SCOPE OF PRACTICE-SUPPORT STAFF IN NUTRITION & DIETETIC SERVICES Revised 11 September 2007

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1 SCOPE OF PRACTICE-SUPPORT STAFF IN NUTRITION & DIETETIC SERVICES Revised 11 September 2007 Introduction The key roles of dietitians are to contribute to the promotion of health, the prevention of ill health and the application of medical nutrition therapy for acute and chronic conditions. This optimisation of nutrition in populations and individuals occurs in a variety of settings; from population based prevention programs, community care, through to institutions such as acute care, rehabilitation, mental health and aged care. The roles of dietitians are constantly changing and diversifying into new areas in a highly changeable work environment 1. Workload demands on dietitians continue to increase whilst resources to meet increasing demands remain finite 2. The use of support staff in nutrition and dietetic services offers opportunities to provide cost efficient and cost effective services while at the same time achieving continual improvement in the quality of client care 3-9. The Dietitians Association of Australia (DAA) has historically set standards for best practice, fostered professionalism and provided the basis for internal clinical governance mechanisms for the protection of members and the public. These standards are specified in the Code of Professional Conduct which is available from the DAA website. DAA also has a position statement on the Scope of Dietetic Practice Framework 10 for dietitians. Members who are also Accredited Practising Dietitians (APD) have demonstrated commitment to ongoing training and education and to compliance with the DAA s guidelines for best practice. Refer to the DAA website for further information. This document defines the scope of practice for support workers (i.e. nutrition assistants and dietetic assistants) who provide assistance to dietitians. This document will provide a framework to guide dietitians and external organisations (e.g. insurance and employing organisations) in determining whether particular activities can be accepted as part of safe practice for these support staff. The training requirements, code of conduct for support staff and operational and professional supervision requirements of these support workers are also included. The scope of practice for Associate members of DAA (with degrees) is outside the scope of this document. Definition of nutrition and dietetic support workers The titles used to describe nutrition and dietetic support positions have changed during the past two decades. Prior to 1991, titles of diet aide and menu monitor were commonly used to describe these support positions. Dietetic technician emerged in 1991 and nutrition assistant and dietetic assistant in the late 1990s. Along with title changes, the scope of practice of these support positions and the supervision models have also evolved. As changes to dietitian roles occur, continued evolution of the roles of these support positions can also be expected. Results of research suggested the definition for nutrition and dietetic support workers (i.e. for position titles of nutrition assistant or dietetic assistant ) should be: DAA Board approved Version 6: 30/08/07 page 1 of 10

2 A support worker in nutrition and dietetic services is a skilled health care worker, who under the supervision of a dietitian assists in the implementation of a client s nutritional care program and who for more than 75% of their work time performs nutrition support tasks (as outlined in the core competency task list). Tasks undertaken by these support workers are specific and should not be undertaken by any other support worker in acute care facilities and other larger scale facilities (> 100 beds). In smaller and/or rural/remote facilities, residential aged care and psychiatric care, community care, day respite centres, where specified nutrition support positions do not exist, the tasks of these positions are important to client/patient care and must be included in other position descriptions. In these settings, reference to these tasks must also be made in defined care pathways, screening protocols and referral mechanisms. The extent to which the support worker is involved in the nutrition care program depends on the policies of the healthcare facility, the direction of the supervising dietitian and the needs of the client. Personal communication Aliakbari & Capra The above definition provides scope for the inclusion of nutrition support tasks into the roles of positions such as Allied Health Assistant. Scope of Practice As the scope of professional practice being carried out within the dietetic profession in Australia is rapidly expanding, more dietitians are now being employed in a variety of settings. These include but are not limited to educational and research, corporate, government, health promotion, community care and residential care. The specific roles undertaken by nutrition and dietetic support workers will be dependent on the type of nutrition and dietetic service and access to support from the supervising dietitian 11. Acknowledging these variations, DAA proposes that the scope of practice for nutrition and dietetic support workers should be broad enough to cover the variations in client needs and care settings and that position titles and position descriptions should reflect the needs of the individual client population and care setting. A support worker in nutrition and dietetic services may undertake adjunctive tasks to support the delivery of nutrition and dietetic services as specified by the supervising dietitian provided those roles do not require: Interpretation of data (i.e. clinical, referral of investigative procedures, research data etc) Assessment (including needs assessment, clinical assessment etc) Dietetic knowledge and skills Formulation or modification of a plan (i.e. for a nutrition project or individual client care plan etc) Explanation of the rationale, risks and options of nutrition and dietetic care or services Follow up and/or evaluation of nutrition and dietetic services DAA Board approved Version 6: 30/08/07 page 2 of 10

