Journal of the American Dietetic Association
Volume 111, Issue 4 , Pages 617-624.e27, April 2011

American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Competent, Proficient, and Expert) in Extended Care Settings

Article Outline

 

Approved December 2010 by the Quality Management Committee of the American Dietetic Association (ADA) House of Delegates and the Executive Committee of Dietetics in Health Care Communities Dietetic Practice Group of the ADA. Scheduled review date: April 2016. Questions regarding the Standards of Practice and Standards of Professional Performance for registered dietitians in extended care settings may be addressed to ADA quality management staff—Sharon McCauley, MS, MBA, RD, LDN, FADA, director, Quality Management, or Cecily Byrne, MS, RD, LDN, manager, Quality Management at quality@eatright.org.

Editor's note: Figure 1, Figure 2, Figure 3 that accompany this article are available online at www.adajournal.org.

The Dietetics in Health Care Communities (DHCC) Dietetic Practice Group of the American Dietetic Association (ADA), under the guidance of the ADA Quality Management Committee and Scope of Dietetics Practice Framework Sub-Committee, has developed Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for registered dietitians (RDs) in extended care settings (ECS). These documents build on the ADA Revised 2008 SOP for RDs in Nutrition Care and SOPP for RDs (1). ADA's Code of Ethics (2) and the 2008 SOP in nutrition care and SOPP for RDs (1) are tools within the Scope of Dietetics Practice Framework (3) that guide the practice and performance of RDs in all settings. The concept of scope of practice is fluid (4), changing in response to the expansion of knowledge, the practice environment, and technology. An RD's legal scope of practice is defined by state legislation (eg, state licensure law) and differs from state to state. An RD may determine his or her own individual scope of practice using the Scope of Dietetics Practice Framework (3), which takes into account federal regulations; state laws; institutional policies and procedures; and individual competence, accountability, and responsibility for his or her own actions.

ADA's Revised 2008 SOP in nutrition care and SOPP (1) reflect the minimum competent level of dietetics practice and professional performance for RDs. ADA's SOP in nutrition care and SOPP (1) serve as blueprints for the development of focus area SOP and SOPP for RDs in competent, proficient, and expert levels of practice. The SOP in nutrition care address the four steps of the Nutrition Care Process (NCP) and activities related to an individual's care (5). They are designed to promote the provision of safe, effective, and efficient food and nutrition services; facilitate evidence-based practice; and serve as a professional evaluation resource. The SOPP are authoritative statements that describe a competent level of behavior in the professional role. Categorized behaviors that correlate with professional performance are divided into six separate standards.

The SOP and SOPP for RDs in ECS are a guide for self-evaluation and expanding practice, a means of identifying areas for professional development, and a tool for demonstrating competence in delivering nutrition care services. They are used by RDs to assess their current level of practice and to determine the education and training required to maintain currency in their focus area and for advancement to a higher level of practice. In addition, the standards may be used to assist RDs in transitioning their knowledge and skills to a new focus area. Like the Revised SOP in nutrition care and SOPP, the indicators (ie, measureable action statements that illustrate how each standard can be applied in practice) (see Figure 1, available online at www.adajournal.org) for the SOP and SOPP for RDs in ECS were developed with input and consensus of content experts representing diverse practice and geographic perspectives. The SOP and SOPP for RDs in ECS were reviewed and approved by the Executive Committee of the DHCC Dietetic Practice Group, the Scope of Dietetics Practice Framework Sub-Committee, and ADA's Quality Management Committee.

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Three Levels of Practice 

Competent Practitioner 

In dietetics, a competent practitioner is an individual who has just attained RD status, is starting in professional employment, and who acquires on-the-job skills as well as engages in tailored continuing education to enhance knowledge and skills. This beginner RD starts with technical training and interaction for advancement and breadth of competence. This RD's practice may include responsibilities across several areas of practice, including, but not limited to, more than one of the following: community, clinical, consultation and business, research, education, and food and nutrition management. A competent RD could be an entry-level RD just starting practice after registration or an experienced RD who has newly assumed responsibility to provide nutrition care in a new focus area. A focus area is defined as an area of dietetics practice that requires focused knowledge, skills, and experience.

