX
      1.8AUses nationally available nutrition assessment data (eg, NHANESj, BRFSS/YRBSS profiles, SHIPsk, Safety Performance Standards)XXX
      1.8BIntegrates knowledge of human nutrition with principles of epidemiologyXX
      1.8CCreates assessment approaches that incorporate assets and lived-experience and minimizes harm to populations/individuals (eg, considers the impact of systemic racism when developing or administering assessments)XX
      1.8DUses biostatistical skills to assess relationships between nutrition-related factors and behaviors/outcomesXX
      1.8EOversees methods and instruments to ensure ongoing collection of valid and reliable quantitative and qualitative assessment data which may include electronic devices or web-based toolsX
      1.9Uses collected data to identify possible problem areas for determining nutrition diagnosesXXX
      1.9AUses health theories to cluster nutrition risk factorsXXX
      1.9BGains deep understanding of epidemiological principles to interpret the magnitude and directionality of nutrition-related risk factorsXX
      1.9CAnalyzes data in a way that minimizes harm and promotes health equityXX
      1.10Documents and communicates:
      1.10ADate and time of assessmentXXX
      1.10BPertinent data (eg, medical, social, behavioral)XXX
      1.10CComparison to appropriate standardsXXX
      1.10DPopulation/individual perceptions, values and motivation related to presenting problemsXXX
      1.10EChanges in population/individual perceptions, values and motivation related to presenting problemsXXX
      1.10FReason for discharge/discontinuation or referral, if appropriateXXX
      1.10GProgress and evaluations to funders, policy makers, community partners, and other stakeholdersXXX
      1.10HAssessment findings via a brief or report with community partners and stakeholdersXXX
      1.10IFeedback from community partners and stakeholders in documenting program justifications and in planning program designXX
      Examples of Outcomes for Standard 1: Nutrition Assessment
      • Appropriate assessment tools and procedures (matching assessment method to situation) are implemented (eg, focus groups to assess population-level barriers to accessing SNAP-Edl) or other federal food/nutrition assistance programs
      • Appropriate and pertinent data are collected across individual, community, and social determinants of health domains (eg, demographic data such as age, gender, race, ethnicity, income, migrant status or health indicator data such as low birth weight, prematurity, anemia, overweight, obesity, special needs, food security)
      • Effective interviewing methods are utilized (eg, USDAm Participant Centered Value Enhanced Nutrition Assessment [VENA])
      • Use of population-level assessment data leads to the determination that a nutrition diagnosis/problem does or does not exist (eg, food/nutrition insecurity among older adults)
      • Consultation with or referral to other community partners and stakeholders is incorporated into program processes (eg, assessment of access to Double Up Food Bucks)
      • Documentation and communication of assessments are complete, relevant, accurate, timely, and minimize harm while promoting health equity (eg, individual care plans and/or population level executive summary reports)
      Standard 2: Nutrition Diagnosis

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

      Rationale:

      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 IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Diagnoses nutrition problems based on evaluation of assessment data and identifies supporting concepts (ie, etiology, signs, and symptoms)XXX
      2.1ARelates problems/diagnoses to demographics and characteristics of population groups; consults with more experienced practitioners as neededXXX
      2.1BIdentifies and labels individual, social, environmental, community or policy conditions that are influencing the problem(s) using health behavior theory such as the social-ecological model; consults with more experienced practitioners as neededXXX
      2.1CRelates risk factors to broad community health indicators (eg, cultural child feeding practices in relation to nutrition/health risk factors)XXX
      2.1DUses epidemiological data to evaluate the personal and social determinants that impact the nutrition diagnosis(es) and overall health equityXX
      2.1EApplies epidemiological methodologies (ie, surveys) and other qualitative methods (ie, focus groups and interviews) to determine the incidence and prevalence of common signs, symptoms and risk factors among population groups including trends in chronic disease risk and health disparitiesXX
      2.1FDesigns nutrition epidemiology studies to understand clustering of signs and symptoms and incorporates an asset-based approachX
      2.2Prioritizes 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
      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 from definitions within The Joint Commission Glossary of Terms56 and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation).50
      perception of importance
      XXX
      2.2ARelates the population’s/individual's diagnosis(es) to food and environment strengths and challenges in the communityXXX
      2.2BPrioritizes individual, social, environmental, community, or policy conditions that can be addressed to mitigate the nutrition diagnosis(es)XX
      2.3Communicates the nutrition diagnosis(es) to patients/clients/advocates, stakeholders, community, family members or other health care professionals when possible and appropriateXXX
      2.3AConsults with other community and public health practitioners and community leadersXXX
      2.3BValidates nutrition diagnosis(es) with nutrition surveillance data, population-based research and community feedbackXX
      2.3CConsiders the framing of the communication and makes adjustments in order to promote health equity and to minimize harm for the population/individualX
      2.4Documents 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 statement(s)] or Assessment [A], Diagnosis [D], Intervention [I], Monitoring [M], and Evaluation [E] [ADIME statement(s)])XXX
      2.4AAssesses prevalence and incidence of nutrition diagnoses at a population levelXX
      2.4BFrames and communicates diagnoses within the context of logic models, health behavior theories, and/or population outcomes data while minimizing harmXX
      2.5Re-evaluates and revises nutrition diagnosis(es) when additional assessment data become availableXXX
      2.5AApplies timely and relevant standards, program evaluation and research-based evidence to population groupsXXX
      2.5BTracks changes and trends in diagnosesXXX
      2.5CConfers with biostatisticians and other experts to discuss methodologiesXX
      2.6Documents and communicates:
      2.6ADate and time of diagnosisXXX
      2.6BPertinent data (eg, medical, social, environmental, behavioral)XXX
      2.6CComparison to appropriate standardsXXX
      2.6DPopulation/individual experiences, perceptions, values and motivation related to diagnosesXXX
      2.6EChanges in population/individual experiences, perceptions, values and motivation related to diagnosesXXX
      2.6FProgress and evaluations to funders, policy makers, community partners, and other stakeholdersXXX
      2.6GDiagnosis via a brief or report with the community partners and stakeholdersXX
      2.6HFeedback from community partners and stakeholders in documenting diagnosisXX
      Examples of Outcomes for Standard 2: Nutrition Diagnosis
      • Nutrition Diagnostic Statements that are: 1) Clear and concise; 2) Specific population- or individual-centered; 3) Science-based; 4) Based on reliable and accurate assessment data; and 5) Includes date and time. Examples:
        • Inadequate physical activity related to limited outside recess after school lunch as evidenced by children returning immediately to class after school lunch
        • Percent of low-income schools implementing policies for recess-before-lunch or at least 30 minutes of daily outside recess
        • Increase in community breastfeeding initiation rates with implementation of social media texting program targeting prenatal women who are in the third trimester
      • Documentation of nutrition diagnosis(es) is relevant, accurate and timely (eg, applicable population-level data reports on public health problems [obesity, anemia, neural tube defects] are generated and retained within a standardized computer database system using a consistent procedure at regular intervals)
      • Documentation of nutrition diagnosis(es) is revised and updated as additional assessment data become available (eg, as maternal weight gain data become available for a population of pregnant women, the data are entered into a computer database system and analyzed on a periodic basis. The determination of prevalence will occur at regular intervals with documentation of any increase or decrease in excessive maternal weight gain over time)
      • Improved health equity in the creation and communication of diagnoses
      Standard 3: Nutrition Intervention/Plan of Care

      The registered dietitian nutritionist (RDN) identifies and implements appropriate, person- and population-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.
      • Planning involves prioritizing the nutrition diagnoses, conferring with the patient/client and others, reviewing practice guidelines, protocols and policies, setting goals and defining the specific nutrition intervention strategy.
      • Implementation is the action phase that includes carrying out and communicating the intervention/plan of care, continuing data collection, and revising the nutrition intervention/plan of care strategy, as warranted, based on change in condition and/or the patient/client/population response.
      An RDN implements the interventions or assigns components of the nutrition intervention/plan of care to professional, technical and support staff in accordance with knowledge/skills/judgment, applicable laws and regulations, and organization policies. The RDN collaborates with or refers to other health care professionals and resources. The nutrition intervention/ plan of care is ultimately the responsibility of the RDN. Population-level programs involve policy, system, and environmental interventions. Direct care from public health and community RDNs can involve the development, implementation, and adaptation of policies, systems, and/or environments as they relate to nutrition outcomes.
