A task force composed of members of the Dietetics Practice Section of the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and the Dietitians in Nutrition Support Dietetic Practice Group (DNS DPG) of the American Dietetic Association (ADA) under the guidance of the A.S.P.E.N. Clinical Practice Committee and the ADA Quality Management (QM) Committee has developed Standards of Practice and Standards of Professional Performance for Registered Dietitians (RDs) in Nutrition Support (Figures 1, 2, 3). These documents are built upon ADA's Standards of Practice in Nutrition Care and Standards of Professional Performance1 found in ADA's Scope of Dietetics Practice Framework.2 The standards build upon and update the 2000 A.S.P.E.N. Standards of Practice for Nutrition Support Dietitians (approved by the A.S.P.E.N. Standards Committee and Board of Directors, and published in Nutrition in Clinical Practice in February 2000).3 The 2000 standards, based upon a role delineation study conducted by the National Board of Nutrition Support Certification,4 were reviewed by a wide variety of members and leaders within ADA and A.S.P.E.N., and were approved by the ADA QM Committee for approval and adoption by ADA.5 A.S.P.E.N. and ADA have demonstrated a more than ten-year commitment to collaboration on standards. Both organizations remain committed to a robust standards development and review process; A.S.P.E.N. has recently published results of a survey designed to make the standards and guidelines process even more effective.6 The indicators for the 2007 standards were developed by the consensus of content experts representing diverse practice and geographic perspectives and have not been validated by a practice audit (role delineation study). The National Board of Nutrition Support Certification (NBNSC) job analysis study, conducted in 2005, provided information to support these standards. These standards were developed by representatives of the A.S.P.E.N. Dietetics Practice Section and DNS DPG of ADA incorporating, as noted above, information from the A.S.P.E.N. Standards of Practice for Nutrition Support Dietitians,3 and were reviewed and approved by additional representatives of the A.S.P.E.N. Clinical Practice Committee, the A.S.P.E.N. Board of Directors, the DNS DPG of ADA, and the QM Committee of ADA. The Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for Registered Dietitians in Nutrition Support are a means for describing competencies in the assessment, selection, delivery and monitoring, of nutrition support therapy, which includes oral diets, enteral tube feeding and parenteral nutrition. The Standards of Practice and Standards of Professional Performance for Registered Dietitians in Nutrition Support should be used in conjunction with A.S.P.E.N. standards for other professionals, and for a variety of practice settings.7–16 The new standards describe three levels of practice in nutrition support therapy: Generalist, Specialty, and Advanced. However, it is acknowledged that nutrition support therapy, and its integral interventions, are most effectively undertaken with an interdisciplinary focus and at a level beyond that usually practiced by the entry-level RD. As stated in the Scope of Practice of the Standards of Practice for Nutrition Support Dietitians, the role of the RD in nutrition support “has clearly emerged as a specialty practice within professional dietetics.”3 These standards, along with ADA's Code of Ethics, answer the questions:“ Why is an RD uniquely qualified to provide nutrition support services?” and “What knowledge, skills, and competencies will an RD demonstrate to provide safe, effective, and quality nutrition support care at the generalist, specialty, and advanced levels?” These standards incorporate the principles of ADA's Nutrition Care Process and Model17 and apply to the continuum of nutrition support therapy (ie, acute care, extended care, home, and community settings).10–13 Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Nutrition Support. Standards of Practice for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; ADL, activities of daily living; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; DEXA, dual energy x-ray absorptiometry; EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; RD, Registered Dietitian. Standards of Practice for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; ADL, activities of daily living; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; DEXA, dual energy x-ray absorptiometry; EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; RD, Registered Dietitian. Standards of Practice for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; ADL, activities of daily living; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; DEXA, dual energy x-ray absorptiometry; EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; RD, Registered Dietitian. Standards of Practice for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; ADL, activities of daily living; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; DEXA, dual energy x-ray absorptiometry; EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; RD, Registered Dietitian. Standards of Practice for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; ADL, activities of daily living; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; DEXA, dual energy x-ray absorptiometry; EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; RD, Registered Dietitian. Standards of Practice for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; ADL, activities of daily living; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; DEXA, dual energy x-ray absorptiometry; EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; RD, Registered Dietitian. Standards of Practice