Proficient Practitioner 

A proficient practitioner is an RD who is ≥3 years beyond entry level into the profession, who has obtained operational job performance skills, and is successful in the chosen focus area of practice. This proficient practitioner demonstrates additional knowledge, skills, and experience in a focus area of dietetics practice. This RD may begin to acquire specialist credentials, if available, to demonstrate proficiency in a focus area of practice.

Expert Practitioner 

An expert practitioner is an RD who is recognized within the profession and has mastered the highest degree of skill in or knowledge of a certain focus or generalized area of dietetics through additional knowledge, experience, or training. An expert practitioner exhibits a set of characteristics that include leadership and vision and demonstrates effectiveness in planning, evaluating, and communicating targeted outcomes. An expert practitioner may have expanded or specialist roles or both, and may possess an advanced credential in a focus area of practice, if available. Generally, the practice is more complex, and the practitioner has a high degree of professional autonomy and responsibility (6).

These standards, along with the ADA's Code of Ethics (2), answer the questions: Why is an RD uniquely qualified to provide nutrition services in the extended care setting? What knowledge, skills, and competencies does an RD need to demonstrate for the provision of safe, effective, and quality nutrition care in the ECS at the competent, proficient, and expert levels?

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Overview 

Seventy percent of people aged 65 years and older will require some form of long-term care services and/or assistance with activities of daily living during their lifetime, according to the US Department of Health and Human Services (7). Currently there are 9 million people living in the United States who are older than age 65 years and require long-term care. That number is expected to increase to 12 million by 2020 (8). It is estimated that individuals will spend at least 3 years in long-term care, of which 2 years will be spent at home taking advantage of community-based programs such as home health care, adult day care, home care, and senior centers (8). As an individual's activities of daily living decline he or she may transition into a health care community such as adult foster care, assisted living, continuing care retirement communities, board and care homes, or skilled nursing facilities.

Traditionally, a nursing home was one of the few options for extended care, but as the population ages, reimbursement for entitlement programs such as Medicare and Medicaid is broadening. In addition, there is a growing consensus that long-term care must be transformed from institution based and provider driven to person centered, consumer directed, and community based. The Money Follows the Person Rebalancing Demonstration Program was authorized by Congress in section 6071 of the Deficit Reduction Act of 2005 (9) and was designed to provide assistance to states to balance their long-term care systems and help Medicaid enrollees transition from institutions to the community.

The paradigm shift to person-centered care has been slowly integrated into skilled nursing facilities. Organizations such as the Pioneer Network are driving person-centered, resident-directed care with core values of dignity, respect, self-determination, and purposeful living (10). The Centers for Medicare & Medicaid Services (CMS) began this culture change in response to the 1987 Omnibus Budget Reconciliation Act by developing rules for Medicare/Medicaid program survey, certification, and enforcement of skilled nursing facilities that focus on improved quality of life and decision making by individuals and/or their surrogate decision makers (11). This has enhanced individual choice in all areas of care, including nutrition care.

Nutrition care in the ECS is broad and typically addresses needs of individuals with multiple complex comorbidities rather than just one ailment. RDs provide nutrition care for individuals living in the ECS. Residents aged 65 years and older commonly present with chronic kidney disease, diabetes mellitus, stroke, cancer, and heart disease (12). An RD may integrate disease-specific published SOP for diabetes, nephrology, and nutrition support (13, 14, 15) while including an individual's right to choose treatment modalities that are consistent with his or her beliefs and goals for health care and quality of life. In the ECS, end-of-life decisions significantly affect the development of nutrition care interventions for hydration and nourishment (16) perhaps more so than in other nutrition care settings.

The depth of RD involvement with an individual is dependent on his/her nutrition needs, the policies of the facility, and the desires and expectations of the individual and surrogate decision makers. The RD is responsible for overseeing the nutrition care of individuals in the ECS whether employed by or contracted with a health care organization. Consultant RDs rely heavily on members of the interdisciplinary team (IDT) for comprehensive overviews of individuals' health status, whereas RDs employed by a facility maintain a more hands-on relationship with individuals. IDT members who care for individuals are specific to the organization and may include the physician, nurse, Minimum Data Set (MDS) coordinator, social worker, therapists (eg, physical, occupational, recreational, and speech-language), pharmacist, dietitian, dietetic technician, chef, dietary manager and food production/safety/sanitation supervisor. Regardless of the practice scenario, RDs must meet regulatory compliance standards set forth by CMS or other regulatory agencies (17, 18, 19) for the particular health care setting while achieving nutrition outcomes consistent with professional standards, person-centered care, and individual wishes.