      Indicators for Standard 3: Nutrition Intervention/Plan of Care
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      Plans the Nutrition Intervention/Plan of Care:
      3.1Addresses the nutrition diagnosis(es) by determining and prioritizing appropriate interventions for the plan of careXXX
      3.1AConsiders the following when determining the nutrition interventions:
      • individual/population needs, wants, and desires
      • immediacy of the problem and severity of nutrition risk or malnutrition, if present
      • readiness of individual/population to receive selected nutrition interventions
      • presence of social determinants of health (eg, housing, food access, health care access) or
      • other conditions that impact transitions of care needs/plans
      XXX
      3.1BConsiders interventions such as integrative and functional therapies, behavior modificationXXX
      3.2Bases intervention/plan of care on best available research/evidence and information, evidence-based guidelines, and best practicesXXX
      3.2ACreates interventions based on funding requirements, including as appropriate, state and federal guidelinesXXX
      3.2BConsiders health behavior theory (eg, socio-ecological model) when developing interventionsXXX
      3.2CConsiders lived experience and cultural norms (eg, ethnicity, religion) when developing interventionsXXX
      3.2DCollaborates with community partners and stakeholders when developing interventionsXXX
      3.2ECollaborates with epidemiologists and/or biostatisticians to refine project goals, available resources, and measuresXX
      3.2FLeads the development of intervention guidelines and outcome measures for local, state, and/or national nutrition services typically with the aim of promoting health equityX
      3.3Refers to policies and procedures, protocols, and program standardsXXX
      3.3AUses community-/population-based national standards and guidelines/standards such as DGAs, MyPlate, and community health indicators in intervention planningXXX
      3.3BCoordinates with community partners and stakeholders to align messages across programs, to strengthen messaging and leverage fundingXX
      3.3CDevelops policy, systems, and environmental change approaches to maximize population reachX
      3.4Collaborates with patient/client/advocate/population, caregivers, interprofessional
      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, psychologists, epidemiologists, social workers, planners, and other public health professionals), depending on the needs of the individual/population. Interprofessional could also mean interdisciplinary or multidisciplinary.
      team, and other health care professionals
      XXX
      3.4ACollaborates with community partners and stakeholders to identify priorities and community needs to promote health equityXXX
      3.4BCommunicates priorities and community needs to policy and other decision makers to support nutritional health of the populationXXX
      3.4CRaises awareness on policy-related issues with community partners, stakeholders, and policy makers that can impact environmental conditions contributing to nutritional health problems (eg, federal food/nutrition programs and food regulations)XX
      3.4DConvenes and collaborates with multi-sector public and private community coalitions and partners (eg, urban planners, NGOsn, non-profits, breastfeeding coalitions, advocacy organizations) to develop and implement policy, systems, and environmental changesX
      3.5Works with patient/client/advocate/population, and caregivers to identify goals, preferences, discharge/transitions of care needs, plan of care and expected outcomesXXX
      3.5ACollaborates with community partners and stakeholders to identify priorities and community needs to promote health equityXXX
      3.5BUses logic model for planning and implementation of interventions, considering population as well as the broader community according to needs assessmentXXX
      3.5CCreates goals that are inclusive of health equity, cultural sensitivity, geographic diversity, socio-economic diversity, practical implementationXXX
      3.5DIncorporates the concepts of the social determinants of health into programs and services that promote health equity and minimize/eliminate health disparitiesXXX
      3.5D1Focuses interventions on prevention approachesXXX
      3.6Develops the nutrition prescription and establishes measurable patient-/client-focused goals to be accomplishedXXX
      3.6AIdentifies, selects, and/or develops evidence-based or best available research/evidence, programs, and science-based nutrition education materials based on nutritional needs of the population; consults with more experienced practitioners as neededXXX
      3.6BImplements health promotion and disease prevention activities that are based on population’s nutritional status and inclusive of health equityXXX
      3.6CIntervenes and coordinates on all levels of the socio-ecological model to promote population healthXX
      3.7Defines time and frequency of care including intensity, duration, and follow-upXXX
      3.7ADevelops short-, intermediate- and long-term interventions using logic models and needs assessment dataXXX
      3.7BUses realistic and appropriate timeframes to measure outcomes, with the understanding that some interventions can take many years to see changeXXX
      3.7B1Describes specific time frames for each level of intervention, with intrapersonal and interpersonal components generally taking shorter periods of time, and community or systems interventions taking yearsXXX
      3.7B2Defines measures specific to intervention outcomes, which could require months, years, or decades for each measureXX
      3.7B3Develops guidelines for timing of interventions and follow-up based on research and best practicesX
      3.8Uses standardized terminology for describing interventionsXXX
      3.8AIncorporates standard terminology from the fields of nutrition and public health, systems/environmental approaches, including the Public Health Community Nutrition Care Process ToolkitXXX
      3.8BFrames intervention-related communication to community partners and stakeholders (eg, policy, legislation, business, community)XX
      3.9Identifies resources and referrals neededXXX
      3.9AApplies factors that impact accessibility, adequacy and safety of food supply, and food/nutrition security to population healthXXX
      3.9A1Connects population groups to services for food/water supplies and systems (via agriculture, business, retail, safety net programs, public institutions, hospitals)XXX
      3.9A2Uses information about nutrients and contaminants in the food and water supply in planning the interventionXX
      3.9BLinks individuals/populations to food and nutrition services to assure optimal nutritional status (eg, food pantries, home-delivered meals programs, SNAP-Ed, free- and reduced-price school meals, Summer Food Service Program, Child and Adult Care Food Program, WIC) and assists them with determining program eligibility and enrollment optionsXXX
      3.9CUses an interprofessional and participatory approach to leverage resources across systemsXX
      3.9DEstablishes and maintains interagency networks based on individual/population intervention needs; links nutrition and other servicesX
      Implements the Nutrition Intervention/Plan of Care:
      3.10Collaborates with colleagues, interprofessional team, and other health care professionalsXXX
      3.10AIdentifies community partners, stakeholders, and collaborators to collaborate on programs and servicesXXX
      3.10BCollaborates within and across agencies and organizations including other governmental sectors, non-profits, community partners, business/insurance companies, industry and coalitions that work on addressing population health issues (eg, disparities in access to food, nutrition intake)XX
      3.10CAdvocates for evidence-based and best available research/evidence approaches to addressing nutrition-related population health issues with policy makers, elected officials, and other influential leadersXX
      3.10DMobilizes community partners and stakeholders including food policy councils/coalitions while building community leadership capacity for change to create health promoting environments and practicesX
      3.11Communicates and coordinates the nutrition intervention/plan of careXXX
      3.11APartners with primary health care providers to ensure community nutrition services comply with individuals’ plans of careXXX
      3.11BParticipates in boards, organizations, task forces, committees, coalitions, and partnerships in the community to support interventionsXX
      3.11CDisseminates intervention plans and outcomes with community partners and stakeholders in a transparent mannerXX
      3.11DConvenes boards, organizations, task forces, committees, coalitions, and partnerships in the community to support interventionsX
      3.12Initiates the nutrition intervention/plan of careXXX
      3.12AUses approved clinical privileges, physician/non-physician practitioner
      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.50,51 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 long-term care 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.53,54 Acronyms:aWIC=Special Supplemental Nutrition Program for Women Infants and Children (United States) (http://www.fns.usda.gov/wic/women-infants-and-children-wic)bBRFSS=Behavioral Risk Factor Surveillance System (http://www.cdc.gov/brfss/index.htm)cYRBSS=Youth Risk Behavior Surveillance System (http://www.cdc.gov/HealthyYouth/yrbs/index.htm)dNSLP=National School Lunch Program (http://www.fns.usda.gov/nslp/national-school-lunch-program-nslp)eNAM=National Academies of Medicine (United States) (https://nam.edu/)fDGA=Dietary Guidelines for Americans (http://www.cnpp.usda.gov/dietaryguidelines)gCDC=Centers for Disease Control and Prevention (United States) (http://www.cdc.gov)hWHO=World Health Organization (http://www.who.int/en/)iNASPE=National Standards for Physical Education (http://www.shapeamerica.org/standards/pe/)jNHANES=National Health and Nutrition Examination Survey (United States) (http://www.cdc.gov/nchs/nhanes.htm)kSHIPs=State Health Improvement Plans (http://www.astho.org/WorkArea/DownloadAsset.aspx?id¼6597)lSNAP-Ed=Supplemental Nutrition Assistance Program Education (http://www.fns.usda.gov/snap/supplemental-nutritionassistance-program-education-snap-ed)mUSDA=US Department of Agriculture (http://www.usda.gov/wps/portal/usda/usdahome)nNGOs=nongovernmental organizations
      -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 policy
      XXX
      3.12A1Implements, initiates, or modifies orders for therapeutic diet, nutrition-related pharmacotherapy management, or nutrition-related services (eg, baby or metabolic formula, medical foods/ nutrition/dietary supplements, food texture modifications, enteral and parenteral nutrition, intravenous fluid infusions, laboratory tests, medications, and education and counseling)XXX
      3.12A1iWorks to ensure access to metabolic formula through federal and state programs (eg, newborn screening/Title V)XXX
      3.12A2Manages 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)XXX
      3.12A3Initiates and performs nutrition-related services (eg, bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, and indirect calorimetry measurements, or other permitted services)XXX
      3.12BEnsures availability of quality nutrition services to target populations including screening, assessment, education, counseling, and referral to food assistance programsXXX
      3.12CConsiders social/ethnic disparities, systemic racism, culture, food access, and socio-economic status in developing nutrition interventionsXXX
      3.12DEmploys a variety of strategies (eg, social media, billboards, flyers, public service announcements, radio ads) to reach/educate populationXX
      3.13Assigns activities to NDTR and other professional, technical and support personnel in accordance with qualifications, organizational policies/ protocols, and applicable laws and regulationsXXX
      3.13ASupervises professional, technical and support personnelXXX
      3.13A1Engages community volunteersXX
      3.13A2Collaborates with and oversees community health workers (ie, paraprofessionals, lay health workers, promotoras)XX
      3.13A3Mobilizes cross-disciplinary staff in program interventions (eg, school and school foodservice staff, government professionals, public university employees, city planners, and community advocates)X
      3.14Continues data collectionXXX
      3.14ATracks progress towards achieving short, intermediate, and long-term outcomes according to intervention plans often using logic modelsXXX
      3.14BObtains and uses individual/population and community input and feedback in asset mapping, needs assessment, gap analysis, program outputs and outcomesXX
      3.14CTrains staff on data collection protocols and methodsXX
      3.15Documents:
      3.15ADate and timeXXX
      3.15BSpecific and measurable treatment goals and expected outcomesXXX
      3.15CRecommended interventionsXXX
      3.15DPopulation/individual/advocate/caregiver/community receptivenessXXX
      3.15EReferrals made and resources usedXXX
      3.15FPopulation/individual/advocate/caregiver/community comprehensionXXX
      3.15GKnowledge, skill, and behavior change of populations/individualsXXX
      3.15HBarriers to changeXXX
      3.15IOther information relevant to providing care and monitoring progress over timeXXX
      3.15JPlans for follow up and frequency of careXXX
      3.15KRationale for discharge or referral if applicableXXX
      3.16Reports to funders, policy makers, community partners, and other stakeholdersXXX
      3.17Communicates and disseminates intervention acceptability, feasibility, and/or efficacy via a brief or report with community partners and stakeholdersXXX
      3.17AIntegrates feedback from community partners and stakeholders on intervention acceptability, feasibility, and/or efficacyXX
      Examples of Outcomes for Standard 3: Nutrition Intervention/Plan of Care
      • Documentation of nutrition intervention/plan of care is: 1) Comprehensive (eg, revisions and updates to WIC policies, education and practices); 2) Specific (eg, ways to incentivize fruit and vegetable purchases); 3) Accurate (eg, uses best available research/evidence approaches); 4) Relevant (eg, allows adaptation for cultural preferences); 5) Timely (eg, relevant to cultural and political context at a given moment); and 6) Dated and Timed (eg, documentation in WIC records)
      • Documentation of nutrition intervention/plan of care is revised and updated as needed and determined by epidemiological/tracking data. Considers nutrition and food/nutrition insecurity as a nutrition diagnosis and refers individuals to nutritional services and food assistance programs
      • Convene stakeholders and community partners (school officials, teachers, food service directors, elected officials) to present plan for increasing school breakfast program offering within a county school system to address high levels of childhood food/nutrition insecurity
      • Appropriate prioritizing and setting of goals/expected outcomes
      • Community partners and stakeholders involvement as an interprofessional team, as appropriate, in developing nutrition intervention/plan of care
      • Appropriate individualized population/individual-centered nutrition intervention/plan of care, including nutrition prescription, is developed (eg, schedule intervention team meeting to plan intervention including review of policies and practices, setting goals to increase participation in congregate meals)
      • Interprofessional collaborations are used (eg, food bank RDNs collaborate with business owners and farmers to increase availability of fresh produce to clients/populations)
      • Logic model is used as a dynamic tool to document intervention/plan of care
      • Improvement of health equity and community engagement in nutrition-related interventions
      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 services 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. Population-level programs involve policy, system, and environmental interventions. Direct care for public health and community RDNs can involve the monitoring and evaluation of nutrition-related policies, systems and/or environments.