3 Competency Standards The following list outlines the competency standards supported by DAA that can be used to guide the work undertaken by nutrition and dietetic support workers. The following competency standards have been designed using the framework for competency standards for entry level dietitians 12 and outcomes of research on the competency tasks proposed for nutrition and dietetic support staff 11. Further details on competency tasks have been included as an attachment to this document. Note: this list is an example and not an inclusive list of competency tasks. Table 1. Unit 1 Unit 2 Unit 3 Unit 4 Unit 5 Competency standards for nutrition and dietetic support staff demonstrates basic general nutrition knowledge and skills relevant to their work and sufficient to ensure safe practice demonstrates basic knowledge and skills of food service or food supply systems and skills relevant to their work and sufficient to ensure safe practice demonstrates basic knowledge and skills of clinical nutrition and dietetic services relevant to their work and sufficient to ensure safe practice collects data relating to nutritional status of individual and groups collects data relating to food service and food supply collects data relating to community and industry Supports the provision of nutrition and dietetic services to individuals as a members of a health care team Supports the provision of food service or food supply to individuals, groups, community and industry Supports the provision of nutrition education to individuals and groups Supports the provision of nutrition education to the community and industry Demonstrates an organised, professional and ethical approach to work Training and Competency Standards On-the-job training and other training that does not include the assessment of core competencies is not considered by DAA as adequate training for these positions. Competence encompasses meeting certain minimum requirements or standards to be able to perform the required activities of a particular profession in the workplace 14. The completion of nationally recognised training by all staff working in positions providing support to nutrition services is strongly supported by DAA. Completion of training should be undertaken irrespective of the type or location of the healthcare setting, and that training should relate to the core competencies (as per the list of competency tasks supported by DAA). Core competencies for nutrition and dietetic support workers have been incorporated into the Certificate III in Nutrition and Dietetic Assistance 15 or DAA Board approved Version 6: 30/08/07 page 3 of 10

4 equivalent nutrition units in other nationally accredited training packages (such as Certificate III for Aboriginal Health Workers). For other positions, such as Allied Health Assistants, nutrition support competencies have been included in the Certificate III and Certificate IV in Health Service Assistance (Allied Health Assistance) 16. This provides opportunity for workers employed in non-nutrition specific support positions to expand their skills and knowledge base and be able to undertake nutrition support tasks under the direction of a dietitian. Ongoing professional development by support workers in nutrition and dietetic services should also be encouraged and supported by their supervising dietitian. Guiding principles Support workers in nutrition and dietetic services should be guided by the following principles: A Dietitian who is also an Accredited Practising Dietitian (APD) is committed to ongoing training and education and to complying with the DAA guidelines for best practice where available 10. They are therefore most qualified to select the nutrition support tasks for delegation to support workers in nutrition and dietetic services and are considered the most appropriate healthcare professional to supervise the tasks of support workers in nutrition and dietetic services Dietitians work towards achieving justice in the provision of healthcare for all people 18, and therefore support workers should similarly work towards this goal Dietitians accept responsibility for all treatment provided by others acting under their supervision 18, and therefore support workers should work within the accepted scope of practice for these positions Dietitians act in accordance with relevant legislation and seek authorisation from employer or insurance provider if in private practice 10. Support workers should also work within relevant legislation and workplace policies and procedures Code of Conduct Support workers in nutrition and dietetic services: respect the rights, autonomy and dignity of all individuals. recognise the extent and limitations of their skills and knowledge and undertake only those tasks (as outlined in the competency task list) for which they have been assessed as competent to perform. respect the confidentiality and security of client information according to relevant state legislation and employer policy co-operate and communicate in a timely and courteous manner to their supervising dietitian, colleagues and other health care providers and agencies in the best interests of the client and the community act in a manner which demonstrates commitment to the DAA Statement of Ethical Practice 18 recognise the position and professional accountability of the supervising dietitian. work within the framework of practice (refer to Framework for service models for nutrition support). 19 DAA Board approved Version 6: 30/08/07 page 4 of 10