Individualizing to the least-restrictive diet possible preferred by and tolerated by an individual is the premise of nutrition care in the ECS (20). Individuals are encouraged to participate in their nutrition care by selecting foods according to their preferences and health care goals. Individuals with complications secondary to food selections may benefit from RD interventions. Understanding the risk/benefit of food choices, as explained by an RD, empowers individuals by giving them an increased feeling of control over their own care.

Screening is a key step in the identification of individuals at increased nutritional risk who require a referral to an RD for assessment. Dietetic technicians, registered (DTRs), competent support personnel, and other trained health care staff can complete a validated screening tool specific to the population served (21, 22, 23). If determined to be at nutritional risk, an individual is referred to an RD for an assessment that incorporates the principles of the NCP (24).

RDs coordinate the nutrition care of individuals in ECS utilizing the NCP, which includes four steps: nutrition assessment, nutrition diagnosis, nutrition intervention, and nutrition monitoring and evaluation (24). A DTR may complete any step of the NCP after the DTR's demonstrated competencies to perform functions in that step have been documented by an RD. RDs are accountable and responsible for overall nutrition care and dining services provided in ECS. An RD must clearly identify the steps to be completed by a DTR in coordinating nutrition care. As part of RD/DTR teams, DTRs work under an RD's supervision when providing person-centered nutrition care and dining services. An RD in ECS must answer to individuals, employers, boards of dietetics licensure, and the legal system if care is compromised. Therefore, RDs must monitor nutrition and food safety outcomes associated with work done by DTRs and support personnel as defined in rules, regulations, occupational codes, compliance laws, state licensure, certification, and/or registration statutes (25, 26, 27).

Nutrition care of individuals in the ECS not only focuses on person-centered, RD-recommended, and physician-ordered diet, but also how the food is ordered, received, stored, planned, prepared, and delivered (dining services). RDs in ECS must apply the interpretive guidance of CMS State Operations Manual, state licensing regulations, and the US Department of Agriculture Food Code or their state's administrative code for food safety (17, 28) when auditing dining services operations, in-servicing facility staff, and interacting with federal and state surveyors.

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ADA SOP and SOPP for RDs in ECS 

An RD may use the ADA SOP and SOPP (competent, proficient, and expert) for RDs in the ECS to:

•identify the competencies needed to provide nutrition care and dining services in the ECS;

•self-assess if he or she has the appropriate knowledge base and skills to provide safe and effective nutrition care and dining services in the ECS for their level of practice;

•identify the areas in which additional knowledge and skills are needed to practice at the competent, proficient, or expert level of nutrition care and dining services in the ECS;

•provide a foundation for public and professional accountability for nutrition care and dining services in the ECS;

•assist management in the planning of nutrition care and dining services in the ECS;

•enhance professional identity and communicate the nature of nutrition care and dining services in the ECS;

•guide the development of nutrition care in the ECS-related education and continuing education programs, job descriptions, and career pathways; and

•assist educators and preceptors in teaching students and interns the knowledge, skills, and competencies needed to work in nutrition care and dining services in the ECS and an understanding of the full scope of this profession.

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Application to Practice 

The Dreyfus model (29) identifies levels of proficiency (novice, advanced beginner, competent, proficient, and expert) (refer to Figure 1, available online at www.adajournal.org) during the acquisition and development of knowledge and skills. This model is helpful in understanding the levels of practice described in the SOP and SOPP for RDs in the ECS. In ADA focus area SOP and SOPP, the stages are represented as competent, proficient, or expert practice levels.

All RDs, even those with significant experience in other practice areas, must begin at the competent level when practicing in a new setting. At the competent level, an RD in the ECS is learning the principles that underpin this focus area and is developing skills for effective ECS practice. This RD, who may be an experienced RD or may be new to the profession, has a breadth of knowledge in nutrition overall and may have proficient or expert knowledge/practice in another area. However, an RD new to the ECS focus area may experience a steep learning curve.