      Indicators for Standard 4: Nutrition Monitoring and Evaluation
      Bold Font Indicators are Academy Core RDN Standards of Practice IndicatorsThe “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      4.1Monitors progress:XXX
      4.1AAssesses patient/client/advocate/population understanding and compliance with nutrition intervention/plan of careXXX
      4.1A1Tracks nutrition-related behaviors at a population levelXXX
      4.1A1iUses principles of epidemiology and basic biostatistics to track trendsXX
      4.1A2Applies a range of evaluative measures (eg, qualitative, quantitative, outcome and process information)XX
      4.1A3Determines evaluation measures and systems for use with population/individual interventionsX
      4.1BDetermines whether the nutrition intervention/plan of care is being implemented as prescribedXXX
      4.1B1Adjusts intervention based on evaluation dataXX
      4.1B2Determines if measures are capturing desired outcomes (ie, reliability and validity of measures)XX
      4.1B3Integrates related health data sets into intervention planning and adjustmentsX
      4.2Measures outcomes:XXX
      4.2ASelects the standardized nutrition care measurable outcome indicator(s)XXX
      4.2A1Identifies and tracks measurable outcome indicators at a population levelXXX
      4.2BIdentifies positive or negative outcomes including impact on potential needs for discharge/transitions of careXXX
      4.2B1Documents effectiveness, accessibility, and quality of population-based servicesXX
      4.2B2Identifies unintended consequences and outcomes, adjusts intervention based on findings (especially at policy, environmental, and system level)X
      4.3Evaluates outcomes:XXX
      4.3ACompares monitoring data with nutrition prescription and established goals or reference standardXXX
      4.3A1Adjusts population level goals based on data outcomes and comparisonsXX
      4.3A2Benchmarks datasets from program participants to national, state, and local public health datasets (eg, Healthy People National Health Objectives, health plan employer data and information set)X
      4.3BEvaluates impact of the sum of all interventions on overall patient/client/population health outcomes and goalsXXX
      4.3B1Participates in the evaluation of interventionsXXX
      4.3B2Leads evaluation of the efficacy and effectiveness of interventions on overall population/individual health outcomes in partnership with stakeholders and the communityXX
      4.3B3Analyzes legislative impact on health programs, federal food/nutrition assistance programs, policies, and interventionsXX
      4.3B4Informs regulation development/changes by the interventions’ impact and outcomesX
      4.3CEvaluates progress or reasons for lack of progress related to problems and interventionsXXX
      4.3C1Assesses program/intervention assessment tools for reliability and validityXX
      4.3C2Engages population, community partners, and other stakeholders to understand evaluation outcomes (eg, satisfaction surveys, focus groups)XX
      4.3C3Communicates evaluation outcomes related to barriers and progress to community partners and stakeholdersXX
      4.3C4Develops and disseminates recommendations to inform regulatory and programmatic changes informed by evaluation progressX
      4.3DEvaluates evidence that the nutrition intervention/plan of care is maintaining or influencing a desirable change in the patient/client/population behavior or statusXXX
      4.3D1Evaluates behavior change through knowledge, skills, and access utilizing the application of social, behavioral, and educational theoriesXXX
      4.3D2Evaluates impact of health status of populations participating in public health nutrition servicesXX
      4.3D3Identifies complex underlying problems beyond the scope of nutrition, based on the social determinants of health, that are influencing the intervention and recommends appropriate intervention, partnering with community partners and stakeholdersX
      4.3ESupports conclusions with evidenceXXX
      4.3E1Applies evidence-based approaches to evaluation at the population levelXXX
      4.3E2Communicates conclusions and recommendations informed by the evidence to community partners and stakeholdersXX
      4.3E3Develops and disseminates conclusions supported by the evaluation evidence to inform regulatory and programmatic changeX
      4.3FApplies surveillance systems to monitor population health over timeXX
      4.3GEvaluates impact of policy on health status of a population groupX
      4.4Adjusts nutrition intervention/plan of care strategies, if needed, in collaboration with patient/client/population/advocate/caregiver and interprofessional teamXXX
      4.4AImproves or adjusts intervention/plan of care strategies based upon outcomes data, trends, best practices, and comparative standardsXXX
      4.4A1Monitors intervention for achievement of expected outcomesXXX
      4.4A2Conducts process evaluations and fidelity assessments to ensure that programs are being implemented according to standards/plans and for potential efficienciesXX
      4.4BUses population level data to inform and adjust program(s) and objectivesXX
      4.4CUses formative research and focus group testing for ongoing program/intervention planning, evaluation, and adjustments for optimal outcomesXX
      4.4DMobilizes community partners/stakeholders in analysis and troubleshootingXX
      4.4EMentors and guides process and planning in unpredictable and dynamic situations (eg, in Community Health Assessment [CHA] and Community Health Improvement Planning [CHIP] processes)X
      4.5Documents:
      4.5ADate and timeXXX
      4.5BIndicators measured, results, and the method for obtaining measurementXXX
      4.5CCriteria to which the indicator is compared (eg, nutrition prescription/goal or a reference standard)XXX
      4.5DFactors facilitating or hampering progressXXX
      4.5EOther positive or negative outcomesXXX
      4.5FAdjustments to the nutrition intervention/plan of care, if indicatedXXX
      4.5GFuture plans for nutrition care, nutrition monitoring and evaluation, follow up, referral, or dischargeXXX
      4.5HUses the logic model as a dynamic tool to document revisions/updates to the plan of care, especially in population-based interventionsXXX
      4.5IReports to funders, policy makers, community partners, and other stakeholdersXXX
      4.6Communicates and disseminates evaluation findings via a brief or report with the community partners and stakeholdersXX
      4.7Integrates feedback from community partners and stakeholders in documenting evaluationXX
      4.7AUses public health principles of epidemiology and Equitable Evaluation Framework (www.equitableeval.org) in all documenting monitoring and tracking of outcomesXX
      Examples of Outcomes for Standard 4: Nutrition Monitoring and Evaluation
      • The population/individual outcome(s) directly relate to the nutrition diagnosis and the goals established in the nutrition intervention/plan of care. Examples include, but are not limited to:
        • Nutrition outcomes (eg, change in knowledge, behavior, food, or nutrient intake)
        • Clinical and health status outcomes (eg, change in laboratory values, body weight, blood pressure, risk factors, signs and symptoms, clinical status, infections, complications, morbidity, and mortality)
        • Individual-centered outcomes (eg, quality of life, satisfaction, self-efficacy, self-management, functional ability)
        • Population-centered outcomes (eg, access to and consumption of fruits/vegetables, changes in prevalence of nutrition and food/nutrition insecurity, increase in rate of breastfeeding duration, increased access to federal food/nutrition assistance programs, and improved food systems)
        • Health care utilization and cost effectiveness outcomes (eg, special procedures, decreased admission for preventable nutrition related problems, prevented or delayed morbidity, and mortality)
      • Documentation of nutrition monitoring and evaluation is comprehensive, specific, accurate, relevant, and timely
      • Process includes long-term tracking and monitoring of health equity and social determinants of health.
      a 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 from definitions within The Joint Commission Glossary of Terms
      The Joint Commission
      Glossary.
      and the Centers for Medicare and Medicaid Services, Hospital Conditions of Participation).
      State Operations Manual: 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.
      b 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, psychologists, epidemiologists, social workers, planners, and other public health professionals), depending on the needs of the individual/population. Interprofessional could also mean interdisciplinary or multidisciplinary.
      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.
      State Operations Manual: 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. 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.
      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 long-term care 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.
