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Valuing Diversity in Dietetics: Considerations for Service Dogs at School, Internships, and the Workplace

      Diversity has become an increasingly important topic within the field of dietetics to create a profession representative of the population it serves, capable of providing culturally appropriate patient care. Yet people with disabilities (PwDs) are often overlooked. The Americans with Disabilities Act (ADA) defines disability as “a physical or mental impairment that substantially limits one or more major life activities, a record of such an impairment, or being regarded as having such an impairment.”
      ADA National Network
      Glossary of ADA terms. Updated November 2021.
      In the United States, approximately 12.6% of the noninstitutionalized population lives with a disability.
      • Bialik K.
      7 Facts about Americans with disabilities.
      One strategy employed by PwDs to mitigate their disabilities is the use of a highly trained service dog (SD).
      PwDs in general and individuals assisted by SDs specifically face significant challenges entering the health care field and accessing medical care. However, data are lacking on disability prevalence among dietetics students, interns, and registered dietitian nutritionists (RDNs).
      • Baxter S.D.
      • Gordon B.
      • Cochran N.
      Enhancing diversity and the role of individuals with disabilities in the dietetics profession.
      PwDs often exhibit many valuable proficiencies, including creativity, flexibility, and peak performance under pressure,
      • Brown E.
      Disability awareness: the fight for accessibility.
      yet also experience unique challenges. For the field of dietetics to become a diverse, equitable, and inclusive profession, it is important for food and nutrition practitioners to understand both the unique challenges and valuable contributions of students, interns, employees, and patients with disabilities assisted by an SD (herein referred to as SD handlers). The purpose of this article is to share best practices for accommodating SD handlers involved in all areas of the field of dietetics.

      Defining SD

      Characteristics that legally define an SD vary based on the applicable law. Three titles of the ADA are relevant when considering access for SD handlers (Figure 1). Title I applies to private employers with 15 or more employees, state and local governments, employment agencies, labor unions, joint management labor committees, and employer agents. Under Title I, there is no specific definition for an SD. Employees can request the presence of an animal to mitigate their disability as a reasonable accommodation. Employers must consider whether or not the animal assists the individual in performing essential job functions to determine if this will qualify as a reasonable accommodation.
      Figure 1Legal protections for different service dog (SD) handler populations. aADA = Americans with Disabilities Act.
      PopulationApplicable lawsSD definitionAccessDocumentationHelpful links
      Students, interns, and patients/clientsTitles II and III of the ADAaA dog individually trained to perform tasks for a person with a disabilityPermitted anywhere the general public is allowedNo legally recognized documentation; proof of disability, registration, certification, vests, or harnesses cannot be required
      Employees and interns for covered employersTitle I of the ADAThe presence of an animal requested as a reasonable accommodation necessary for performing essential job functionsDecided on a case-by-case basis as a reasonable accommodationProof of disability may be required in the case that the disability-related need is not obvious
      The ADA definition of an SD applicable to Titles II and III (covering state and local governments and places of public accommodation, respectively
      ADA National Network
      Service animals and emotional support animals.
      ) is “a dog individually trained to do work or perform tasks for an individual with a disability.”
      ADA National Network
      Service animals and emotional support animals.
      A task is a specific action the dog takes directly related to mitigating the person’s disability.
      US Dept of Justice
      Frequently asked questions about service animals and the ADA.
      Some examples of tasks include alerting a visually impaired handler to changes in elevation, retrieving dropped objects for a person with limited mobility, or interrupting a flashback for someone experiencing posttraumatic stress disorder. Providing comfort, relief from isolation, or other emotional benefits through the dog’s presence alone does not qualify as a task; therefore, therapy dogs and emotional support dogs are not SDs.
      US Dept of Justice
      Frequently asked questions about service animals and the ADA.
      Covered entities under Titles II and III must allow PwDs to be accompanied by their SD anywhere the general public is allowed.
      US Dept of Justice
      Service animals.
      Covered entities may ask whether or not the dog is an SD required due to a disability and what task(s) the SD has been trained to perform.
      ADA National Network
      Service animals and emotional support animals.
      Handlers are not required to provide advanced notice of their SD.
      • Brown S.E.
      ADA Knowledge Translation Center
      Legal brief: Service animals and individuals with disabilities under the Americans with Disabilities Act (ADA). ADA Knowledge Translation Center Legal Brief No. 2.1.
      The Department of Justice does not recognize or require any registration, certification, vests, or harnesses for SDs.
      US Dept of Justice
      Frequently asked questions about service animals and the ADA.
      Pet owners can easily obtain gear or documentation to misrepresent their pet as an SD. Places of public accommodation may exclude an SD in the case that it poses a direct threat to the health and safety of others, is not house broken, or is not under control and the handler does not take effective action to control it.
      US Dept of Justice
      Frequently asked questions about service animals and the ADA.
      However, fear of dogs or allergies may not be used as a reason to exclude an SD.
      ADA National Network
      Service animals and emotional support animals.

