Professional Development Guidance Document on Extended Scope Practice

Transcription

1 Professional Development Guidance Document on Extended Scope Practice

2 Contents Context and Drivers... 3 Definitions... 3 Key Considerations for the Development of an Extended Role... 4 Risk Management... 7 Evaluation... 8 Audit... 8 Final Thoughts

3 Context and Drivers As with most scientific professions, Dietetics is not a static discipline but constantly evolving to meet the demands of the service and service users. The settings within which dietetics is practiced has also changed considerably over the years. Although the majority of dietitians still work within the National Health Service, a growing number work in a variety of diverse settings, from industry to television, from sports nutrition to website development. As dietetics has evolved so too have dietitians, constantly adapting and challenging the traditional professional boundaries. This guidance paper aims to clarify the extended role, and attempts to address some key issues which need to be considered when developing an extended role. In the health service, extended practice is a potential solution to a number of management issues including waiting lists; manpower issues and the need to create a more flexible workforce in line with Government policy. For the health professional the perceived benefits include increased job satisfaction, a sense of autonomy and improved career prospects, with a knock on effect on recruitment and retention. For the public, extended scope practice is potentially a means of increasing access to a more holistic service, with reduced need for further referrals. Definitions The core role of a dietitian is: To negotiate specific practical dietary changes with individuals/groups to meet nutritional and/or therapeutic goals To assess dietary adequacy To empower individuals/groups to overcome their barriers to dietary change To provide information, training, expert opinion or advice on current thinking/evidence-based/best practice in nutrition and dietetics to individuals/groups and other health professionals and organisations To develop practical tools to support changes in dietary behaviour To contribute expertise in the development of multi-disciplinary strategy, policy, protocols and guidelines relating to nutrition To contribute to the evidence and research base in nutrition and dietetics For example: 1. A dietitian providing advice on a general ward for weight loss and loss of appetite and patients referred for naso-gastric feeding. 2. A dietitian providing an education session on healthy eating in Type 2 diabetes in the community setting. The specialist/advanced dietetic practitioner will focus on the application of core skills within a specialist area such as oncology, diabetes, community nutrition. They will have in-depth knowledge, training and practical experience in that field which has been acquired over time. 3

4 Examples of specialist/advanced roles: 1. A dietitian advising the nutrition team on appropriate TPN feeds. 2. A diabetes specialist dietitian advising patients with both diabetes and renal failure. 3. A dietitian running a home enteral tube feeding service. 4. A dietitian using behavior change therapy in obese patients The extended role dietetic practitioner undertakes new practices outside the core and specialist roles. They are usually (but not exclusively) roles traditionally carried out by other health professionals as a core duty or role extension. They will require additional skills and knowledge acquired through formal training. The extended role practitioner must advance dietetic practice and contribute to improving outcomes. Examples of extended role 1. A dietitian replacing gastrostomy tubes in the community. 2. A dietitian inserting peripheral midlines for IV feeding. 3. A dietitian advising on appropriate exercise regimes. The dietetic consultant is an expert in a specialist field. They will have exceptional clinical and leadership skills as well as being able to demonstrate highly advanced levels of clinical reasoning and decision making. They will work at a strategic level to achieve significant health outcomes and extend the boundaries of dietetic practice. It is important to note that for all roles including extended roles, there is no specifically assigned level. For example an extended role is not automatically a level 7. Ultimately it will be the outcome of the job evaluation process that determines remuneration under the Agenda for Change system. Key Considerations for the Development of an Extended Role Scope of practice Adapted from The Scope of Practice for Physiotherapists. Information Paper no. PA44. June The Chartered Society of Physiotherapists. Before embarking on the task of discussing the extended scope of practice it is perhaps important to firstly address the concept of individual scope of practice. 4

5 Identifying your scope of practice is not easy as the boundaries will be different for each practitioner and will be evolving over time. When an individual defines their own scope, it is a broad picture of their practice and may describe some or all of the following: Occupational role Eg. (clinician, researcher, education) Sector (private practice, industry, higher education) Environment (acute, community, GP practice) Client Group (children, elderly, people with learning difficulties) Speciality (diabetes, public health, obesity) Treatment approaches (behavioural therapy, group education) Types of cases for referral elsewhere (other dietitians) A much more specific scope of practice is described in relation to individual patients/clients or circumstances. When presented with a patient, the dietitian should undertake a personal risk assessment as part of the overall assessment asking themselves key questions before proceeding: Is the patient/client safe? Am I safe? Can I justify the decision I have made during the assessment (for example have the research, evidence, standards, guidance been considered)? Can I identify the most appropriate approach for the patient/client group? Do I have the correct balance skills, knowledge and experience to be competent in my chosen approach? Whatever role the dietitian commits to, extended or otherwise, they must constantly be aware of their individual scope of practice, and practice within this. The extended role. Any extended role being considered should be developed around an identified need or gap in service, with particular focus on the patient, client or service. They should undertake a needs analysis. The practitioner must question Will this role benefit the patient/client and will it benefit the service? Is the service sustainable? How often will I be required to undertake the extended role? will it become part of my regular practice or is it only occasionally? If only occasionally/rarely is the role really necessary, and will I be able to maintain a level of competence? Where appropriate an extended role should be supported by examples of similar roles, published evidence, or other national guidance, e.g. NICE, SIGN, CREST. Within the constraints of the health service no extended role should be developed solely around the health professional and their personal aspirations or development needs and should be in agreement with the line manager/team lead. Freelance dietitians may not have the same limitations but should always be mindful of HPC regulations and the responsibility to remain within scope of practice. It is important that the team/practitioner identifies clear boundaries which limit where extended practice will end and when further referral is needed. These boundaries should be clearly indicated in the supporting protocol. 5