At the proficient stage, an RD may possess a specialist credential such as Board Certified Specialist in Gerontological Nutrition. This RD has developed a deeper understanding of nutrition care and dining services in the ECS and is better equipped to apply evidence-based guidelines and best practices than at the competent level. Unique situations for this RD include ability to modify the intervention based on the current needs of individuals. For example, an individual receiving nectar- or honey-thick liquids secondary to dysphagia continuously drinks thin liquids due to thirst, increasing risk for aspiration pneumonia. An RD works with the individual and IDT in initiating the Frazier Free Water Protocol (30), a safe method of drinking thin water by individuals with dysphagia.

At the expert stage, an RD—who may possess an advanced credential—thinks critically about dietetics in ECS, demonstrates a more intuitive understanding of ECS nutrition care and dining services, displays a range of highly developed clinical and technical skills, and formulates judgments acquired through a combination of practice experience and education. Essentially, practice at the expert level requires the application of composite dietetics knowledge, with practitioners drawing not only on their clinical experience, but also on the experience of ECS dietetics practitioners in various disciplines and practice settings. Experts, with their extensive experience and ability to see the significance and meaning of nutrition care and dining services in the ECS within a contextual whole, are fluid and flexible and, to some degree, autonomous in practice. They not only implement nutrition care and dining services in the ECS, they also drive and direct clinical practice, conduct and collaborate in research, contribute to multidisciplinary teams, and lead the advancement of nutrition care and dining services in the ECS.

Indicators for the SOP (Figure 2, available online at www.adajournal.org) and SOPP (Figure 3, available online at www.adajournal.org) for RDs in the ECS are measurable action statements that illustrate how each standard may be applied in practice. Within the SOP and SOPP for RDs in the ECS, an X in the competent column indicates that an RD who is caring for individuals in ECS is expected to complete this activity and/or seek assistance to learn how to perform at the level of the standard. A competent RD in the ECS could be an entry-level RD just starting practice after registration or an experienced RD who has newly assumed responsibility to provide nutrition care and dining services for individuals in the ECS. An X in the proficient column indicates that an RD who performs at this level has a deeper understanding of nutrition care and dining services in the ECS and has the ability to modify therapy to meet the needs of individuals in various situations (eg, an individual receiving enteral feedings adequate to meet estimated nutrition needs continues to lose weight. This RD, in addition to collaborating with the IDT to identify physical reasons for weight loss, would review facility systems specific to enteral feeding and evaluate their effectiveness). A proficient RD may hold a specialist credential. An X in the expert column indicates that an RD who performs at this level possesses a comprehensive understanding of nutrition care and dining services in the ECS and a highly developed range of skills and judgments acquired through a combination of experience and education. An expert RD builds and maintains highest level of knowledge, skills, and behaviors, including leadership, vision, and credentials.

Standards and indicators represented in Figure 2 in boldface type originate from ADA's Revised 2008 SOP in Nutrition Care and SOPP for RDs (1) and apply to RDs in all three categories. Several indicators not in boldface type are identified as applicable to all levels of practice. Where Xs are placed in all three categories of practice, it is understood that all RDs in the ECS are accountable for practice within each of these indicators. However, the depth with which an RD performs each activity will increase as the individual moves beyond the competent level. Level of practice considerations warrant taking a holistic view of the SOP and SOPP for RDs in the ECS. It is the totality of individual practice that defines the level of practice and not any one indicator or standard.

RDs should review the SOP and SOPP in the ECS at regular intervals to evaluate individual focus area nutrition knowledge, skill, and competence. Regular self-evaluation is important because it helps identify opportunities to improve and/or enhance practice and professional performance. This self-appraisal also enables ECS dietitians to better utilize the Commission on Dietetic Registration's Professional Development Portfolio (31) for self-assessment, planning, improvement, and commitment to lifelong learning (31). These standards may be used in each of the five steps in the Professional Developmental Portfolio process (Figure 4). RDs are encouraged to pursue additional training, regardless of practice setting, to maintain currency and to expand individual scope of practice within the limitations of the legal scope of practice, as defined by state law. Individuals are expected to practice only at the level at which they are competent, and this will vary depending on education, training, and experience (32). See Figure 5 for case examples of how RDs in different roles, at different levels of practice, use the SOP and SOPP in the ECS.

  • View full-size image.
  • Figure 4. 

    Application of the Commission on Dietetic Registration Professional Development Portfolio process. aThe Commission on Dietetic Registration Professional Development Portfolio process is divided into five interdependent steps that build sequentially upon the previous step duringeach 5-year recertification cycle and succeeding cycles.

