Chapter 23 Scope of Practice for the RDN and NDTR

gains on-the-job skills and tailored continuing educa- tion to enhance proficiency and knowledge. Additional aptitude in training and technical skills in a specified focus area may have been achieved in the education process by the professional (1).

Proficient level of practice describes an RDN or NDTR who is three-plus years beyond entry into the profession, has obtained operational job performance skills, and is successful in the chosen focus area of practice. The RDN or NDTR obtains additional formal education degree(s) or credential(s) to show evidence of a higher level of practice ability or simulation train- ing to further skill level and participates in research. At this level, the RDN or NDTR is identified as a well- known speaker or is published in a focus area of prac- tice and is sought after for practice and operational advice (1).

At the expert level of practice is an RDN or NDTR who is recognized within the profession and has mastered the highest degree of skill in or knowl- edge of a certain focus or generalized area of nutrition and dietetics through additional education, advanced and specialist credentials, certificates of training, skills acquisition, and experience. The expert RDN or NDTR is a profound thinker, distinguished by his or her wisdom, who applies sound judgment to quality care and issue resolution. An RDN or NDTR who reaches the expert level of practice is recognized for excellence and duly accorded authority and status by both his or her peers and the public in a specific, well-defined domain (1).

SCOPE OF PRACTICE In the pursuit of ongoing, voluntary, and self-motivated knowledge; advancing abilities and expertise to con- tinue successful competence; and practicing at the highest level of scope of practice, the RDN and NDTR must continually self-assess his or her skills, education, training, and knowledge, as well as his or her auton- omy, responsibility, and accountability in the practice of nutrition and dietetics. These are the critical compo- nents of a profession. How a profession determines its unique role is answered through sources of profes- sional direction. Professions develop documents or statements about what the members feel are important in order to guide their practice, to establish control over practice, and to influence the quality of that prac- tice. Examples are social policy statements, scope and standards of practice, codes of ethics, and state boards that operate under a practice act detailing regulations to protect the health and safety of the public (19). Statutory scope of practice is defined by the Academy based on the Center for the Health

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Professions, University of California, San Francisco definition: “Legal scopes of practice for the health care professions establish which professionals may provide which health care services, in which settings, and under which guidelines or parameters. With few excep- tions, determining scopes of practice is a state-based activity. State legislatures consider and pass the prac- tice acts, which become state statute or code. State reg- ulatory agencies, such as medical and other health professions’ boards, implement the laws by writing and enforcing rules and regulations detailing the acts” (1). Individual scope of practice in nutrition and dietet- ics encompasses the range of roles, activities, and reg- ulations within which nutrition and dietetics practitioners perform. For credentialed practitioners, scope of practice is typically established within the practice act and interpreted and controlled by the agency or board that regulates the practice of the pro- fession in a given state. RDNs and NDTRs must comply with the Academy of Nutrition and Dietetics/ Commission on Dietetic Registration Code of Ethics for the Profession of Dietetics (1,14).

Scope of Practice Decision Tool As RDNs and NDTRs enhance their functional areas of practice to elevate their career opportunities—espe- cially in the older adult nutrition care area—or are requested to perform new, enhanced care activities, questions about scope of practice often come to mind, such as, “May an RDN obtain approval to perform initial swallowing screening? Perform nasogastric tube placement? Order and modify therapeutic diets, enteral feedings, and supplements? Order labs? Conduct finger sticks for glucose monitoring? May an NDTR modify the intervention/plan of care?” To support the RDN and NDTR in answering whether a particular activity is within his or her scope of practice, the Academy developed the Scope of Practice Decision Tool (20). This interactive tool is online and includes links to

additional Academy resources. It allows RDNs and NDTRs to critically evaluate their knowledge, skill, and demonstrated competence by using criteria resources. RDNs and NDTRs must understand that competence to perform designated activities within defined older adult care practice settings is an essential element of the scope of practice in nutrition and dietet- ics. Practitioners are expected to practice in the areas in which they are competent, but level of experience, skills, and proficiency to perform designated activities vary, and individual practitioners may not be compe- tent in all aspects of the nutrition care of the older adult. Practitioners are thus encouraged to pursue addi- tional education and experience to expand their indi- vidual scope of practice (20).