for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; ADL, activities of daily living; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; DEXA, dual energy x-ray absorptiometry; EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; RD, Registered Dietitian. Standards of Practice for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; ADL, activities of daily living; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; DEXA, dual energy x-ray absorptiometry; EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; RD, Registered Dietitian. Standards of Practice for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; ADL, activities of daily living; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; DEXA, dual energy x-ray absorptiometry; EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; RD, Registered Dietitian. Standards of Practice for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; ADL, activities of daily living; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; DEXA, dual energy x-ray absorptiometry; EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; RD, Registered Dietitian. Standards of Practice for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; ADL, activities of daily living; A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; DEXA, dual energy x-ray absorptiometry; EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition; RD, Registered Dietitian. The Dreyfus model18 identifies levels of proficiency (Novice, Proficient, and Expert) during the acquisition and development of knowledge and skills. This model is helpful for understanding the levels of practice described in the Standards of Practice and Standards of Professional Performance for RDs in Nutrition Support. In ADA Standards of Practice and Standards of Professional Performance, the stages described by Dreyfus are represented as generalist, specialty, and advanced practice levels (Figure 4). All RDs, even those with significant work experience, begin at the Novice stage when practicing in a new setting. At the Novice stage (Generalist level) the RD in nutrition support is learning the principles that underpin its practice, and developing skills that enable effective entry level practice in nutrition support. 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 specialty or advanced knowledge/practice in another area. However, the RD will experience a steep learning curve in the practices and principles of nutrition support therapy. At the Proficient stage (Specialty level), the RD has developed a deeper understanding of nutrition support therapy and is much better equipped to apply best practice and evidence-based principles. This RD is also able to modify practice according to unique situations. At the Expert stage (Advanced level), the RD thinks critically about nutrition support therapy, exhibits a range of highly developed clinical and technical skills (which may include but are not limited to performing comprehensive nutrition-focused physical assessment, placement of enteral feeding tubes, and management of high acuity patients requiring enteral and/or parenteral nutrition including formulation of components, initiation of monitoring indices [weight, laboratory and radiology tests, formula infusion rate, etc]) and formulating judgments based on a combination of experience and education. Practice at the advanced level requires the application of composite nutrition knowledge, with practitioners drawing not only on their clinical experience, but also on the experience of other nutrition support practitioners in various disciplines and practice settings. Expert practice in nutrition support therapy is often evidenced by competency-based actions authorized by physician-approved protocols. Experts, with their extensive experience and ability to see the significance and meaning of nutrition support therapy within a contextual whole, are fluid, flexible, and to some degree, autonomous, in practice. Several models for advanced practice in nutrition support are described in the literature. Davis et al describe a model for advancing clinical privileges for RDs in nutrition support therapy.19 The model includes a highly specific competency assessment tool and a credentialing flow chart specific to the organization involved. Moreland et al described the process by which RDs obtained privileges for nutrition order writing in a long-term, acute-care hospital.20 The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations) defines clinical privileges as “authorization granted by the appropriate authority (for example, the governing body) to a practitioner to provide specific care, treatment, and services in an organization within well-defined limits, based on the following factors, as applicable: license, education, training, experience, competence, health status, and judgement.”21 Clinical privileges must be determined to be within the RD's professional, institutional, individual and state-specific scopes of practice. Depending on the organization, specific clinical privileges may not be required if the RD is making decisions in accordance with an approved algorithm or protocol and physician oversight.22 Organizations may require institutional credentialing/privileging for complex roles and responsibilities such as those suggested for an RD practicing in nutrition support therapy at the advanced level. Quantifying the exact number of registered dietitians who practice in nutrition support is difficult. As of October 2006, 3,463 RDs were members of the DNS DPG of ADA, and 3,456 RDs were members of A.S.P.E.N. Approximately 1,275, or 37%, of the RDs belong to both organizations. RDs who specialize in nutrition support may practice in a variety of patient care settings, such as short- and long-term acute care, extended care