History and evolution of a successful certification program in nutrition support: the CNSD experience

As early as the 1970s, articles were published on the role of dietitians in nutrition support. Both the American Society for Parenteral and Enteral Nutrition and The American Dietetic Association addressed the issues of specialization and certification. Development of a specialty area credential requires a strong demand by practicing clinicians, a unique area of clinical practice with a distinct body of knowledge and the commitment to evolve with clinical practice. Numerous dietitians were involved in the inception, development, and leadership that brought forth certification in nutrition support. This article documents the efforts and participation of a dedicated group of professionals whose common goals resulted in the establishment of a successful, sustaining certification in a specialty area of clinical dietetics: certified nutrition support dietitian. The certified nutrition support dietitian program is now in its 15th year with 2,000 dietitians currently certified both nationally and internationally. A primary focus of the credential is to recognize minimum competency for dietitians practicing in the field of enteral and parenteral nutrition and to provide safe and effective nutrition support therapy. This article provides a framework for persons in other specialty areas attempting to develop certification programs.     

Allocation of feeding pumps: an ethical question

Situations arise in clinical practice that force the dietitian to make a moral/ethical decision. Traditional undergraduate dietetic programs have not routinely included learning activities on ethical decision making. Therefore, a dietitian confronted with such an issue may defer to someone else the responsibility for finding a viable ethical solution. If the dietitian does accept the challenge, she/he must develop a systemic way to solve the problem. This case study demonstrates how a nutrition support dietitian solves a complex ethical problem involving the allocation of two enteral feeding pumps to seven critically ill patients. The three tools used to aid in the decision making were the Standards of Professional Responsibility of The American Dietetic Association, the Four-Step Process of Moral Judgment and Action of Purtilo and Cassel, and the Nutrition Support Team. It is hoped that this case example will provide some insight to other dietitians faced with similar ethical dilemmas.     

Nutrition support at the end of life: opinions of Louisiana dietitians

The purpose of this study was to determine the opinions of registered dietitians in Louisiana concerning nutrition support at the end of life. A questionnaire was mailed to the 777 active members of the Louisiana Dietetic Association. Questions addressed 3 issues: removal of nutrition support, the role of patients and family in decision making, and the role of the dietitian in decisions to use nutrition support for the terminally ill. A mean composite score was determined for each category. Kruskal-Wallis 1-way ANOVA was conducted on the composite scores to determine differences in responses by age, years of practice, and area of current practice. At least 60% of the respondents agreed with foregoing, withholding, or withdrawing nutrition support at the end of life. Most of the dietitians agreed that the patient or family is more qualified than the health care professional to make decisions about nutrition support at the end of life. More than 95% of the dietitians agreed that the dietitian should be involved in the decision-making process. However, only 50% of the dietitians felt fully qualified to provide the information needed to help a patient or family make the decision about nutrition support at the end of life. Differences of opinions about the removal of nutrition support were found by age, number of years of practice, and current area of practice. Results from this study may encourage dietitians to explore their own attitudes and seek continuing education on ethical dilemmas to enable them to make better decisions, provide better care, and become better patient advocates.     

Computerized Patient Record: Are we Prepared for our Future Practice?

Objective To survey members of The American Dietetic Association (ADA) regarding care documentation systems, computerization of patient care records, and factors to be considered in developing a documentation system compatible with a computer-based patient record.Design The survey instrument was developed in conjunction with a survey consultant/statistician, then mailed to the study sample.Subjects/setting The sample of 500 was drawn from three ADA dietetic practice groups expected to include a high percentage of clinical practitioners.Statistical analysis performed Basic frequency displays were used on all questionnaire items. Pearson correlation coefficients were used among numeric variables, and one-way analysis of variance was used for categoric variables with quantitative variables.Results A total of 171 usable surveys were returned (34%), primarily from dietitians working in an acute-care inpatient environment. The SOAP format (subjective, objective, assessment, and plan) was used by 60% of respondents to document nutrition assessments, although a number of other documentation formats were reported. Most commonly used data in nutrition decision making were medical diagnosis, diet order, anthropometric data, and laboratory values. Most commonly used outcomes measures included laboratory values, tolerance of the nutrition regimen, weight changes, and intake changes. Only 15% of respondents reported that they currently used a computerized patient record. Ninety-three percent of respondents favored standardized nutrition diagnoses, and 95% believed standardized nutrition interventions would prove useful.Applications/conclusions We recommend that dietitians evaluate, standardize, and streamline their documentation to prepare for implementation of computerized systems. The diagnoses and interventions presented in this study could be a starting point. J Am DietAssoc. 1997;97:1099–1104.     