      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)
      US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      ,
      State Operations Manual. Appendix PP: Guidance to surveyors for long-term care facilities (Rev. 173, 11-22-17); § 483.30 Physician Services, § 483.60 Food and Nutrition Services
      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed June 7, 2022.
      Figure 5Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Public Health and Nommunity Nutrition. The term customer is used in this evaluation resource as a universal term. Customer could also mean population, client/patient/customer, family, participant, consumer, or any individual, group, or organization to which the RDN collaborates with or provides service.
      Standards of Professional Performance for Registered Dietitian Nutritionists in Public Health and Community Nutrition

      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:CompetentProficientExpert
      1.1Complies with applicable laws and regulations as related to his/her area(s) of practiceXXX
      1.1AAdheres to laws and regulations regarding discrimination (eg, hiring, contractors, and customers), and provides appropriate signage and training as needed (eg, USDAa nondiscrimination statement)XXX
      1.2Performs within individual and statutory scope of practice and applicable laws and regulationsXXX
      1.2AIncorporates the Public Health Core Functions and 10 Essential Services in practice (https://www.cdc.gov/publichealthgateway/publichealthservices/essentialhealthservices.html)XXX
      1.2BFollows any additional scope of practice requirements related to additional credentialing or position (eg, Certified Health Education Specialist [CHES], Certified Diabetes Care and Education Specialist [CDCES])XXX
      1.3Adheres to sound business and ethical billing practices applicable to the settingXXX
      1.3AProvides accurate and timely financial reports to funders (eg, federal, tribal, state, local or community governmental organizations, foundations, and non-profits) as fiscal stewards of public and philanthropic fundsXX
      1.4Uses national quality and safety data (eg, National Academies of Sciences, Engineering, and Medicine: Health and Medicine Division, National Quality Forum, Institute for Healthcare Improvement) to improve the quality of services provided and to enhance customer-centered servicesXXX
      1.4AContributes to interprofessional team to promote understanding and adoption of national quality and safety dataXX
      1.4BLeads local, state, national, and/or international quality initiative efforts to support public health and community nutrition goals and best practicesX
      1.5Uses a systematic performance improvement model that is based on practice knowledge, evidence, research, and science for delivery of the highest quality servicesXXX
      1.5AIncorporates health behavior theory, logic models, and/or other appropriate models to plan and implement programs and services; consults with more experienced practitioners as neededXXX
      1.5BDevelops logic models and/or other appropriate models to plan and implement programs and servicesXX
      1.5CMentors less experienced practitioners on using appropriate models to plan and implement programs and servicesX
      1.6Participates in or designs an outcomes-based management system to evaluate safety, effectiveness, quality, person-centeredness, equity, timeliness, and efficiency of practiceXXX
      1.6AInvolves colleagues and others, as applicable, in systematic outcomes managementXXX
      1.6A1Engages community members, funders, and interprofessional stakeholders in developing and monitoring outcomes-based management systemsXX
      1.6BDefines expected outcomesXXX
      1.6B1Includes process, impact, and outcome indicators, often with the support of logic modelsXXX
      1.6B2Relates program outcomes to multi-level outcomes (eg, agency, program, population/individual outcomes/needs)XX
      1.6CUses indicators that are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.)XXX
      1.6C1Develops benchmarks to evaluate the success of the nutrition initiativeXX
      1.6DMeasures quality of services in terms of structure, process, and outcomesXXX
      1.6D1Considers short-, medium- and long-term outcomes, collaborating across agencies and partners, including cost effectivenessXX
      1.6EIncorporates electronic clinical quality measures to evaluate and improve care of population/individuals at risk for malnutrition or with malnutrition (www.eatrightpro.org/emeasures) or nutrition/food insecurityXXX
      1.6E1Ensures that nutrition assessment using evidence-based screening tools for the setting and/or population is a component of program planningXXX
      1.6FDocuments outcomes and patient reported outcomes (eg, PROMIS
      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.
      )
      XXX
      1.6F1Engages interprofessional partners, including the community, in documenting outcomes and impactXX
      1.6GParticipates in, coordinates, or leads program participation in local, regional or national registries and data warehouses used for tracking, benchmarking, and reporting service outcomesXXX
      1.7Identifies and addresses potential and actual errors and hazards in provision of services or brings to attention of supervisors and team members as appropriateXXX
      1.7AApplies food safety and sanitation protocols within food distribution programsXXX
      1.7BWorks closely with federal, tribal, state, and local regulatory bodies to inform the public on food recalls, supply chain issues and environmental hazards based on epidemiological surveillance dataXX
      1.7CApplies Health Impact Assessments (https://www.cdc.gov/healthyplaces/hia.htm) and/or biostatistical assessments to address unintended consequencesXX
      1.7DLeads, in collaboration with stakeholders, development of processes to identify, address, and prevent errors or hazards (eg, state food safety protocols)X
      1.8Compares actual performance to performance goals (ie, Gap Analysis, SWOT Analysis [Strengths, Weaknesses, Opportunities, and Threats], PDSA Cycle [Plan-Do-Study-Act], DMAIC [Define, Measure, Analyze, Improve, Control])XXX
      1.8AReports and documents action plan to address identified gaps in care and/or service performanceXXX
      1.9Evaluates interventions and workflow process(es) and identifies service and delivery improvementsXXX
      1.9AParticipates in dissemination and collection of intervention evaluationsXXX
      1.9BEngages community members and stakeholders in intervention evaluations (eg, satisfaction surveys, alignment with cultural norms, process and outcome evaluations)XX
      1.9CDesigns systems and process for obtaining community and stakeholder participation in intervention evaluationsX
      1.10Improves or enhances population/individual care and/or services working with others based on measured outcomes and established goalsXXX
      1.10AUses culturally sensitive group engagement processes to improve /enhance servicesXXX
      1.10BEnsures that services account for social determinants of health, health disparities, cultural competence, racial equity, and health equityXXX
      1.10COversees and revises process and outcome evaluation efforts to improve servicesXX
      1.10DLeads the development of performance improvement activities; designs and implements evaluation protocols, analyzes data, and implements improvementsX
      Examples of Outcomes for Standard 1: Quality in Practice
      • Actions are within scope of practice and applicable laws and regulations (eg, in providing MNTb/counseling; resources and guides individuals/populations based on state WIC, school nutrition, and/or CACFP policies)
      • Use of national quality standards and best practices are evident in individual/population-centered services (eg, organizes, participates in training on, and demonstrates effective application of Value Enhanced Nutrition Assessment)
      • Performance indicators are specific, measurable, attainable, realistic, and timely (S.M.A.R.T.) (eg, ensures program objectives align with and evaluation tools are valid and reliable in measuring intended outcomes)
      • Aggregate outcomes meet pre-established criteria (eg, application of safe food handling guidelines results in lowered risk/incidence of foodborne illness in food rescue program)
      • Results of quality improvement activities direct refinement and advancement of practice (eg, focus groups and client feedback forms are used to measure satisfaction with program participation and areas for improved delivery)
      Standard 2: Competence and Accountability

      The registered dietitian nutritionist (RDN) demonstrates competence in and accepts accountability and responsibility for ensuring 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 for individuals and populations.