      Students with SDsin University Science Labs

      Academic requirements for becoming an RDN consist of a bachelor’s degree, shifting to a master’s degree for incoming RDNs in 2024, including coursework approved by the Academy of Nutrition and Dietetics Accreditation Council for the Education of Nutrition and Dietetics.
      • Ellis E.
      Qualifications of a registered dietitian nutritionist.
      Some academic requirements include laboratory courses in chemistry, microbiology, and food preparation. However, diversity, equity, and inclusion are major challenges facing postsecondary institutions in the United States. Students with disabilities comprise 11.1% of undergraduate students and 7.6% of graduate students, underrepresenting the 12.6% of PwDs in the total US population.
      • Bialik K.
      7 Facts about Americans with disabilities.
      ,
      • Snyder T.D.
      • Dillow S.A.
      Digest of Education Statistics.
      ,
      US Dept of Education, Institute of Education Sciences, National Center for Education Statistics
      Profile of students in graduate and first-professional education: 2007-08.
      This suggests PwDs may choose to forego pursuing graduate-level education due to disability-related barriers.
      • Wilson K.
      • Getzel E.
      Enhancing the post-secondary campus climate for students with disabilities.
      These barriers include implicit bias potentially causing an aversion to hiring an SD handler for highly competitive graduate research opportunities.
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Barriers to inclusion: Service dog handlers in science laboratories.
      Specifically, SD handlers face access challenges or complete exclusion from laboratories.
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Barriers to inclusion: Service dog handlers in science laboratories.
      Most academic policies neglect addressing SDs or only provide guidelines for their exclusion.
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Barriers to inclusion: Service dog handlers in science laboratories.
      There has been an increase in both students registering for disability-related accommodations and use of SDs nationwide.
      National Council on Disability
      People with disabilities and post-secondary education—position paper.
      ,
      • Zier E.R.
      Which one to follow? Service animal policy in the United States.
      Section 503 of the Rehabilitation Act of 1973 is deliberately ambiguous to provide individualized accommodations in unique situations.
      US Dept of Education
      34 CFR.
      Case-by-case determinations by each school may not be assessed objectively. Science professionals have called for major science societies to create guidelines for SDs in laboratories.
      • Hammett A.J.M.
      • Spencer J.V.
      Who let the dogs out? A plea for official guidelines on service animals in the teaching laboratory.
      ,
      • Myer E.
      • Rengarajan K.
      • Meechan P.
      • Fowler P.
      A section on service animals in the microbiology teaching laboratory has been included in the 2019 update to the guidelines for biosafety in teaching laboratories.
      In addition, SDs are currently prohibited from animal research facilities around the country due to concerns the presence of a dog will negatively influence laboratory animals.
      US Dept of Agriculture, Animal and Plant Health Inspection Service. USDA Animal Care: Animal Welfare Act and Animal Welfare Regulations. APHIS 41-35-076.
      ,
      National Research Council of the National Academies, Committee for the Update of the Guide for the Care and Use of Laboratory Animals
      Guide for the Care and Use of Laboratory Animals.
      Yet, scent or sight of a domestic dog has not been found to cause consistently negative outcomes on rodent physiology or behavior.
      • Banks P.
      • Nelika K.
      • Hughes A.
      • Rose T.
      Do native Australian small mammals avoid faeces of domestic dogs? Responses of Rattus fuscipes and Antechinus stuartii.
      Generally, accommodating an SD in a laboratory environment requires few modifications.
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Comment on “service dogs and safety in academic laboratories.”.
      Individualized risk assessments can be used to provide reasonable accommodations tailored to each student’s needs.
      Americans with Disabilities Act. 2010 ADA standards for accessible design. Chapter 9: Built-in elements.
      One article considers biosafety level (BSL) 1 and chemical safety level (CSL) D as almost universally appropriate for SDs, BSL 2 and CSL C as often appropriate for SDs possibly with personal protective equipment (PPE), and BSL 3 and 4 as well as CSL B and A as requiring more rigorous assessment.
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Barriers to inclusion: Service dog handlers in science laboratories.
      ,
      American Society for Microbiology
      ASM guidelines for biosafety in teaching laboratories.
      • Redden P.A.
      • Sweet C.S.
      Service dogs in the chemistry lab.
      American Chemical Society Institute
      Safety basics & RAMP.
      Undergraduate core laboratory courses are almost always BSL 2 or CSL C or D.
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Barriers to inclusion: Service dog handlers in science laboratories.
      The American Chemical Society and the American Society of Microbiology recommend requiring SDs to wear similar PPE as other students, such as boots, goggles, or a lab coat.