A review of guidelines for nutrition care of renal patients.

The third edition of the Guidelines for Nutrition Care of Renal Patients has been developed to follow the American Dietetic Association's Medical Nutrition Therapy (MNT) Protocol format and to further assist dietitians in providing optimal and consistent care to renal patients. The guidelines define the level, content, and frequency of nutrition care that is appropriate based on the best available scientific information and expert opinion. Seven separate guidelines, primarily written for care provided in the outpatient setting, are defined in the publication. Each guideline focuses on a different patient population and/or treatment modality for renal disease: Pre-End-Stage Renal Disease, Hemodialysis and Peritoneal Dialysis, Hospitalized Dialysis, Transplantation, Acute Renal Failure, Enteral/Parenteral Nutrition Support, and Pregnancy in Renal Disease. The Guidelines for Nutrition Care of Renal Patients, Third Edition is meant to support and assist dietitians as providers of MNT in kidney disease, to provide uniform treatment care guidelines and nutritional status identification criteria for all aspects of kidney disease and its complications, and to help secure the dietitian as the provider of these services for optimum cost-effective care. The guidelines should help to increase effectiveness of care by promoting consistency among practitioners and should facilitate the measurement of the quality and effectiveness of care.     

Staffing patterns in hospital clinical dietetics and nutrition support: a survey conducted by the Dietitians in Nutrition Support dietetic practice group.

The Dietitians in Nutrition Support dietetic practice group of The American Dietetic Association administered a questionnaire to evaluate changes in nutrition support services provided to hospitalized patients and home patients in 1989 and compared the results with results of a survey administered in 1986. The 1986 survey documented an increase in tube feeding to inpatients during 1984 to 1986 and greater dietitian staffing in tertiary care hospitals than in primary care hospitals and in larger hospitals in 1986. The 1989 questionnaire was mailed to clinical nutrition managers from a nationwide random sample of 1,000 hospitals from American Hospital Association members; 271 responses were received. Full-time equivalent (FTE) registered dietitians (RDs)--including clinical RDs, nutrition support service RDs, and clinical nutrition managers--decreased 11% from 1986 to 1989. FTE dietetic technicians decreased 22%. The number of FTE nutrition support service RDs and clinical nutrition managers decreased significantly (P less than .05). The mean number of FTE clinical dietitians per 100 beds decreased from 1.4 to 1.0 from 1986 to 1989. These decreases in dietetics staffing occurred despite an overall increase in total hospital FTE staff of 2.9%. Reported daily provision of nutrition support modalities to inpatients was 3.5% for parenteral nutrition, 4.9% for enteral tube feeding, and 9.6% for oral supplements. Decreased dietetics staffing was accompanied by other factors that negatively affect productivity (and therefore ability to provide adequate patient care), including inadequate delegation of technical tasks to dietetic technicians, limited availability of secretarial and computer support, and minimal provision of pocket pagers. These trends may be evidence of inadequacy of dietetics staffing to meet the needs of the US population for nutrition care.     

Practitioners' opinions on Food and Nutrition Care Indicators in assisted living facilities for older adults

This study assessed the utility of the 57-indicator Food and Nutrition Care Indicators Checklist for assessing food and nutrition services in assisted-living facilities for older adults among registered dietitians (RDs). They were members of two American Dietetic Association practice groups focusing on aging and long-term care and were also employed in assisted-living facilities. The 1,281 respondents rated the importance of each checklist item and provided their views on the role of assisted-living facilities and their level of agreement with statements regarding the importance of residents' autonomy for making food choices and their ability to make wise dietary choices. Registered dietitians practicing in assisted-living facilities considered all of the domains on food and nutrition quality indicators on the Food and Nutrition Care Indicators Checklist to be highly important (92% of dining room environment items, 83% of foodservice operations, 92% of general nutrition, and 89% of therapeutic nutrition items). They preferred a service style that included both health and amenities, as did national health and aging experts. Registered dietitians should work with other professionals to further validate the checklist, promote its use, and establish optimal service models for food and nutrition services in assisted-living facilities for older adults.     