In some instances, components of the SOP and SOPP for RDs in the ECS do not specifically differentiate between proficient and expert level practice. In these areas, it was the consensus of the content experts that the distinctions are subtle, captured in the knowledge, experience, and intuition demonstrated in the context of advanced practice, which combines dimensions of understanding, performance, and value as an integrated whole (33). A wealth of knowledge is embedded in the experience, discernment, and practice of expert level RD practitioners. The knowledge and skills acquired through practice will continually expand and mature. The indicators will be refined as expert level RDs systematically record and document their experience using the concept of clinical exemplars. Clinical exemplars include a brief description of the need for action and the process used to change the outcome. An experienced practitioner observes clinical events, analyzes them to make new connections between events and ideas, and produces a synthesized whole. Clinical exemplars provide outstanding models of the actions of individual ECS dietitians in clinical settings and the professional activities that have enhanced client care.

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Future Directions 

The SOP and SOPP for RDs in the ECS are innovative and dynamic documents. Future revisions will reflect changes in practice, dietetics education programs, and outcomes of practice audits. The authors acknowledge that the three practice levels require more clarity and differentiation in content and role delineation and that competency statements that better characterize differences among the practice levels are needed. Creation of this clarity, differentiation, and definition are the challenges of today's ECS dietitians to better serve tomorrow's practitioners and their patients, clients, and customers.

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Conclusions 

The SOP and SOPP for RDs in the ECS are complementary documents and are key resources for RDs at all knowledge and performance levels. These standards can and should be used by RDs in daily practice to consistently improve and appropriately demonstrate competency and value as providers of safe and effective nutrition care and dining services. These standards also serve as a professional resource for self-evaluation and professional development for RDs specializing in nutrition care and dining services in the ECS. The development and evaluation process is dynamic. Just as a professional's self-evaluation and continuing education process is an ongoing cycle, these standards are also a work in progress and will be reviewed and updated every 5 years. Current and future initiatives of ADA will provide information to use in these updates and in further clarifying and documenting the specific roles and responsibilities of RDs at each level of practice. As a quality initiative of ADA and the DHCC Dietetic Practice Group, these standards are an application of continuous quality improvement and represent an important collaborative endeavor.

These standards have been formulated to be used for individual self-evaluation and the development of practice guidelines, but not for institutional credentialing or for adverse or exclusionary decisions regarding privileging, employment opportunities or benefits, disciplinary actions, or determinations of negligence or misconduct. These standards do not constitute medical or other professional advice, and should not be taken as such. The information presented in these standards is not a substitute for the exercise of professional judgment by a health care professional. The use of the standards for any other purpose than that for which they were formulated must be undertaken within the sole authority and discretion of the user.

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The authors thank Carol Gilmore, MS, RD, LD, FADA, Janet S. McKee, MS, RD, LD/N, Linda Handy, MS, RD, and Carol A. Pitts, MS, RD, LN, for their contributions. The authors also thank the DHCC Executive Committee (Brenda E. Richardson, MA, RD, LD; Cynthia Piland, MS, RD, LD; Lisa Eckstein, MS, RD, LD; and Sharon Emley, MS, RD, LD) for approving the manuscript.

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Appendix 

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References 

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L. Roberts is president, Linda Roberts & Associates, Inc, Wheaton, IL.

S. C. Cryst is director, Nutrition Services, Maria Joseph Nursing and Rehabilitation Center, Dayton, OH.

G. E. Robinson is a corporate consultant, Ada, OH.

C. H. Elliott is president, Elliott Consulting, Inc, Ormond Beach, FL.

L. C. Moore is president and chief executive officer, Nutrition Systems, Inc, Port Gibson, MS.

M. Rybicki is a consultant dietitian, Nevins Nursing Home, Wakefield, MA.

M. P. Carlson is executive director, Dietetics in Health Care Communitites, Waterloo, IA.

 Address correspondence to: Cecily Byrne, MS, RD, LDN, Manager, Quality Management, American Dietetic Association, 120 South Riverside Plaza, Suite 2000, Chicago, IL 60606-6995. E-mail: cbyrne@eatright.org

PII: S0002-8223(11)00004-6

doi:10.1016/j.jada.2011.01.003

Journal of the American Dietetic Association
Volume 111, Issue 4 , Pages 617-624.e27, April 2011

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