      American Society for Microbiology
      ASM guidelines for biosafety in teaching laboratories.
      ,
      • Redden P.A.
      • Sweet C.S.
      Service dogs in the chemistry lab.
      The ADA requires that there be one accessible recessed bench per laboratory, which often provides sufficient space for the SD.
      Americans with Disabilities Act. 2010 ADA standards for accessible design. Chapter 9: Built-in elements.
      ,
      • Hayes C.
      Handicapped accessible emergency showers & eyewashes.
      Classroom relocation should be considered if this is not the case. Alternatively, a designated place within the laboratory can be established for the handler that is out of the way and near an exit, eyewash station, and safety shower.
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Barriers to inclusion: Service dog handlers in science laboratories.
      If necessary, arrangements for obtaining required supplies can be implemented such as setting up supplies near the handler or designating that the handler’s laboratory partner will retrieve all chemicals. Faculty should assist in ensuring that other students are adhering to appropriate SD ettiquette.
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Barriers to inclusion: Service dog handlers in science laboratories.
      This includes avoiding petting, speaking to, feeding, or initiating eye contact with the SD.
      In addition to science labs, dietetics students are required to complete food preparation courses. SDs are generally restricted from entering food preparation areas.
      • Sehulster L.M.
      • Chinn R.Y.W.
      Guidelines for environmental infection control in health-care facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).
      , During food preparation or other labs where the SD cannot be in the immediate presence of the handler, faculty should assist in finding a nearby area where the SD can be left for the duration of the class that is safe, avoids high traffic areas, and where the dog will be undisturbed.
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Barriers to inclusion: Service dog handlers in science laboratories.
      If the handler cannot be accompanied by their SD, alternative accommodations may be necessary to compensate for not having the SD. For example, a deaf student may need an alternative way to be alerted to alarms, whereas a student with epilepsy may need to notify faculty how to respond should they experience a seizure.
      A university-wide policy should be created detailing not only required PPE and physical placement of the SD in the laboratory, but also the skills an SD must have to enter a laboratory (Figure 2).
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Barriers to inclusion: Service dog handlers in science laboratories.
      Some commonly recommended skills include staying on a mat, using a behavior other than a nose nudge for an alert, remaining in sight of the handler, entering a safety shower, and not retrieving dropped objects automatically.
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Barriers to inclusion: Service dog handlers in science laboratories.
      However, each handler has varying disabilities and each SD receives individualized training. Physical contact from the SD may be necessary to reliably recognize the alert. A visually impaired student may need their SD to be in reach. In some labs, it may present the least risk to place the SD in a low traffic area of the room in a crate or on a short tether. Although faculty are not permitted to inquire directly about the student’s disability or require the SD demonstrate tasks, a discussion of the SD’s tasks can be useful in developing an individualized plan for the laboratory. It may be most advantageous for universities to develop policies that discuss several options for reasonable accommodations, to balance the need for uniform objective policies to allow equal access for SD handlers in laboratories while also recognizing that each handler requires individual accommodations. In most cases, an SD handler can be accommodated in a laboratory environment by having the SD wear any necessary PPE and remaining in a down stay within reach or sight of the handler.
      • Ramp J.
      • Parker C.G.
      • Rhodes J.S.
      • Malik P.
      Barriers to inclusion: Service dog handlers in science laboratories.
      Figure 2Best practices for accommodating service dog (SD) handlers.
      PopulationBest practices
      Lab instructors
      • Engage in conversation with handlers to determine appropriate reasonable accommodations
      University administration
      • Develop an objective yet flexible policy for SDs in laboratory courses
      • Propose potential reasonable accommodations and guidelines
      • Make policy readily available for students and faculty to review
      Internship directors and preceptors
      • Initiate conversation with intern SD handlers to determine reasonable accommodations that best incorporate the SD into the intern’s role
      Hospital administration
      • Develop an SD policy consistent with the Americans with Disabilities Act
      • Include differentiating SDs from pets, therapy dogs, and emotional support dogs
      • Train all staff on implementation of this policy
      Registered dietitian nutritionists
      • Focus on the client’s nutrition related needs
      • If allergic to or fearful of dogs, develop a plan for providing care to client SD handlers while minimizing symptoms