5 Supervision The DAA supports the findings of Australian research that recommends qualified health professionals who have achieved a qualification in nutrition and dietetics (i.e. dietitian) should be responsible for both operational and professional management of nutrition support positions in all healthcare facilities and settings ( 11 Aliakbari & Capra, personal communication). As dietitians are responsible for ensuring the quality of nutrition care to the client or group, employing organisations should ensure that clinical dietitians maintain accountability for appropriate delegation of nutrition and dietetic support tasks to these support workers. The provision of professional supervision for nutrition and dietetic support staff will ensure the maintenance of clinical standards of nutrition care. Nutrition support positions may be established in rural and remote localities where direct access to professional supervision from a qualified dietitian would be limited. The use of a variety of communication modalities including telephone, fax, and or videoconference mode should be included in the design of professional supervision. However, as long as due consideration is given to the issues of client acuity, intensity of nutrition intervention, length of stay and access to a dietitian, DAA supports a shared supervision model in facilities that do not employ a clinical dietitian. In these facilities, the clinical dietitian would provide clinical supervision of these nutrition support positions, while positions such as a senior nursing position, (a nurse unit manager/ director of nursing services), foodservice/ catering manager, other allied health professionals or other team leader positions could be used for the operational management. Such facilities could include, but are not limited to smaller residential aged care, psychiatric care, multifunctional health centres and health facilities based in rural and remote locations. Nutrition and dietetic support staff supporting home based nutrition services, and corporate, industry, research and development or public health settings could also be included in this shared supervision model. The decision on what position would provide operational management for positions undertaking nutrition and dietetic support would be dependent on the mix of competency tasks being carried out; the level of client acuity or scope of nutrition service/project being conducted and the complexity of nutrition intervention/support being implemented. This decision should therefore be determined at the individual facility or setting level. In smaller, rural and remote facilities where access to dietetic services is available only on a part-time or consultancy basis, the recommendation is that professional management for nutrition and dietetic support staff be available by a dietitian through distant support, possibly through telephone, , fax or videoconferencing. Given that the dietitian is accountable for planning, implementation and monitoring of the nutrition and dietetic care, other positions, including nurse managers, foodservice/catering managers/chefs are not recommended by DAA as suitable to provide professional supervision of these support positions; unless the individual employed in those positions has relevant clinical dietetic qualifications. DAA acknowledges that supervision and management of these support staff requires a level of knowledge and skill to ensure quality supervision and safe practice. DAA recommends that employing organisations ensure appropriate processes are in place to achieve these outcomes through professional development and mentoring programs for supervising dietitians. DAA Board approved Version 6: 30/08/07 page 5 of 10

6 Summary DAA acknowledges the need for the delineation of the scope of practice for support workers in nutrition and dietetic services and recognises that as the role of dietitians continues to expand, so too is the potential for the evolution of the roles of support workers in nutrition and dietetic services. DAA also recognises that although there are several models for the supervision of tasks delegated to the support workers, professional supervision of any nutrition competency tasks undertaken by these support workers should be performed by a health professional with dietetic qualifications. The model of utilising support workers in nutrition and dietetic services should recognise the distinct roles and responsibilities of supervising dietitians and the adjunct roles and responsibilities of the support workers in these services. Ultimately, dietitians are responsible for all interventions provided for clients under their nutrition care 17. References 1. O Sullivan Maillet J, Skates J, Pritchett E. American Dietetic Association: Scope of Dietetics Practice Framework. J Amer Diet Assoc 2005; 4: Queensland Health. Practice Guidelines for Allied Health Assistants. Queensland Health, Ahmed LB, Kitson A. Complementary roles of nurse and health-care assistant. J Clinical Nurs 1993; 2: Saunders L. The Role of Physiotherapy Helpers in Out-patient Physiotherapy Services. Physiotherapy 1995; 81: Saunders L. Managing Delegation to Physiotherapy Assistants. Application of a Functional Analysis Model. Physio 1996; 82: Wolgin FJ. 1997, Evaluating the Implementation of Multi-skilled Workers. J Staff Develop1997; January/February: Rolfe G, Jackson N, Gardner L et al. Developing the role of a generic healthcare support worker: phase 1 of an action research study. Internal J Nurs Stud 1999; 36: Russell KV, Kanny EM. Use of Aides in Occupational Therapy Practice. Amer J Occup Ther 1998; 52: Duncan DG, Beck SJ, Hood K, Johansen A. Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutrition support in an acute trauma ward. Age and Ageing 2005; 35: Dietitians Association of Australia. Scope of Dietetic Practice Framework. Dietitians Association of Australia, Aliakbari J, Capra S. Personal Communication, Phillips S, Ash S, Tapsell T. Dietitians views on the current competency standards for entry level dietitians. Aust J Nutr Diet 2000; 57: Aliakbari J, Capra C. Developing cost-effective models of service delivery where do nutrition and dietetic support staff fit? 22 nd National DAA Conference, 2004 (available from: accessed April 2007) DAA Board approved Version 6: 30/08/07 page 6 of 10