facilities, ambulatory/outpatient clinics, and in home care.3 In addition, RDs practicing in nutrition support may (solely, or in combination with a clinical practice) conduct research, teach, consult, and write for peer-reviewed professional publications. Nutrition support therapy encompasses provision of nutrients orally, enterally, or parenterally with therapeutic intent. This includes, but is not limited to, provision of enteral or parenteral nutrition to maintain and/or restore optimal nutrition status and health. The RD practicing in nutrition support collaborates with other healthcare professionals such as speech pathologists, respiratory therapists, pharmacists, nurses, and physicians to support, restore, and maintain optimal nutrition health in individuals with known or potential compromise in nutrition status.3 This interdisciplinary team approach has been shown to reduce cost and improve patient outcomes, and the RD is a key resource in various aspects of nutrition support therapy, including determinations of route and timing.23 Skipper24 suggests that the dietetics profession consider the model of the profession of advanced practice nursing, which is a definitive model for progressive clinical practice. For the advanced level practice RD in nutrition support, this model could include activities such as management of insulin therapy, catheter and device care, etc.24 The ADA defines dietetics as “the integration and application of principles derived from the sciences of food, nutrition, management, communication, and biological, physiological, behavioral, and social sciences to achieve and maintain optimal human health with flexible scope of practice boundaries to capture the breadth of the profession.”2 ADA's Scope of Dietetics Practice Framework, developed as a cornerstone for all members of the dietetics profession, was published in the April 2005 Journal of the American Dietetic Association. 2“ This framework defines core evaluation resources, Standards of Practice in Nutrition Care, Standards of Professional Performance, and a Code of Ethics to be used by individual practitioners in conjunction with relevant state, federal, and licensure laws so that practitioners can determine whether a particular activity falls within their own legitimate scope of practice and evaluate their performance.”2 The core Standards of Practice in Nutrition Care and Standards of Professional Performance were also published in the April 2005 issue of the Journal of the American Dietetic Association.1 The Standards of Practice in Nutrition Care and Standards of Professional Performance were designed as blueprints to accommodate the development of specialty and advanced level practice standards for RDs in specific areas of practice.1 Figure 4 presents the ADA's definitions for specialty and advanced level dietetics practice. The Standards of Practice and Standards of Professional Performance for RDs in Nutrition Support is the fourth set of practice-specific standards to be developed under the Scope of Dietetics Practice Framework, building on the core RD Standards of Practice for Nutrition Care and the Standards of Professional Performance. Others, also published by ADA, describe standards in the areas of diabetes, behavioral health, and oncology.25–27 The RD uses the A.S.P.E.N/ADA Standards of Practice and Standards of Professional Performance for the Registered Dietitians (Generalist, Specialty and Advanced) in Nutrition Support (Figures 1, 2, 3) to: identify the competencies needed to provide nutrition support therapy to patients in a variety of settings; self-assess whether they have the appropriate skill and knowledge to provide safe and effective nutrition support therapy for their level of practice; identify the areas in which additional knowledge and skills are needed to practice at the generalist, specialty, or advanced level of nutrition support therapy; provide a foundation for public accountability; assist management in the planning of services and resources; enhance professional identity and communicate the nature of dietetics; and guide the development of nutrition support therapy-related dietetics education programs, job descriptions, and career pathways. 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 the healthcare The of these standards for other than that for which they were formulated must be undertaken within the authority and of the individual who the RD may be of performing at of the three on the education and work experience, competencies and professional practice. may be for professional but not However, advanced and/or education may be needed in order to the knowledge and skills to to a competency level. knowledge, experience, and the competency of the in nutrition Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality Standards of Professional Performance for Registered Dietitians in Nutrition Support. ADA, American Dietetic Association; for Healthcare and A.S.P.E.N., American Society for Parenteral and Enteral Nutrition; for and for Healthcare for National Committee on Quality for RDs to practice in nutrition support include at three of the Certification by the as a Nutrition Support education, training, and/or professional education in nutrition support A of professional practice to the practice of nutrition support in the healthcare nutrition support activities in professional to nutrition support of these standards aspects of the knowledge and skills required for the the The specialty level of practice described in these documents is not to that by the the specialty level described in this encompasses the skill level of an RD who for patients nutrition support therapy beyond the level in the entry level nutrition support RD who is also a has experience and has the the ability to practice nutrition