      Interns and Employees with SDs

      Another requirement for becoming an RDN is completing 1,200 hours of supervised practice experience.
      • Ellis E.
      Qualifications of a registered dietitian nutritionist.
      Upon passing a registration examination, RDNs work in environments such as hospitals, long-term-care facilities, and foodservice. Although the ADA prohibits discrimination in all public life areas, including employment,
      ADA National Network
      What is the Americans with Disabilities Act (ADA)? Updated November 2021.
      implicit bias is a significant barrier to obtaining internships and jobs. Section 503 of the Rehabilitation Act of 1973 mandates that federal contractors include disabilities in their recruitment and hiring strategies.
      ADA National Network
      Fact Sheets. Section 503 of the Rehabilitation Act Rules.
      Hospitals, federal medical facilities, and institutions receiving federal research funding should intentionally recruit and hire qualified PwDs.
      ADA National Network
      Fact Sheets. Section 503 of the Rehabilitation Act Rules.
      Such legislation seeks to ensure qualified PwDs are fairly considered for jobs, as well as promoting diverse perspectives in the workplace. Although interns are covered under Title II or III of the ADA in places of public accommodation, PwDs are covered under Title I if they are interns or employees for a covered employer.
      US Equal Employment Opportunity Commission
      Office of Legal Counsel. Informal Discussion Letter—federal EEO laws: when interns may be employees.
      Employers and institutions must make reasonable accommodations for PwDs to provide equal opportunities without fundamentally altering the program’s nature.
      • McGough J.D.
      • Murray J.F.
      Know your campus resources.
      Accommodations in a clinical setting are best accomplished with advanced planning, a team approach, and the inclusion of a disability services provider with knowledge of the clinical rotation and the person’s disability.
      • Baxter S.D.
      • Gordon B.
      • Cochran N.
      Enhancing diversity and the role of individuals with disabilities in the dietetics profession.
      The US Department of Labor’s Office of Disability Employment Policy has made available a generic how-to guide for creating inclusive internships.
      US Dept of Labor, Office of Disability Employment Policy. Inclusive internship programs: a how-to guide for employers.
      Information about each person’s disability should be kept confidential.
      • Silbert-Flag J.
      • Shilling S.D.
      • Lucas L.
      • et al.
      Preparing for a student with a service animal.
      Although SDs are generally well accepted in public in the United States, SD presence may lead to confusion in the case that the disability is not readily apparent, or the term service dog is used inconsistently.
      • Schoenfeld-Tacher R.
      • Hellyer P.
      • Cheung L.
      • Kogan L.
      Public perceptions of service dogs, emotional support dogs, and therapy dogs.
      Understanding the SD’s tasks may assist in determining if the dog meets the definition of an SD and when the dog is not under the handler’s control. For example, an SD barking as a trained alert, differs from a dog barking out of inadequate training.
      • Froling J.
      Service dog tasks for psychiatric disabilities.
      Titles II and III of the ADA permit SD handlers anywhere the public is allowed, with the exception of burn units and operating rooms.
      ADA National Network
      Service animals and emotional support animals.
      ,
      US Dept of Justice
      Frequently asked questions about service animals and the ADA.
      Providing access for an SD handler to areas where employees with similar roles have access is a reasonable accommodation. The Centers for Disease Control and Prevention recommends therapy animals be excluded from central sterile supply, food preparation areas, intensive care units, operating rooms, isolation rooms, laundry areas, medication preparation areas, and interacting with immunocompromised patients; yet recommendations for SDs simply include allowing an SD handler access anywhere people are normally allowed without taking precautions to prevent disease transmission, such as using PPE.
      • Sehulster L.M.
      • Chinn R.Y.W.
      Guidelines for environmental infection control in health-care facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).
      Unlike therapy dogs who interact with many people, SDs need only to interact with their handler, thereby reducing the risk of pathogen transmission.
      Discussion between the handler and preceptor or employer can be initiated to ensure that the SD can avoid becoming a tripping hazard or distraction during chaotic situations such as alarms, moving equipment, and unpredictable patient behavior without becoming protective or stressed.
      • Froling J.
      Service dog tasks for psychiatric disabilities.
      Placing the SD in a down stay or on a designated mat are options when the SD will be in the same room at a distance from the handler or only left briefly. When unsupervised for an extended period, the SD should be placed on a short tether or in a crate ideally with minimal interference from others. Interns with SDs do not necessarily need to have the same experiences as other interns, so long as requirements and objectives are met. For example, assigning the handler to patients that are not in isolation when there are multiple interns or RDNs available may minimize disease risk and separation from medical equipment, without compromising learning or patient care.