Academy of Nutrition and Dietetics: Revised 2021 Standards of Professional Performance for Registered Dietitian Nutritionists (Competent,Proficient, and Expert) in Management of Food and Nutrition Systems

Management of food and nutrition systems (MFNS) encompasses the varied roles of registered dietitian nutritionists (RDNs) with administrative responsibilities for food and nutrition services within an organization. RDNs in MFNS are frequently employed in acute care, but also expand into a multitude of other settings in which management of nutrition and foodservice is required, for example, foodservice departments in assisted living and post-acute and long-term care; colleges and universities, kindergarten through grade 12 and pre-kindergarten schools and childcare; retail foodservice operations; correctional facilities; and companies that produce, distribute, and sell food products. RDNs in MFNS aim to create work environments that support high-quality customer-centered care and services, attract and retain talented staff, and foster an atmosphere of collaboration and innovation. The Management in Food and Nutrition Systems Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has revised the Standards of Professional Performance (SOPP) for RDNs in MFNS for 3 levels of practice: competent, proficient, and expert. The SOPP describes 6 domains that focus on 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. Indicators outlined in the SOPP depict how these standards apply to practice. The standards and indicators for RDNs in MFNS are written with the leader in mind—to support an individual in a leadership role or who has leadership aspirations. The SOPP is intended to be used by RDNs for self-evaluation to assure competent professional practice.     

Medical Nutrition Therapy in Adults with Chronic Kidney Disease: Integrating Evidence and Consensus into Practice for the Generalist Registered Dietitian Nutritionist

Chronic kidney disease is classified in stages 1 to 5 by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative depending on the level of renal function by glomerular filtration rate and, more recently, using further categorization depending on the level of glomerular filtration rate and albuminuria by the Kidney Disease Improving Global Outcomes initiative. Registered dietitian nutritionists can be reimbursed for medical nutrition therapy in chronic kidney disease stages 3 to 4 for specific clients under Center for Medicare and Medicaid Services coverage. This predialysis medical nutrition therapy counseling has been shown to both potentially delay progression to stage 5 (renal replacement therapy) and decrease first-year mortality after initiation of hemodialysis. The Joint Standards Task Force of the American Dietetic Association (now the Academy of Nutrition and Dietetics), the Renal Nutrition Dietetic Practice Group, and the National Kidney Foundation Council on Renal Nutrition collaboratively published 2009 Standards of Practice and Standards of Professional Performance for generalist, specialty, and advanced practice registered dietitian nutritionists in nephrology care. The purpose of this article is to provide an update on current recommendations for screening, diagnosis, and treatment of adults with chronic kidney disease for application in clinical practice for the generalist registered dietitian nutritionist using the evidence-based library of the Academy of Nutrition and Dietetics, published clinical practice guidelines (ie, National Kidney Foundation Council on Renal Nutrition, Renal Nutrition Dietetic Practice Group, Kidney Disease Outcomes Quality Initiative, and Kidney Disease Improving Global Outcomes), the Nutrition Care Process model, and peer-reviewed literature.     

Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: Revised 2021 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent,Proficient, and Expert) in Nutrition Support

Nutrition support is a therapy that crosses all ages, diseases, and conditions as health care practitioners strive to meet the nutritional requirements of individuals who are unable to meet nutritional and/or hydration needs with oral intake alone. Registered dietitian nutritionists (RDNs), as integral members of the nutrition support team provide needed information, such as identification of malnutrition risk, macro- and micronutrient requirements, and type of nutrition support therapy (eg, enteral or parenteral), including the route (eg, nasogastric vs nasojejunal or tunneled catheter vs port). The Dietitians in Nutrition Support Dietetic Practice Group, American Society for Parenteral and Enteral Nutrition, along with the Academy of Nutrition and Dietetics Quality Management Committee, have updated the Standards of Practice (SOP) and Standards of Professional Performance (SOPP) for RDNs working in nutrition support. The SOP and SOPP for RDNs in Nutrition Support provide indicators that describe the following 3 levels of practice: competent, proficient, and expert. The SOP uses the Nutrition Care Process and clinical workflow elements for delivering patient/client care. The SOPP describes the 6 domains that focus on professional performance. Specific indicators outlined in the SOP and SOPP depict how these standards apply to practice. The SOP and SOPP are complementary resources for RDNs and are intended to be used as a self-evaluation tool for assuring competent practice in nutrition support and for determining potential education and training needs for advancement to a higher practice level in a variety of settings.     

Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Nutrition and Dietetics Technicians,Registered

Nutrition and dietetics technicians, registered (NDTRs) face complex situations every day. Competently addressing the unique needs of each situation and applying standards appropriately are essential to providing safe, timely patient-/client-/customer-centered quality nutrition and dietetics care and services. The Academy of Nutrition and Dietetics (Academy) leads the profession by developing standards that can be used by NDTRs (who are credentialed by the Commission on Dietetic Registration) for self-evaluation to assess quality of practice and performance. The Standards of Practice reflect the NDTR’s role under the supervision of registered dietitian nutritionists in nutrition screening and the Nutrition Care Process and workflow elements, which includes nutrition screening, nutrition assessment, nutrition diagnosis, nutrition intervention/plan of care, nutrition monitoring and evaluation, and discharge planning and transitions of care. The Standards of Professional Performance consist of 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. Within each standard, indicators provide measurable action statements that illustrate how the standard can be applied to practice. The Academy’s Revised 2017 Standards of Practice and Standards of Professional Performance for NDTRs along with the Academy/Commission on Dietetic Registration Code of Ethics, and the Scope of Practice for the NDTR provide minimum standards and tools for demonstrating competence and safe practice, and are used collectively to gauge and guide an NDTR’s performance in nutrition and dietetics practice.     

Evaluating Evidence‐Based Nutrition Support Practice Among Healthcare Professionals With and Without the Certified Nutrition Support Clinician Credential

Background: The National Board of Nutrition Support Certification credentials healthcare professionals and certifies that holders of the Certified Nutrition Support Clinician (CNSC) credential have specialized knowledge of safe and effective nutrition support therapy. The purpose of this pilot study was to survey healthcare professionals affiliated with the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) regarding their approaches to nutrition support practice using a complex patient case scenario in accordance with established clinical guidelines. Materials and Methods: An electronic survey was emailed to individuals affiliated with A.S.P.E.N. Eight multiple‐choice knowledge questions addressed evidence‐based nutrition support practice issues for a patient with progressing pancreatitis. Demographic and clinical characteristic data were collected. Results: Of 48,093 email invitations sent, 4455 (9.1%) responded and met inclusion criteria. Most respondents were dietitians (70.8%) and in nutrition support practice for 10.3 years, and 29.3% held the CNSC credential. Respondents with the CNSC credential answered 6.18 questions correctly compared with 4.56 for non‐CNSC respondents (P < .001). For all 8 questions, CNSC respondents were significantly more likely to choose the correct answer compared with non‐CNSC respondents (P < .001). Conclusion: Professionals with the CNSC credential scored significantly higher on a complex case‐based knowledge assessment of guideline recommendations for the nutrition support treatment of pancreatitis compared with those without a credential.     

Nutrition Intervention Program of the Modification of Diet in Renal Disease Study: A Self-Management Approach

Objective To characterize the Modification of Diet in Renal Disease (MDRD) Study nutrition intervention program by determining the frequency of intervention strategies used by the dietitians and the usefulness of program components as rated by participants.Design Dietitians recorded which of 32 intervention strategies they used at each monthly visit. Participants rated the usefulness of 19 program components.Subjects 840 adults with renal insufficiency.Intervention Participants were assigned randomly to usual-, low-, or very-low-protein diet groups. Each eating pattern also specified a phosphorus intake goal. Each participant met monthly with a dietitian for an average of 26 months.Statistical analyses Analyses of variance and χ² analyses.Results Dietitians used the following intervention strategies most often in all groups: providing feedback based on self-monitoring and/or food records, reviewing adherence or biochemistry data, providing low-protein foods, and reviewing graphs of adherence progress. In general, the dietitians used feedback, modeling, and support strategies more often, and knowledge and skills strategies less often, with participants who had to make the greatest reductions in protein intake and those with more advanced disease. In all groups, the dietitians’ use of knowledge and skills, feedback, and modeling strategies decreased over time (P<.001), whereas use of support strategies was maintained. The type and frequency of intervention strategies used by dietitians and the usefulness ratings of participants did not vary by educational level of the participant. Both self-monitoring and dietitian support were rated as “very useful” by 88% of the participants.Conclusions Three features were central to the MDRD Study nutrition intervention program: feedback, particularly from self-monitoring and from measures of adherence; modeling, particularly by providing low-protein food products; and dietitian support. We recommend the self-management approach. J Am Diet Assoc. 1995; 95:1288-1294.     