      Indicators for Standard 2: Competence and Accountability
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      2.1Adheres to the code(s) of ethics (eg, Academy/CDR, other national organizations, and/or employer code of ethics)XXX
      2.1AApplies Public Health Code of Ethics (https://www.apha.org/-/media/files/pdf/membergroups/ethics/code_of_ethics.ashx) and the principle of interdependence of people and the health of the communityXXX
      2.1BApplies Academy/CDR and Public Health Codes of Ethics within the context of federal, tribal, state, local, and agency guidelines (eg, advocacy guidelines)XXX
      2.2Integrates the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) into practice, self-evaluation, and professional developmentXXX
      2.2AIntegrates applicable focus area SOPs and SOPPs into practice according to populations served (eg, Sustainable, Resilient, and Healthy Food and Water Systems, Diabetes Care, Pediatric Nutrition)XXX
      2.2BIncorporates the Public Health Community Nutrition SOP and SOPP into human resources systems (eg, job descriptions and performance plans, competence assurance evaluations)XX
      2.3Demonstrates and documents competence in practice and delivery of customer-centered service(s)XXX
      2.3ADocuments the engagement of the community and stakeholders in the delivery of servicesXXX
      2.4Assumes accountability and responsibility for actions and behaviorsXXX
      2.4AIdentifies, acknowledges, and corrects errorsXXX
      2.4A1Reports errors and problems to funding agencies and ethical review boardsXX
      2.4BUses lessons learned from previous projectsXX
      2.4CEnsures that all staff (including paraprofessionals or colleagues in other disciplines) have adequate training to deliver appropriate services; seeks consultation if neededXX
      2.4DDirects and develops policies that assure accountabilityX
      2.5Conducts self-assessment at regular intervalsXXX
      2.5AIdentifies needs for professional developmentXXX
      2.5BUses self-assessment tools such as those incorporated in the Guidelines for Developing and Enhancing Skills in Public Health and Community Nutrition Practice, 3rd Edition (https://www.phcnpg.org/phcn/resources/2018-3rd-edition-the-guide) and/or Maternal Child Health Navigator (https://www.mchnavigator.org/assessment/)XXX
      2.6Designs and implements plans for professional developmentXXX
      2.6ADevelops plan and documents professional development activities in career portfolio (eg, organizational policies and procedures, credentialing agency[ies])XXX
      2.6A1Includes professional development goals around core competencies for public health practice (https://www.phf.org/programs/corecompetencies/Pages/Core_Competencies_Domains.aspx)XXX
      2.6A2Includes professional development goals to develop or enhance knowledge and skills related to public health nutrition categories of practice (eg, nutrition; advocacy; communication; research; policy, systems, and environmental change; and leadership)XX
      2.7Engages in evidence-based practice and uses best practicesXXX
      2.7AIncorporates best practices for addressing the health needs of individuals and population groupsXXX
      2.7BCollaborates with key partners and allied professionals (eg, urban planners, social workers) to ensure incorporation of evidence-based and best practices from their fields in program planning and implementationXXX
      2.7CUses health behavior theories as the framework for best practicesXXX
      2.7DParticipates in councils, committees, and taskforces that shape evidence-based guidelines and practices supported by policyXX
      2.8Participates in peer review of others as applicable to role and responsibilitiesXXX
      2.8AAddresses public health domains in evaluation of self-performance and peer or employee evaluationsXXX
      2.9Mentors and/or precepts othersXXX
      2.9AGuides the professional development and training of paraprofessionals, volunteers, community health workers and promotoras working in the communityXXX
      2.9BMentors or serves as a preceptor for community nutrition students and dietetic interns as well as novice public health students considering specialties in nutrition and food systemsXXX
      2.9CParticipates in mentoring students, dietetic interns, entry-level RDNs and RDNs changing field(s)XX
      2.9DProvides expertise and council to educational institutions related to mentoring and training of community and public health nutrition professionalsX
      2.10Pursues opportunities (education, training, credentials, certifications) to advance practice in accordance with laws and regulations, and requirements of practice settingXXX
      2.10ARemains informed on nutrition practice-related laws and public policyXXX
      2.10BParticipates in training to ensure that programs are fair and equitableXXX
      2.10CMonitors public health nutrition program integrity and gains professional development as it relates to program regulations and nutrition standards (eg, FNSc programming: WICd, CACFPe, NSLPf)XX
      Examples of Outcomes for Standard 2: Competence and Accountability
      • Practice reflects codes of ethics and adheres to ethical principles relevant to public health issues (eg, Skills for the Ethical Practice of Public Health, James Thomas, PhD, MPH, Univ. of N. Carolina – Public Health Leadership Society, 2004)
      • Practice reflects the PHCN SOP and SOPP as a basis for all interactions with organizations, communities, populations, and individuals
      • Competence is demonstrated and documented (Core Competencies for Public Health Professionals, Council on Linkages between Academia and Public Health Practice http://www.phf.org/programs/corecompetencies)
      • Safe, quality population/individual service is provided which is population-/individual-centered recognizing community linkages and relationships among multiple factors/determinants (eg, uses the social–ecological model)
      • Practice incorporates successful strategies for interactions with populations/individuals from diverse backgrounds (cultural, socioeconomic, educational, racial, gender, age, ethnic, sexual orientation, religious, mental/physical capabilities)
      • Self-assessments are conducted regularly using this SOP and SOPP
      • Professional development needs are identified and incorporate assessment of skills for Public Health Professionals (eg, Competency Assessment, Public Health Foundation)
      • Practice reflects evidenced–based practice and best practices – partnerships are developed with other Public Health/Community professionals to build the scientific base
      • Commission on Dietetic Registration recertification requirements are met
      Standard 3: Provision of Services

      The registered dietitian nutritionist (RDN) provides safe, quality service based on 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 the populations/individuals it serves.
      Indicators for Standard 3: Provision of Services
      Bold Font Indicators are Academy Core RDN Standards of Professional

      Performance Indicators
      The “X” signifies the indicators for the level of practice
      Each RDN:CompetentProficientExpert
      3.1Contributes to or leads in development and maintenance of programs/services that address needs of the population(s) and individual(s)XXX
      3.1AAligns program/service development with the mission, vision, principles, values, and service expectations and outputs of the organization/businessXXX
      3.1A1Uses logic models in order to meet the health outcomes of individuals/populationsXXX
      3.1A2Collaborates with stakeholders to meet the needs of population(s)/individualsXX
      3.1A3Develops programs with short-, medium- and long-term goals with a shared vision of health across all levels of the socio-ecological model in order to maximize the reach and effectiveness of programsX
      3.1BUses the needs, expectations, and desired outcomes of the populations/individuals (eg, patients/clients, families, community, decision makers, administrators, client organization[s]) in program/service developmentXXX
      3.1B1Includes the community, policy makers, and other stakeholders in the development of programs in all stages of program development and implementationXXX
      3.1B2Employs a health equity lens to the development of programsXXX
      3.1B3Integrates population-based/formative assessments findings into service deliveryXX
      3.1CMakes decisions and recommendations that reflect stewardship of time, talent, finances, and environmentXXX
      3.1C1Shapes, modifies, and adapts program and service delivery in alignment with population/individual inputXX
      3.1C2Shapes, modifies, and adapts program and service delivery in alignment with funding requirements and prioritiesXX
      3.1C3Works to transform community environments through population-level programs that promote health equityX
      3.1DProposes programs and services that are customer-centered, culturally appropriate, minimize disparities, and promotes health equityXXX
      3.1D1Follows federal guidance (eg, USDA, FNS, and CDCg) to ensure that programming incorporates inclusivity, equality, and equityXXX
      3.1D2Collaborates with community stakeholders in the development, adaptation, and sustainability of programsXXX
      3.1D3Uses and collects data to track changes in health disparities and ensure inclusivity, equality, and equityXX
      3.1D4Creates messages and opportunities to address social justice and social equityXX
      3.1D5Develops recommendations in collaboration with community stakeholders related to policy, systems, and environmental supportX
      3.2Promotes public access and referral to credentialed nutrition and dietetics practitioners for quality food and nutrition programs and servicesXXX
      3.2AContributes to or designs referral systems that promote access to qualified, credentialed nutrition and dietetics practitionersXXX
      3.2A1Ensures that RDNs are part of a interprofessional approach across collaborative programs and effortsXXX
      3.2A2Establishes and/or facilitates networks that include RDNs or nutrition and dietetics technicians, registered and other disciplines who promote PHCNXX
      3.2BRefers customers to appropriate providers when requested services or identified needs exceed the RDN’s individual scope of practiceXXX
      3.2B1Verifies potential referral provider’s care reflects evidence-based information/research and professional standards of practiceXXX
      3.2B2Implements established agreements and referral systems for social and health-related services (eg, dental, family planning, community action agencies)XXX
      3.2B3Creates policies and practices that support a strong safety net for populations/individualsXX
      3.2B4Establishes agreements and referral systems with health and community partnersX
      3.2B5Supports referral sources with curriculum and training regarding needs of individual/populationX
      3.2CMonitors effectiveness of referral systems and modifies as needed to achieve desirable outcomesXXX
      3.2C1Collects and uses data to track effectiveness of referral systems (eg, WIC information systems) for targeted outcomesXXX
      3.2C2Shares aggregate referral data and related outcomes of the referral with external partners (eg, reports on smoking rates)XXX
      3.2C3Completes process and outcome evaluation of referral system and reports back to stakeholders and/or fundersXX
      3.2C4Modifies referral system in collaboration with stakeholders to improve effectivenessXX
      3.3Contributes to or designs population- /individual-centered servicesXXX
      3.3AAssesses needs, beliefs/values, goals, resource, and social determinants of health of the population/individual,XXX
      3.3A1Conducts needs assessments (eg, community health assessments) in partnership with community stakeholders; consults with more experienced practitioners as neededXXX
      3.3A2Develops targeted, tailored, and/or personalized services based on needs assessments and cultural normsXXX
      3.3A3Conducts formative assessments/research in developing servicesXX
      3.3BUses knowledge of the population’s/individual’s health conditions, cultural beliefs, and business objectives/services to guide design and delivery of customer-centered servicesXXX
      3.3B1Collaborates with community stakeholders to ensure comprehensive servicesXXX
      3.3B2Tailors interventions based on health behavior theory (eg, stages of change, socio-ecological model, social cognitive theory)XXX
      3.3B3Uses common terminology with community stakeholders to promote nutrition initiatives/servicesXXX
      3.3B4Creates programs tailored to populations’ needs based on nutrition-related factors identified in assessmentsXX
      3.3B5Convenes stakeholder meetings to continually incorporate feedback from community partners into nutrition-related programmingXX
      3.3B6Co-designs nutrition interventions with community partners and stakeholders (eg, uses spectrum of public health participation framework; https://www.iap2.org/mpage/Home)X
      3.3CCommunicates principles of disease prevention and behavioral change appropriate to the customer or target populationXXX
      3.3C1Communicates the relationship between food, environment/systems, and disease prevention as the foundation for nutrition education, programs, and prevention approachesXXX
      3.3C2Connects food and the environment/systems using the socio-ecological model for clients, individuals, populations, and stakeholdersXX
      3.3C3Supports and creates opportunities for systems-level long-term interventions to improve health equity for populations/individualsX
      3.3DCollaborates with the population/individual to set priorities, establish goals, and create population-/individual-centered action plans to achieve desirable outcomesXXX
      3.3D1Uses and prioritizes a participatory process to engage populations/individuals at all stepsXXX
      3.3EInvolves customers in decision makingXXX
      3.4Executes programs/services in an organized, collaborative, cost effective, and customer-centered mannerXXX
      3.4ACollaborates and coordinates with peers, colleagues, stakeholders, and within interprofessional
      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, psychologists, epidemiologists, social workers, planners, and other public health professionals), depending on the needs of the population/individual. Interprofessional could also mean interdisciplinary or multidisciplinary.