support therapy according to the core principles of nutrition support. RDs who have the to the may practice nutrition support at the specialty or advanced the by not this level of practice. specialty or advanced level practice for RDs in nutrition support therapy In 2006, the on a new of for nutrition support therapy in who the nutrition support by the will the of Nutrition Support This will nutrition support therapy professionals based on a core of practice practitioners of all the Standards of Practice (Figure and Standards of Professional Performance (Figure an in the that an RD who is for patients requiring nutrition support therapy is to be able to the stated activity and/or to in learning to the activity at the level of the The in nutrition support could be an entry level RD or an experienced RD who has only recently care of patients who require nutrition support. The could also be an experienced individual who has the focus of or nutrition support practice to another to or to another specialty to Figure in the Specialty that an RD who at this level requires a deeper understanding of nutrition support therapy and has the ability to modify therapy to the of patients in various situations. in the that the RD who at this practice level must have a comprehensive understanding of nutrition support therapy and a highly developed range of skills and judgments a combination of experience and education. standards and indicators from ADA's Standards of Practice in Nutrition Care and Standards of Professional Performance1 and should apply to RDs in all some were not in all three within standards to the unique nature of nutrition support therapy with other areas of nutrition are in all three of practice, it is that all RDs in nutrition support are for practice within of these However, the with which an RD activity will as the individual beyond the level. of practice a of the Standards of Practice and Standards of Professional Performance for RDs in Nutrition Support. is the of individual practice that the level of practice and not or RDs should review the Standards of Practice and Standards of Professional Performance for RDs in Nutrition Support at to evaluate their nutrition support knowledge, and self-evaluation is it to identify opportunities to improve and/or enhance practice and professional This also RDs to better the Commission on Dietetic Professional for and commitment to These standards may be used in of the in the Professional process (Figure are to practice only at the level at which they are and this will on education, training, and RDs are to additional knowledge and skill training, of practice to their scope of nutrition support therapy practice. Figure for of RDs in at levels of practice, may the Standards of Practice and Standards of Professional Performance for Registered Dietitians in Nutrition Support in their practice. In some of the Standards of Practice for Registered Dietitians in Nutrition Support do not specialty and advanced level practice. In these it was the consensus of the content experts that the are in the knowledge, experience, and demonstrated in the of practice at the advanced which of and as an A of knowledge is in the experience, and practice of advanced level nutrition support therapy The knowledge and skills with it will and will be in indicators as advanced level RDs their the of clinical The clinical and for and a Clinical describe of the actions of individuals in clinical or professional activities that have and patient include a of the for and the process used to the The Standards of Professional Performance for RDs in Nutrition Support the in practice level. For example, in Figure of includes an that the knowledge and skills to determine the most appropriate This includes to all levels of practice, and nutrition support knowledge and skills specific to specialty and advanced level knowledge and skills at the specialty level knowledge of specialty demonstrated by an understanding and of the and practices to nutrition support of the clinical to determine the most appropriate for advanced level knowledge and skills at the advanced level advanced and comprehensive knowledge of nutrition support demonstrated by an understanding and of advanced and to determine the most appropriate The Standards of Practice and Standards of Professional Performance for Registered Dietitians in Nutrition Support are and is a and their will in dietetics education and of practice The that the three practice levels require more and in content and role as as more clearly competency that the practice level of this and are the for nutrition support RDs, to better practitioners and their The Standards of Practice for the Registered in Nutrition Support therapy and the Standards of Professional Performance for the Registered in Nutrition Support therapy are key for RDs at all knowledge and These standards can and should be used by RDs in daily practice to improve and demonstrate competency and as of safe and effective nutrition support therapy. The standards development and evaluation process is These standards will be reviewed at for to practice. and of A.S.P.E.N. and ADA will provide information that will be used in these and in and the specific roles and responsibilities of practitioners at level. As a quality of A.S.P.E.N., its Dietetics Practice ADA and its DNS the standards are an application of quality and American Dietetic Association (ADA) of from the ADA Scope of Dietetic Practice of the Commission on Dietetic Professional of Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for the Registered (Generalist, Specialty, and Advanced) in Nutrition Support.
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Russell et al. (2007) studied this question.
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