Position of the American Dietetic Association: individualized nutrition approaches for older adults in health care communities

It is the position of the American Dietetic Association that the quality of life and nutritional status of older adults residing in health care communities can be enhanced by individualization to less-restrictive diets. The American Dietetic Association advocates for registered dietitians to assess and evaluate the need for nutrition interventions tailored to each person's medical condition, needs, desires, and rights. Dietetic technicians, registered, assist registered dietitians in the assessment and implementation of individualized nutrition care. Health care practitioners must assess risks vs benefits of therapeutic diets, especially for older adults. Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in undernutrition and related negative health effects. Including older individuals in decisions about food can increase the desire to eat and improve quality of life. The Practice Paper of the American Dietetic Association: Individualized Nutrition Approaches for Older Adults in Health Care Communities provides guidance to practitioners on implementation of individualized diets and nutrition care.     

Nephnologists’ and Internal Medicine Physicians’ Expectations of Renal Dietitians and General Dlinical Dietitians

Objective To document and compare nephrologists’ and internal medicine physicians’ expectations of renal dietitians and general clinical dietitians.

Design Subjects completed a mailed survey. Respondents provided demographic information and used a 5-point Likert scale to note whether each of 14 job functions was appropriate for general clinical dietitians, renal dietitians, or both.

Subjects Five hundred forty-one physicians registered with the Ohio State Medical Board (OSMB) were surveyed. Within this group were 283 nephrologists (the population of nephrologists registered with the OSMB) and 258 internal medicine physicians (selected randomly by the OSMB). A total of 133 physicians (25%) returned the survey; 119 surveys were usable: 70 from nephrologists and 49 from internists.

Statistical analyses performed A composite variable was created by coding and summing physicians’ responses regarding dietitian job functions. This variable was averaged for both physician categories. A t test was conducted to compare composite variable results between the two physician groups.

Results At least 50% of nephrologists and internists agreed that both types of dietitians should conduct nutrition assessments, determine patients’ energy needs, evaluate medication-nutrient interactions, recommend diet and tube-feeding orders, instruct patients about physician-ordered diets, and teach nutrition concepts to hospital interns. Few physicians agreed that either type of dietitian should order diets, tube feedings, or diet instructions.

Applications/conclusions Clinical dietitians can educate physicians about dietitians’ roles informally in their institutions and formally by supporting programs like The American Dietetic Association Physician Nutrition Education Program. In addition, dietetics educators can hone their students’ communication and problem-solving skills to promote positive physician-dietitian interaction. J Am Diet Assoc. 1997;97:1389-1393.     

Academy of Nutrition and Dietetics: Revised 2017 Standards of Practice in Nutrition Care and Standards of Professional Performance for Registered Dietitian Nutritionists

Registered dietitian nutritionists (RDNs) face complex situations every day. Competently addressing the unique needs of each situation and applying standards appropriately are essential to providing safe, timely, patient-/client-/customer-centered, quality nutrition and dietetics care and services. The Academy of Nutrition and Dietetics (Academy) leads the profession by developing standards that can be used by RDNs (who are credentialed by the Commission on Dietetic Registration) for self-evaluation to assess quality of practice and performance. The Standards of Practice reflect the Nutrition Care Process and workflow elements as a method to manage nutrition care activities with patients/clients/populations that include nutrition screening, nutrition assessment, nutrition diagnosis, nutrition intervention/plan of care, nutrition monitoring and evaluation, and discharge planning and transitions of care. The Standards of Professional Performance consist of 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. Within each standard, specific indicators provide measurable action statements that illustrate how the standard can be applied to practice. The Academy’s Revised 2017 Standards of Practice and Standards of Professional Performance for RDNs, along with the Academy’s Code of Ethics and the Revised 2017 Scope of Practice for the RDN, provide minimum standards and tools for demonstrating competence and safe practice and are used collectively to gauge and guide an RDN’s performance in nutrition and dietetics practice.