      teams
      XXX
      3.4A1Consults and provides expertise with partners and stakeholders to ensure evidence-based nutrition servicesXXX
      3.4A2Shares initiatives and health outcomes of services with all levels of stakeholders and policy makers (eg, evaluations shared with government and legislature, policy makers, school communities); consults with more experienced practitioners as neededXX
      3.4A3Ensures that nutrition is integrated in interprofessional programs across the life span (eg, childcare, schools, senior programs)XX
      3.4A4Leads interprofessional and/or interagency teams addressing community and public health nutrition prioritiesX
      3.4BUses and participates in, or leads in the selection, design, execution, and evaluation of population/individual programs and services (eg, nutrition screening system, medical and retail foodservice, electronic health records, interprofessional programs, community education, grant management)XXX
      3.4B1Comments on state and federal rules to actively shape nutrition programs (eg, MCHBh block grant and federal food/nutrition assistance programs)XXX
      3.4B2Incorporates social determinants of health and health equity into program and service evaluationXX
      3.4B3Communicates feasibility and fiscal implications of services with funders, policy makers, and stakeholdersX
      3.4B4Justifies public dollars and ROIi based on servicesX
      3.4B5Writes and reviews guidelines and regulations for local, state, tribal, and federal programsX
      3.4CUses 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, Health Insurance Portability and Accountability Act [HIPAA]-compliant telehealth platforms), and training materials that reflect evidence-based practice in accordance with applicable laws and regulationsXXX
      3.4C1Participates in training on policies and proceduresXXX
      3.4C2Conducts reviews to ensure that policies and procedures are followedXX
      3.4C3Demonstrates effectiveness of staff training in compliance with policies and proceduresXX
      3.4C4Ensures that program staff have the appropriate technology, infrastructure, and tools to implement programs/services according to policies and proceduresXX
      3.4C5Coordinates and critically examines access to and infrastructure for food and water, especially during public health emergencies (eg, ensures refrigeration transportation and storage; supply chain disruptions)XX
      3.4C6Documents that policies and practices are being implemented appropriately to provide a data-driven practiceXX
      3.4C7Solicits funds for safe and healthy food and water and the infrastructure for safe delivery and transport, especially during public health emergenciesX
      3.4C8Interprets federal regulations for local and state policy implementationX
      3.4C9Conducts feasibility analyses to ensure alignment with expected outcomes and sustainabilityX
      3.4C10Forecasts financing and mechanisms for funding nutrition servicesX
      3.4DUses and participates in or develops processes for order writing and other nutrition-related privileges, in collaboration with the medical staff
      Medical staff: Medical staff is composed of doctors of medicine or osteopathy and may in accordance with State law, including scope of practice laws, include other categories of physicians, and non-physician practitioners who are determined to be eligible for appointment by the governing body.50
      , or medical director (eg, post-acute care settings, dialysis center, public health, community, free-standing clinic settings), consistent with state practice acts, federal, tribal, state, and local regulations, organization policies, and medical staff rules, regulations, and bylaws
      XXX
      3.4D1Uses and participates in or leads development of processes for privileges or other facility-specific processes related to (but not limited to) implementing physician/non-physician practitioner
      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.50,51 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 long-term care 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.53,54 Acronyms:aUSDA=United States Department of Agriculture (http://www.usda.gov/wps/portal/usda/usdahome) aDGAs=Dietary Guidelines for Americans (http://www.cnpp.usda.gov/dietaryguidelines)bMNT=Medical Nutrition TherapycFNS=USDA Food and Nutrition Service (http://www.fns.usda.gov/)dWIC=Special Supplemental Nutrition Program for Women Infants and Children (U.S.) (http://www.fns.usda.gov/wic/women-infants-and-children-wic)eCACFP=Child and Adult Care Food Program (U.S.) (http://www.fns.usda.gov/cacfp/child-and-adult-care-food-program)fNSLP=National School Lunch Program (http://www.fns.usda.gov/nslp/national-school-lunch-program-nslp)gCDC=Centers for Disease Control and Prevention (U.S.) (http://www.cdc.gov)hMCHB=Maternal and Child Health Bureau (http://mchb.hrsa.gov/)iROI=Return on investmentjEAL=Academy of Nutrition and Dietetics Evidence Analysis Library (http://andeal.org)kAPHA=American Public Health Association (http://www.apha.org)lNAM= National Academies of Medicine (United States) (https://nam.edu/)mWHO=World Health Organization (http://www.who.int/en/)nHRSA=Health Resources and Services Administration (http://www.hrsa.gov/index.html)oUSPSTF=US Preventive Services Task Force (http://www.uspreventiveservicestaskforce.org/)pHHS=US Department of Health and Human Services (http://www.hhs.gov/)qAAP=American Academy of Pediatrics (https://www.aap.org/en-us/Pages/Default.aspx)rDANEH=Developing and Assessing Nutrition Education Handouts (http://healthyfoodbankhub.feedingamerica.or/wp-content/uploads/2013/12/Nutrition-Education-Handout-Checklist-rev-10-17-13.pdf)sHECAT=Health Education Curriculum Analysis Tool (http://www.cdc.gov/healthyyouth/HECAT/)tCQI=Continuous Quality Improvement
      -driven delegated orders or protocols, initiating or modifying orders for therapeutic diets, medical foods/nutrition supplements, dietary supplements, enteral and parenteral nutrition, laboratory tests, medications, and adjustments to fluid therapies or electrolyte replacements
      XXX
      3.4D2Uses and participates in or leads development of processes for privileging for provision of nutrition-related services, including (but not limited to) initiating and performing bedside swallow screenings, inserting and monitoring nasoenteric feeding tubes, providing home enteral nutrition or infusion management services (eg, ordering formula and supplies), and indirect calorimetry measurementsXXX
      3.4D3Complies with federal, tribal, state, and local regulations to administer individual nutrition services (eg, special WIC formulas and special diets in schools)XXX
      3.4EComplies 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 practicesXXX
      3.4E1Collects data to support funding and program costsXXX
      3.4E2Manages financial operations in accordance with grant/funding requirements and guidelinesXX
      3.4E3Oversees rules regarding braid (mixing and intertwining) funding (eg, state money with foundation funds) are being followedX
      3.4E4Maximizes population impact by leveraging funding and institutes policies and practices to prevent supplanting of fundsX
      3.4FCommunicates with the interprofessional team and referring party consistent with the HIPAA rules for use and disclosure of customer’s personal health informationXXX
      3.4F1Operates in accordance with local, state, federal, and tribal guidance on disclosure/protection of personal identifying informationXXX
      3.5Uses professional, technical, and support personnel appropriately in the delivery of population-/individual-centered care or services in accordance with laws, regulations, and organization policies and proceduresXXX
      3.5AAssigns activities, including direct care to populations/individuals, consistent with the qualifications, experience, and competence of professional, technical, and support personnelXXX
      3.5A1Designs procedures to appropriately assign referrals based on nutrition risk and competence level of health professionals (eg, support personnel such as paraprofessionals providing nutrition education in WIC)XX
      3.5A2Creates and provides continuing education for staff at all levels and partnering agenciesXX
      3.5BSupervises professional, technical, and support personnelXXX
      3.6Designs and implements food delivery systems to meet the needs of individuals/target populationsXXX
      3.6ACollaborates 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, visitors to retail venues, schools, child and adult day care centers, community feeding sites, farm to institution initiatives, local food banks)XXX
      3.6A1Tailors food availability within federal programs (eg, WIC food packages) to populations’ and individuals’ needsXXX
      3.6A2Supports and leverages increased healthy food access across food assistance programs (eg, food banks and food assistance programs)XXX
      3.6A3Collaborates with interprofessional partners to create and improve access to healthy food systems (eg, farmers markets, healthy food financing, food policy councils/ coalitions, community supported agriculture initiatives)XXX
      3.6A4Participates in outreach and/or referrals to ensure those who are eligible participate in federal food/nutrition assistance programsXXX
      3.6A5Considers access to food and water delivery systems, (eg, during public health emergencies)XXX
      3.6A6Advocates for public and private food outlets to be considered essential services, especially during public health emergenciesXX
      3.6BParticipates in, consults/collaborates with, or leads the development of menus to address health, nutritional, and cultural needs of population(s) consistent with federal, tribal, state or funding source regulations or guidelinesXXX
      3.6B1Provides age- and culturally-appropriate menu recommendations for federally-funded nutrition programs (eg, fruit and vegetable snacks for early childhood education and texture-friendly meals for home delivered meals)XXX
      3.6B2Engages in menu-planning guidelines/regulation development with state licensing authoritiesXX
      3.6B3Informs the development of meal plans/patterns at the federal level (eg, National School Lunch Program [NSLP] meal patterns)X
      3.6CParticipates 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)XXX
      3.7Maintains records of services providedXXX
      3.7ADocuments according to organization policies, procedures, standards, and systems including electronic health recordsXXX
      3.7A1Creates reports as required by state, tribal and federal program regulations and/or grant requirementsXX
      3.7BImplements data management systems to support interoperable data collection, maintenance, and utilizationXXX
      3.7B1Transfers local and state data to federal agencies (eg, USDA Participant Characteristics Report)XXX
      3.7B2Participates in nutrition surveillance systemsXXX
      3.7B3Aligns measures with state, tribal, and federal recommendationsXX
      3.7B4Creates data management systems for local and state nutrition surveillanceXX
      3.7B5Implements the collection of new measures and data in order to improve understanding of impact of servicesX
      3.7CUses data to document outcomes of services (ie, staff productivity, cost/benefit, budget compliance, outcomes, quality of services) and provide justification for maintenance or expansion of servicesXXX
      3.7C1Monitors and documents short-, medium- and long-term outcomesXXX
      3.7C2Shares program outcomes and impact with the program participants, stakeholders, and publicXXX
      3.7C3Provide structure and systems for staff to create reports to identify program outcomes and gapsXX
      3.7C4Uses data to guide strategic decisions about programming and servicesX
      3.7DUses data to demonstrate program/service achievements and compliance with accreditation standards, laws, and regulationsXXX
      3.7D1Conducts (eg, though management evaluations) reviews to ensure compliance with state policies and tribal and federal regulationsXX
      3.8Advocates for provision of quality food and nutrition services as part of public policyXXX
      3.8ACommunicates with policy makers regarding the benefit/cost of quality food and nutrition servicesXXX
      3.8A1Identifies policies and proposed legislation at local, state, tribal, federal, and international levels that impact public health nutritionXXX
      3.8A2Considers organization policies related to advocacyXXX
      3.8A3Promotes policy change in support of public health and community nutrition servicesXX
      3.8A4Collaborates with groups working on public health nutrition policies and legislation at local, state, tribal, federal, and international levelsXX