7 14. Dietitians Association of Australia. DAA Manual for Accreditation of Dietetic Education Programs. Dietitians Association of Australia, National Training Information Service. Certificate III in Nutrition and Dietetic Assistance Community Services and Health Training Australia. HLT07 Qualification Descriptors Supporting the Health Training Package. Community Services and Health Training Australia Ltd, Hewat, C. Dietitians Association of Australia response to The Health Workforce Issues Paper (Draft), DAA. Canberra, Dietitians Association of Australia. Statement of Ethical Practice, Dietitians Association of Australia, Aliakbari J, Capra S. Defining Nutrition Support Staff using the Policy Delphi Technique. 21 st National Dietitians Association of Australia Conference, Queensland, (available from accessed April 2007) Framework for best practice models for support staff in nutrition and dietetic services Dietitian delegates tasks to Assistant Level of task performed is dependent on the stability of the client s issues related length of stay, client acuity, intensity of nutrition support/ intervention Care Planning Assessment/ Screening Implementation Monitoring Responsibility of dietitian to maintain standards of professional care that is the design of the nutrition care processes Communication link between Assistant and supervisory Dietitian (professional and line management) Variable Client Condition Stable Figure 2 Theoretical framework for best practice models utilising support staff in nutrition services Reference 19. Aliakbari J, Capra S. Defining Nutrition Support Staff using the Policy Delphi Technique. 21 st National DAA Conference, Queensland, DAA Board approved Version 6: 30/08/07 page 7 of 10

8 Framework for best practice models for nutrition support using generic allied health staff in smaller or rural and remote facilities Care Planning The nutrition care planning is the responsibility of the qualified dietitian. Dietitian delegates tasks to Assistant Level of task performed is dependent on the stability of the client s issues related length of stay, client acuity, intensity of nutrition support/ intervention Assessment/ Screening Implementation Monitoring Variable Client Condition Stable Communication and management links: Professional Dietitian & Assistant Line AHP Line Manager & Assistant Care Co-ordination AHP Line Manager Reference 13. Aliakbari J, Capra S. Developing cost-effective models of service delivery where do nutrition and dietetic support staff fit? 22 nd National DAA Conference, Victoria, DAA Board approved Version 6: 30/08/07 page 8 of 10

9 Competency standards 19 Examples: Unit 1 Competency tasks Assist with safe preparation of client meals or client meal services which may include: collection of requirements for prescribed diets from relevant personnel (healthcare providers) and reviewing where necessary according to pre-determined protocols and guidelines preparation of meal orders or a meal ordering system for clients, including the writing of meal orders for clients unable to self select and changing diet requirements as required; the marking of meals required for prescribed diets and supplements for clients who cannot or do not want to choose for themselves and checking orders before service to ensure that a meal order is present for all clients (including those who require a meal required under dietary prescription) preparation or processing of nourishment requests or oral nutrition support requests for clients on routine prescribed diets (such as high energy/ high protein) Support for client meal services including: collection of client lists for determining workloads priorities filing of prescribed diet patterns and calculations for clients no longer receiving support from a nutrition and dietetic service follow-up on client complaints regarding meal service Assist with the establishment and/or maintenance of an inventory system which may include: an inventory of menus and/or nutrition support supplements and supplies or a system for meal (or oral nutrition supplement) ordering and delivery (such as home delivered meals) or oral nutrition supplements Unit 2 Competency tasks Collection of relevant information including: client s food preferences; client s ability to comprehend written and verbal instructions; or information on client s ability to select a meal (and/or snacks) in accordance with a nutrition care plan, information on a client s ability to consume meals and supplements by observing and recording consumption of meals, snacks or oral nutrition supplements client s nutritional status through completion of nutrition screening; collecting information on client s usual diet or prescribed diet requirements; history of client s weight changes and appropriateness of client meal order; and recording pertinent findings from nutrition screening as per standard procedures and guidelines DAA Board approved Version 6: 30/08/07 page 9 of 10

10 Unit 3 Competency tasks providing client care in accordance with pre-established criteria in the form of protocols and care plans recording of nutrition care tasks including actions taken by nutrition & dietetic assistant as per standard clinical procedures and guidelines assisting in the communication of relevant nutrition and dietetic information to other service providers (including nursing, allied health, food services/ supply sources) including changes to prescribed diet requirements, relevant transfer of care information Unit 4 Competency tasks providing simple diet instruction to client s patients who are on texture modified or prescribed diet plans after appropriate training and competency assessment supporting the dietitian in client education by assisting in structured nutrition and dietary classes after appropriate training and competency assessment Unit 5 Competency tasks recording and maintenance of data related to nutrition and dietetic assistant activities, such as service statistics involvement in and/or supportive of quality activities involvement in and/or supportive of research activities providing client care in accordance to pre-established criteria communicating with the supervising dietitian regarding client s compliance with their prescribed diet working under direction of the supervising dietitian DAA Board approved Version 6: 30/08/07 page 10 of 10

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