      Patients Accompanied by an SD

      SD handlers, like any other patients, need and are entitled to medical care. Health care professionals generally receive little to no education concerning interacting with patients with an SD.
      • Singleton J.K.
      • Picard L.
      • Ferrara L.
      Canines assisting in health: service dogs, essential information for healthcare providers.
      SD handlers are permitted in all areas of hospitals, clinics, long-term-care facilities, private practices, and anywhere else the public is allowed.
      US Dept of Justice
      Frequently asked questions about service animals and the ADA.
      SDs should not be excluded on the grounds that staff can provide the same services as an SD. However, patients, not staff, are solely responsible for the SD’s care.
      US Dept of Justice
      Frequently asked questions about service animals and the ADA.
      Handlers may arrange for friends or family to assist in caring for the SD if they are hospitalized. Only in the case that the handler cannot care for the SD or arrange care can the hospital initiate steps such as boarding the SD.
      Any dog that is not task trained, house broken, or under the handler’s control can be removed.
      US Dept of Justice
      Frequently asked questions about service animals and the ADA.
      Because fear or allergies generally cannot be used as a reason to exclude an SD, RDNs who are fearful or allergic to dogs must develop strategies for interacting with SD handlers in advance. Some possible strategies include the installation of a high-proficiency particulate air filter, providing a blanket for the SD to lay on, frequent cleaning of shared spaces, or use of PPE such as a mask to minimize allergic symptoms while interacting with SD handlers.
      • Sehulster L.M.
      • Chinn R.Y.W.
      Guidelines for environmental infection control in health-care facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).
      ,
      • Foreman A.M.
      • Glenn M.K.
      • Meade B.J.
      • Wirth O.
      Dogs in the workplace: a review of the benefits and potential challenges.
      RDNs should focus on the handler’s nutritional requirements as with other patients, rather than discussing only the SD or asking intrusive questions about the handler’s disability. However, in the case that the SD assists the handler in achieving access to safe and adequate food, water, physical activity, or other nutrition-related activities of daily living, this can be documented in the nutrition assessment note by utilizing the appropriate Nutrition Care Process Terminology.
      Academy of Nutrition and Dietetics
      Nutrition Care Process Terminology (eNCPT), 2020 Edition.

      Conclusions

      It is becoming increasingly common for PwDs to choose an SD to mitigate their disability. Developing best practices and educating food and nutrition practitioners concerning interactions with and access for SD handlers, including students, interns, RDNs, or patients, will promote diversity, equity, and inclusion in the field of dietetics. The Academy of Nutrition and Dietetics can assist in this effort by creating resources (eg, case studies, fact sheets, and model policies), offering webinars and other forms of continuing education, and including ability in all definitions and examples of cultural competency and implicit bias. Generally, equal access can be achieved by recognizing SDs are akin to medical equipment unlike emotional support animals, therapy animals, and pets; adhering to SD etiquette; and providing the handler access with their SD anywhere the presence of the SD will not cause a legitimate safety risk that cannot be mitigated.

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      Biography

      Danielle Sykora, graduate student, Department of Nutrition and Food Studies, Montclair State University, Oxford, NJ.
      Lauren M. Dinour, DrPh, RD, associate professor, Department of Nutrition and Food Studies, Montclair State University, Oxford, NJ