      3.8A5Performs public health and community nutrition policy analysis, identifies gaps and opportunities in current public policies, and adjusts strategies as neededX
      3.8A6Develops and implements a communication plan to educate policy makers about benefit/cost of quality public health and community nutrition servicesX
      3.8BAdvocates in support of food and nutrition programs and services for populations with special needs and chronic conditionsXXX
      3.8B1Advances access to healthy food/water and food assistance programs for underserved populations including underserved groups (eg, individuals living on reservations)XXX
      3.8CAdvocates 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)XXX
      3.8C1Serves on local, state, tribal, federal, or international committees that support policies and initiatives that improve the delivery of public health and community nutrition as appropriate to experience and skill levelXXX
      3.8C2Organizes dynamic grassroots campaigns to educate and engage the community on benefit/cost of quality public health and community nutrition servicesXX
      3.8C3Provides leadership to colleagues (RDNs, community members, and other public health professionals) on nutrition and public policyXX
      3.8C4Facilitates forums about proposed legislation, rules, or codes that impact the delivery of quality public health and community nutrition servicesXX
      3.8C5Takes on leadership roles in local, state, and national advisory groups related to public health nutrition laws and regulationsX
      3.8C6Develops draft legislation or policies in cooperation with policy makers that advance public health and community nutrition servicesX
      Examples of Outcomes for Standard 3: Provision of Services
      • Program/service design and systems aligns with organization/agencies mission and is centered around population/individual needs and impact
      • Populations and communities participate in establishing goals and population/individual-focused action plans
      • Population/individual needs are met and feel that public health/community nutrition programs are responsive to population/individual concerns about nutrition and health
      • The public is actively engaged in improving the health of themselves and their larger community
      • Evaluations reflect expected outcomes including efficiency, effectiveness, and ability to achieve equity among populations
      • Effective screening and referral services are established
      • Populations/Individuals have access to food assistance that promotes health and well-being
      • Populations/Individuals have access to food and nutrition services at the federal, tribal, state, and local levels
      • Support personnel are supervised when applying nutrition care standards in programs and policies
      • Ethical and transparent funding practices are used in all aspects of grant management
      • Health equity is improved for populations/individuals
      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:CompetentProficientExpert
      4.1Reviews best available research/evidence and information for application to practiceXXX
      4.1AUnderstands basic research design and methodologyXXX
      4.1BIdentifies evidence-based information from multiple disciplines and sources (eg, government, national/international nongovernmental organization publications)XXX
      4.1CDemonstrates understanding of research design and methodology, data collection, interpretation of results, and application within individual and population groupsXX
      4.1DDemonstrates the experience and critical thinking skills required to evaluate strength of original research, including limitations and potential bias, and evidence-based guidelines relevant to public health and community nutritionXX
      4.2Uses best available research/evidence and information as the foundation for evidence-based practiceXXX
      4.2AFollows evidence-based practice guidelines and recommendations (eg, Academy EALj, APHAk, NAMl, CDC, WHOm, HRSAn, USDA, MCHB, USPSTFo, HHSp, AAPq) to provide quality care and services for populations and communitiesXXX
      4.2BInterprets current research in public health and community nutrition and related areas and applies to professional practice as appropriateXXX
      4.2CUses the Academy EAL as a resource in writing or reviewing research papersXXX
      4.2DIncorporates latest evidence to support delivery of public health programs and services in grant proposalsXX
      4.2EApplies an evidence-based approach to develop and/or evaluate programs and services in relationship to existing public health nutrition research, laws/regulations, and recommendationsX
      4.3Integrates best available research/evidence and information with best practices, clinical and managerial expertise, and customer valuesXXX
      4.3ACreates opportunities for community engagement to address population needs in public health and community nutrition research and evaluationXXX
      4.3BEvaluates and responds to the unintended consequences and externalities of public health and community nutrition practiceXX
      4.3CMentors others in identifying and applying best available research/evidence and best practices to integrate into practiceX
      4.4Contributes to the development of new knowledge and research in nutrition and dieteticsXXX
      4.4AUses evidence-based guidelines, best practices, and experience to generate new knowledge and contribute to development of guidelines, programs, and policies in public health and community nutritionXXX
      4.4BParticipates in interprofessional research teams to address public health and community nutrition issuesXXX
      4.4CInitiates research and evaluation with population groups to address public health and community nutrition needs in collaboration with others (eg, biostatistician, epidemiologist)XX
      4.4DEvaluates the impact of public health and community nutrition services on environmental, economic, social, and health outcomesXX
      4.4EContributes to the development of evidence-based practice guidelines and position papers related to public health and community nutritionXX
      4.4FFunctions as an author or major contributor or reviewer of research and organization position papers, and other scholarly workX
      4.4GServes as advisor, mentor, preceptor, and/or committee member for graduate-level researchX
      4.5Promotes application of research in practice through alliances or collaboration with food and nutrition and other professionals and organizationsXXX
      4.5AParticipates as a member/consultant to collaborative teams addressing public health and community nutrition issues by providing evidence-based expertiseXXX
      4.5BDisseminates the results and emphasizes the significance and value of public health and community nutrition research findingsXXX
      4.5CIdentifies stakeholder groups and their public health and community nutrition priorities for further research collaborationsXX
      4.5DAdvocates to stakeholder organizations for prioritizing and funding of public health and community nutrition research projectsX
      4.5EServes as a primary or senior investigator in collaborative research and evaluation teams that examines relationships among environmental, economic, social, and health outcomesX
      Examples of Outcomes for Standard 4: Application of Research
      • Evidence-based practice, best practices, clinical and managerial expertise, population/individual values, and public health and community nutrition principles are integrated in the delivery of nutrition and dietetics services
      • Innovations in nutrition services are provided based on the effective application of best available research/evidence
      • Improvements to federal, tribal, and state nutrition guidelines and/or programs are made based on trends and data from public health and community nutrition programs and studies
      • Research leads to improvement of health equity
      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:CompetentProficientExpert
      5.1Communicates and applies current knowledge and information based on evidenceXXX
      5.1ADemonstrates critical thinking and problem-solving skills when communicating with othersXXX
      5.1A1Incorporates appropriate communication strategies to meet the needs of internal and external partners/stakeholdersXXX
      5.1A2Evaluates and addresses environmental, economic, social, and health variables in communications with diverse stakeholdersXX
      5.1BAddresses potential bias (eg, funding, motivation, values) and the importance of transparency in public health and community nutrition-related scienceXXX
      5.1CModels critical thinking skills and provides open and inclusive environments for discussionsXX
      5.2Selects appropriate information and the most effective communication method or format that considers customer-centered care and the needs of the individual/group/populationXXX
      5.2AUses communication methods (ie, oral, print, one-on-one, group, visual, electronic, and social media) targeted to various audiencesXXX
      5.2A1Considers the current knowledge and viewpoints of the audience related to PHCN issues and responds to concerns in a respectful mannerXXX
      5.3A2Communicates public health and community nutrition information and trends through social media networksXXX
      5.3A3Adapts public health and community nutrition information and trends through different communication methods with consideration for audienceXX
      5.2BUses information technology to communicate, disseminate, manage knowledge, and support decision makingXXX
      5.2B1Adapts messaging for different information technology communication toolsXX
      5.2B2Implements systems including health/management information systems in order to facilitate, communicate, and collaborate with partners to deliver services (eg, WIC electronic prescription systems and closed-loop electronic referral systems)X
      5.2CIncorporates health literacy, cultural competence, and developmental appropriateness in communications and educational materialsXXX
      5.2C1Evaluates materials for health literacy, cultural competence, developmental appropriateness (eg, CDC’s Simply Put, Academy DANEHr, HECATs)XXX
      5.3C2Adapts public health and community nutrition materials with consideration for health equity messaging (eg, ensuring messaging does not reinforce stigmatizing content or images)XX
      5.2C3Advises others as a subject matter expert on health literacy, cultural competence, developmental appropriatenessX
      5.3Integrates knowledge of food and nutrition with knowledge of health, culture, social sciences, communication, informatics, sustainability, and managementXXX
      5.3ANetworks with multilevel partners and stakeholders that impact federal, tribal, state, and local PHCN programsXXX
      5.3A1Addresses the environment, policy, and systems with regards to nutrition/food access and community needsXX
      5.3A2Leads activities that engage multilevel partners and stakeholders in collaborations around local, state, tribal, national, and/or international public health and community nutrition programsX
      5.4Shares current, evidence-based knowledge, and information with various audiencesXXX
      5.4AGuides customers, families, students, and interns in the application of knowledge and skillsXXX
      5.4A1Provides interprofessional education and experiential learning opportunities to staffXX
      5.4A2Contributes to the education and professional development of RDNs, public health and/or health care professionals through formal and informal mentoring/teachingXX
      5.4A3Expands course curricula, site-specific learning activities and research projects to include public health and community nutrition principles and applicationX
      5.4BAssists individuals and groups to identify and secure appropriate and available educational and other resources and servicesXXX
      5.4B1Promotes and supports programs, businesses, policies, and resources that incorporate public health and community nutrition principlesXXX
      5.5B2Provides and communicates referrals to social service resources in PHCN programsXXX
      5.5B3Implements interprofessional referral systems to connect public health and community nutrition education, services, and resourcesXX
      5.5B4Creates tiered assistance approaches based on cultural and language needsX
      5.4CUses professional writing and verbal skills in all types of communicationsXXX
      5.4C1Sharpens written and oral communication skills with the ability to translate complex scientific and policy information to the publicXXX
