Although most states allow RDN OW, many RDNs have not been able to take


advantage of this practice. Dietitians in Nutrition Support (an Academy of Nutrition and Dietetics dietetic practice group) and ASPEN conducted a survey of more than 500 RDNs to better understand RDN OW practices and barriers preventing RDNs from writing orders.29


The study included RDNs who provided nutrition care for


adult patients; the majority of the RDNs in the sample were practicing in a com- munity or academic medical center. A nutrition specialty credential, most commonly the Certified Nutrition Support Clinician (CNSC) credential, was more prevalent in those with OW privileges. Although about 50% of all RDNs in the study had some level of PN ordering privileges, 47% did not. Among the RDNs with full or partial PN OW privileges, 68% had a nutrition specialty credential. RDNs reported they were denied or had not applied for OW privileges due to opposition from other disciplines, lack of education or experience, liability concerns, or limitations due to state regu- lations (to name just a few of the reasons). More encouraging was the finding that approximately 80% of RDNs had some degree of EN OW privileges. Of RDNs with complete or partial EN OW privileges, 65% had a nutrition specialty credential. This study demonstrates that RDNs have made progress in OW privileges, but several challenges still exist. CNMs can collaborate with their clinical nutrition team, their organizational leaders, and externally with CNMs in neighboring facilities to ad- dress barriers to obtaining OW privileges. Figure 4.4 addresses common barriers and considerations related to each one.15,16,25-29 Research supports RDN OW as a practice that improves patient and orga-


nizational outcomes. In addition, RDNs with OW privileges report increased job satisfaction and recognition from physicians and others on the health care team. Therefore, unless they are in a state with regulations preventing RDN OW, CNMs should consider pursuing approval for RDN OW privileges. However, some orga- nizations may need time to establish policies and workflows as well as develop current staff or hire the right staff to ensure competency. A stepwise approach may build confidence among RDNs and other providers and offer a foundation for expansion of OW in the future.


Registered Dietitian Nutritionists and Feeding Tube Placement


Enteral feeding tube placement has been within the RDN scope of practice for decades, and some RDNs adopted this into their practice in the early 2000s.30-34


How-


ever, while the exact number of RDNs in the United States placing feeding tubes is not known, it is not a common practice at most organizations. The reasons for this vary from organization to organization but may be related to lack of comfort with or interest in tube placement by RDN staff, insufficient RDN staffing to perform ex- isting tasks, low awareness by other disciplines that RDNs can place feeding tubes, or the presence of an effective process whereby feeding tubes are placed by another discipline or department. Like RDN OW, RDN involvement in bedside feeding tube placement requires as-


sessment of internal and external factors. The CNM should determine if the current tube placement process could be improved and if RDN staff have an interest in tube placement. If the organization already has a process that promotes timely, efficient, effective, and safe feeding tube placement, there may not be a case for changing practice. However, if one or more of these elements is of concern, it represents an op-


CHAPTER 4: Clinical Nutrition Management 89


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