6 Support and training Appropriate and comprehensive training is an essential factor when considering an extended role and it is important to consider the impact of time and cost implications of undertaking the required training both personally and on department resources. There may be additional implications for colleagues covering work while additional education and training is carried out. The practitioner will need to investigate what formal training is required to undertake the extended role. Ultimately the role must be carried out to the same level of competence as that expected of the practitioner for whom the role is core. Professional competence refers to the patient/client/customers expectation that the professional they come into contact with is up to the job. It requires a firm educational grounding, followed by a period of formal training to acquire the relevant knowledge and skills in the workplace. Thereafter continued competence rests on a combination of education, continuous development, confidence and experience. Thus, acquiring and maintaining professional competence involves collaboration between the individual, the educational institutions, the employer, and those who set and enforce standards of professional competence (Bristol Inquiry 2001) Any training will be provided through accredited, nationally or professionally recognised courses, leading to a qualification or certificate. Where this is not available training may take the form of in-house training through short courses provided by the employer or formal one to one sessions with a member of the team or other specialist. It is the responsibility of the practitioner to review and update their training as appropriate, and be aware of any legislative or policy change with regard to official training requirements. Any training undertaken must include assessment by an appropriate member of the team and this assessment must be regularly reviewed, e.g. annually. All dietitians should ensure they have access to clinical supervision (or equivalent peer review system). It is a fundamental part of all dietetic posts and should be a key consideration in developing any extended role Practice Supervision for Dietitians, BDA July It is important to add that for the extended role practitioner, and indeed specialist/advanced practice roles the supervisor may not be a dietitian. 6

7 Risk Management The potential risks involved in undertaking the new role must be risk assessed. How great is the risk to the patient/client or service? What measures are in place to minimise this risk? Where is the support if things should go wrong? As with any treatment or procedure the patient/client must be made aware of the risks involved and given the opportunity to raise any concerns. The patient/client will always retain the right to consent or decline the treatment. Under all circumstances effective and timely communication within the multi-disciplinary team will help to reduce risk. Before commencing an extended role within the healthcare setting it is important to seek approval from the Trust/Board risk department. Documentation 1. Rationale As discussed earlier it is important that the rationale for extending practice is clearly documented, along with the identified benefit to the service and service user. 2. Protocol/Procedure This should describe in detail the step by step guide to how the role will be undertaken. It should also include any limitations or exclusions and identify the point at which the extended role ends and a referral on is required. All procedures, protocols and competence to undertake the extended role must be signed off by the supervisor/ team leader/ manager. 3. Certificates Certificates of training and education for the extended role should be retained. 4. Evidence Any supporting published evidence or peer review. 5. Risk Areas of potential risk should be clearly identified as discussed earlier together with the measures in place to reduce this risk. 6. Review/Audit The date of review of the practitioner s competence along with all procedures and protocols must be included. A date for undertaking audit on the new role should also be established. 7. Organisation / Peer Ratification In all settings official ratification should be sought. In most instances it is the employing organisation who will ratify the extended practice and they may require as policy, all of the above documentation before ratification. Freelance/self employed dietitians will not need to seek approval from any organisation, however, it is strongly recommended that peer approval is sought for the extended role, for example through BDA specialist groups. In addition guidance on insurance cover for the extended practice must be sought from the BDA. If the BDA s insurance provider does not provide cover for the extended role then it is the responsibility of the practitioner to seek out additional insurance cover before commencing the role. 7

8 8. Continuing professional development Once the extended role becomes practice it is important to build in Continuing Professional Development (CPD) and reflection. CPD and reflection should not be thought of as an add on but should be an integral part of practice. Evaluation The HPC will be requiring all registrants to undertake and record CPD activity and will seek to ensure that the CPD carried out is robust and effective. This is supported by the BDA Professional Standards for Dietitians 2004 (Standard1.3.1) Dietitians must engage in CPD activity, which is grounded in reflection, evaluation and everyday practice. The practitioner is responsible for taking all reasonable steps to ensure that the entry in a record is accurate and comprehensive. The BDA Guidance on Records and Record Keeping takes a more in depth look at the subject area. Audit Audit is a systematic approach to evaluating current practice, identifying possible improvements and providing mechanism for change (Getting Started in Research and Audit BDA 1998) Best practice dictates that practitioners should regularly undertake audit. As many extended roles in dietetics are as yet untested, it is perhaps even more essential to audit practice in order to establish efficacy and deliver a quality service. Final Thoughts Extended roles push professional boundaries and can provide the patient/client with an improved, more holistic, timely service, as well as providing the practitioner with enhanced job satisfaction. As dietitians take on new roles the profession will need to ask itself - Has some aspect of dietetic practice been left behind? How can we ensure the core role is not lost? Some may see extended practice as an erosion of the profession, others will see it as an opportunity for dietetics to continue to evolve and remain responsive and challenging. This paper has been produced by Najia Qureshi, Professional Development Officer on behalf of the Professional Practice Board. BDA July Review date July The British Dietetic Association 5th Floor, Charles House, 148/9 Great Charles Street Queensway, Birmingham B3 3HT Tel: Fax: info@bda.uk.com Commercial copying, hiring or lending without the written permission of the BDA is prohibited. bda.uk.com 8