      5.4C2Disseminates public health and community nutrition lessons learned and best practicesXXX
      5.5C3Collaborates with language translation and interpretation services based on the audience to ensure written and verbal communications are provided in relevant languagesXXX
      5.4C4Develops grants and white papers, delivers presentations, and authors books and articles that incorporate public health and community nutrition for peers, consumers, health professionals, community groups, policy makers, and food systems leadersXX
      5.4C5Functions as an expert or media spokesperson on public health and community nutrition (eg, interviews, guest commentary, editorials)X
      5.4DReflects knowledge of population characteristics in communication methods (eg, literacy and numeracy levels, need for translation of written materials and/or a translator, and communication skills, and learning, hearing, or vision disabilities)XXX
      5.4D1Disseminates nutrition recommendations and tailors communications to population groups and individualsXXX
      5.4D2Uses health equity principles to ensure inclusive communication (eg, uses inclusive language)XX
      5.5Establishes credibility and contributes as a food and nutrition resource within the interprofessional public health and management team, organization, and communityXXX
      5.5AConducts activities and provides resources to educate members of the interprofessional team about public health and community nutrition, its applications and impacts on human, environmental, economic, and social healthXXX
      5.5BParticipates in interprofessional collaborations at a systems level (eg, community advisory boards, food policy councils/coalitions, licensure boards)XX
      5.5CTranslates evidence-based research (eg, epidemiological trends, program outcomes) and policy to practical application in communications with diverse stakeholders and the publicXX
      5.5DServes as an expert in public health and community nutrition with diverse stakeholdersXX
      5.5EContributes nutrition-related expertise to high-level national projects and professional organizations (eg, USDA programs, Healthy People, NAM)X
      5.6Communicates performance improvement and research results through publications and presentationsXXX
      5.6APresents evidence-based public health and community nutrition research and information to community groups and colleaguesXXX
      5.6BInterprets demographics, statistical, epidemiological, programmatic, and scientific informationXX
      5.6CServes in a leadership role for public health community nutrition-related scholarly work (eg, reviewer, editor, editorial advisory board) and in program planning for conferences (eg, local, regional, national, and international)X
      5.6DDirects collation of research data (eg, position papers, practice papers, meta-analysis, review articles) into publications and presentationsX
      5.6ETranslates performance improvement and research findings for incorporation into development of policies, regulations, procedures, and guidelinesX
      5.7Seeks opportunities to participate in and assume leadership roles with local, state, tribal, and national professional and community-based organizations (eg, government-appointed advisory boards, community coalitions, schools, foundations or non-profit organizations serving the food insecure) providing food and nutrition expertiseXXX
      5.7AFunctions as a public health and community nutrition resource as an active member of local/state/national organizationsXXX
      5.7BParticipates in interprofessional leadership teams providing food and nutrition expertiseXX
      5.7CServes as a subject matter expert in public health and community nutrition with local, state, national organizationsX
      5.7DManages and directs the integration of public health and community nutrition principles within larger systemsX
      5.7EDevelops, directs, and manages PHCN professional workshops, conferences, and meetings, ensuring diversity, equity, and inclusion in conference experts and attendeesX
      Examples of Outcomes for Standard 5: Communication and Application of Knowledge
      • Expertise in food, nutrition and management is demonstrated and shared (eg, document and communicate expertise through policy briefs, articles, position statements and proposals)
      • Information technology is used to support practice (eg, support the daily practice/work, enhance efficiency, productivity, and effectiveness through the use of shared networks and applications such as SharePoint)
      • Effective and efficient communications occur through appropriate and professional use of email, instant messaging, texting, and social media tools
      • Individuals/populations and stakeholders:
        • Receive current and appropriate information and population-/individual-centered service
        • Demonstrate understanding of information received
        • Know how to obtain additional guidance from the RDN
      • Leadership is demonstrated through active professional and community involvement (eg, participate on committees, boards, and workgroups for organizations such as State Public Health Associations and Health Coalitions, American Heart Association and American Diabetes Association, Academy of Nutrition and Dietetics, and in policy and advocacy groups)
      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:CompetentProficientExpert
      6.1Uses a systematic approach to manage resources and improve outcomesXXX
      6.1AUses logic model or other appropriate models to guide the planning, implementation, and evaluation of servicesXXX
      6.1BManages and implements information management systems to disseminate resources, policies, and trainings while maximizing staff resourcesXX
      6.1CImplements programs with long-term sustainability plans, leveraging diverse resources and funding streamsXX
      6.1DIntegrates the use of project management tools to ensure compliance with grant deliverables, timelines, and work plansXX
      6.1EOversees the responsible and accurate management of sub-grants in order to achieve comprehensive outcomesX
      6.2Evaluates management of resources with the use of standardized performance measures and benchmarking as applicableXXX
      6.2AUses the Standards of Excellence Metric Tool to self-assess quality in leadership, organization, practice, and outcomes for an organization (www.eatrightpro.org/excellencetool)XXX
      6.2BParticipates in operational planning of food, nutrition, and public health and community nutrition programs (eg, grant writing, management of deliverables, collecting program evaluation data, budgeting staff and resources in accordance with grant allocation and expected outcomes)XXX
      6.2CManages effective delivery of nutrition programs and services (eg, business and marketing planning, cost-benefit analysis, program administration, delivery of programs, materials development, program evaluation) related to public health and community nutrition programsXX
      6.2DDirects or manages business and strategic planning for the design and delivery of nutrition services in public health and community nutrition for federal, tribal, state, and/or local settingsX
      6.2EDirects operational review reflecting evaluation of performance and benchmarking data to manage resources and modifications for design and delivery of PHCN programs and servicesX
      6.3Evaluates safety, effectiveness, efficiency, productivity, sustainability practices, and value while planning and delivering services and productsXXX
      6.3AIncorporates formative evaluation through a participatory approach including diverse stakeholders and community membersXXX
      6.3BAssesses and communicates short-, medium-, and long-term program effectiveness given the use of public funds to deliver servicesXX
      6.3CEnsures organization practices are in concert with changes in the public health and community nutrition system and the larger social, political, and economic environmentX
      6.3DImplements CQIt processes for assessing and adapting practices related to public health and community nutrition effectiveness and safety, especially during public health emergenciesX
      6.4Participates in quality assurance and performance improvement (QAPI) and documents outcomes and best practices relative to resource managementXXX
      6.4AEngages the community and stakeholders in CQI processes that are inclusive and centers health equityXXX
      6.4BAnticipates outcomes and consequences of different approaches and makes necessary modifications to achieve desired outcomes (eg, health impact assessment process) in context of resourcesXX
      6.4CEvaluates QAPI processes and communicates outcomes and best practices to leadership, stakeholders, and customersXX
      6.4DReports outcomes of delivery of services against goals and performance targetsXX
      6.4EDirects the development and management of CQI systems (eg, fiscal, personnel, services, materials, data)X
      6.4FPartners with health economists to assess ROI of services and programsX
      6.5Measures and tracks trends regarding internal and external customer outcomes (eg, satisfaction, key performance indicators)XXX
      6.5AConducts regular surveys with participants and stakeholders to assess population/individual satisfactionXXX
      6.5BCommunicates the need for change based on collected dataXXX
      6.5CResolves internal and external challenges and barriers that may affect the delivery of essential public health and community nutrition servicesXX
      6.5DAnalyzes and disseminates public health and community nutrition data and trends to inform the adoption of new policies and approaches to improve outcomesX
      Examples of Outcomes for Standard 6: Utilization and Management of Resources
      • Resources are effectively and efficiently managed to promote population/individual health
      • Documentation of resource use is consistent with requirements of funding and oversight agencies
      • Data are used to promote, improve, and validate interventions, organization practice, and public policy
      • Desired outcomes are achieved, documented, and disseminated to stakeholders
      a 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.
      b 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, psychologists, epidemiologists, social workers, planners, and other public health professionals), depending on the needs of the population/individual. Interprofessional could also mean interdisciplinary or multidisciplinary.
      c Medical staff: Medical staff is composed of doctors of medicine or osteopathy and may in accordance with State law, including scope of practice laws, include other categories of physicians, and non-physician practitioners who are determined to be eligible for appointment by the governing body.
      State Operations Manual: 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.
      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.
      State Operations Manual: 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. 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.
      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 long-term care 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.
      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)
      US Department of Health and Human Services, Centers for Medicare and Medicaid Services.
      ,
      State Operations Manual. Appendix PP: Guidance to surveyors for long-term care facilities (Rev. 173, 11-22-17); § 483.30 Physician Services, § 483.60 Food and Nutrition Services
      US Department of Health and Human Services, Centers for Medicare and Medicaid Services. Accessed June 7, 2022.
      Acronyms:

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      Biography

      M. Bruening is a professor, Nutritional Sciences Department, The Pennsylvania State University, University Park; at the time of the study, she was an associate professor, College of Health Solutions, Arizona State University, Phoenix.
      S. Perkins is a public health nutrition consultant/MCH Nutrition Program director, Association of State Public Health Nutritionists, Howard, KS.
      A. Udarbe is executive director, Pinnacle Prevention, Chandler, AZ.

      Linked Article

      • Erratum
        Journal of the Academy of Nutrition and DieteticsVol. 122Issue 11
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          Erratum to: Academy of Nutrition and Dietetics: Revised 2022 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Public Health and Community Nutrition
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